Summary-In order to examine the effectiveness of cognitive behavioral therapy for patients with rheumatoid arthritis (RA) three patients groups were studied; a cognitive behavioral therapy group (CBT), an occupational therapy group (OT), and a waiting-list control group. The CBT received a comprehensive, 10-session treatment package that taught progressive relaxation, rational thinking and the differential use of pain coping strategies, CBT resulted in minor changes in pain coping behavior at posttreatment, while CBT and OT showed an increase of knowledge of RA. N o therapeutic effects with regard to health status were demonstrated at posttreatment and at 6 months follow-up. Clinical and laboratory measures of disease activity revealed progressive deterioration of the patients during the course of the study. It is suggested that the ineffectiveness of CBT might be due to the progressive course o f RA in the patients studied, as well as to the rather small changes in coping behavior. I N T R O D U C T I O

AimsIt has been suggested that home-based heart failure (HF) management in primary care may be an alternative to clinic-based management in HF patients. However, little is known about adherence to HF guidelines and adherence to the medication regimen in these home-based programmes. The aim of the current study was to determine whether long-term follow-up and treatment in primary care is equally effective as follow-up at a specialized HF clinic in terms of guideline adherence and patient adherence, in HF patients initially managed and up-titrated to optimal treatment at a specialized HF clinic. Methods and resultsWe conducted a multicentre, randomized, controlled study in 189 HF patients (62% male, age 72 11 years), who were assigned to follow-up either in primary care (n = 97) or in a HF clinic (n = 92). After 12 months, no differences between guideline adherence, as estimated by the Guideline Adherence Indicator (GAI-3), and patient adherence, in terms of the medication possession ratio (MPR), were found between treatment groups. There was no difference in the number of deaths (n = 12 in primary care and n = 8 in the HF clinic; P = 0.48), and hospital readmissions for cardiovascular (CV) reasons were also similar. The total number of unplanned non-CV hospital readmissions, however, tended to be higher in the primary care group (n = 22) than in the HF clinic group (n = 10; P = 0.05). Conclusionsless thanp id="ejhf173-para-0003"greater thanPatients discharged after initial management in a specialized HF clinic can be discharged to primary care for long-term follow-up with regard to maintaining guideline adherence and patient adherence. However, the complexity of the HF syndrome and its associated co-morbidities requires continuous monitoring. Close collaboration between healthcare providers will be crucial in order to provide HF patients with optimal, integrated care.

Funding Agencies|Netherlands Heart Foundation (NHF) [2008B083]

Background: Patients’ self-care behaviour is still suboptimal in many heart failure (HF) patients and underlying mechanisms on how to improve self-care need to be studied. Aims: (1) To describe the trajectory of patients’ self-care behaviour over 1 year, (2) to clarify the relationship between the trajectory of self-care and clinical outcomes, and (3) to identify factors related to changes in self-care behaviour. Methods: In this secondary analysis of the COACH-2 study, 167 HF patients (mean age 73 years) were included. Self-care behaviour was assessed at baseline and after 12 months using the European Heart Failure Self-care Behaviour scale. The threshold score of ⩾70 was used to define good self-care behaviour. Results: Of all patients, 21% had persistent poor self-care behaviour, and 27% decreased from good to poor. Self-care improved from poor to good in 10%; 41% had a good self-care during both measurements. Patients who improved self-care had significantly higher perceived control than those with persistently good self-care at baseline. Patients who decreased their self-care had more all-cause hospitalisations (35%) and cardiovascular hospitalisations (26%) than patients with persistently good self-care (2.9%, p < 0.05). The prevalence of depression increased at 12 months in both patients having persistent poor self-care (0% to 21%) and decreasing self-care (4.4% to 22%, both p < 0.05). Conclusion: Perceived control is a positive factor to improve self-care, and a decrease in self-care is related to worse outcomes. Interventions to reduce psychological distress combined with self-care support could have a beneficial impact on patients decreasing or persistently poor self-care behaviour.

There a several studies on HF care at home, testing interventions with a variety in number of components. Comparing the results to current standards, aspects such as collaboration between primary care and hospital care, titration of medication, and patient education can be improved.