We read with great interest the scientific letter published by González et al1 in Revista Española de Cardiología, and, after first congratulating the authors, would like to make several comments on its content.
We know that heart failure is a complex and multifactorial syndrome that affects a high percentage of patients. Moreover, the number of patients is increasing due to the progressive aging of the population. Clinical practice guidelines recommend the implementation of multidisciplinary programs as a priority.2 One of the keys to the success of these programs lies in health education interventions, essentially carried out by nurses, as reflected by several studies.3 Given their high workload, physicians have less room for maneuver for dedicating more time to patients.4 Nurses therefore take on most of the burden of the educational process, although without undermining the roles of other members of the team.
With regard to the published letter, we have several doubts. First, it would be interesting to know whether the nurses’ telephone calls follow a predetermined structure or protocol depending on the reason for the call or whether they simply respond to the demands of the patient. Second, we would also need to know which interventions are performed by nurses, depending on the reason for the call. Finally, the number of bureaucratic questions addressed by the nurses is noteworthy and such doubts could perhaps be resolved by administrative staff.
It is our understanding that within an educational program, taking calls should be a complementary activity to other, more important interventions. In fact, telephone support has not been shown to provide a benefit and the evidence is not sufficiently solid to support recommendation in the clinical practice guidelines.2
In the figure that is published in the letter indicating the reasons for calling, we noted that patients have problems essentially with treatment. These results may suggest that the number of calls increases due to lack of a prior educational intervention on the patient’ treatment plan, leading to subsequent doubts.
A substantial proportion of calls may be due to strong trust in the unit staff and their accessibility, making the patients dependent on the system. In fact, older patients call about other noncardiologic treatments. This would appear to go against encouraging self-care, one of the initial objectives and one that has been assessed in previous studies.5
With regard to the multidisciplinary approach, we should not forget other levels of care and seek the involvement of primary health care professionals, who are usually the first point of contact when older patients attend the clinic for symptoms of acute heart failure.6 In addition, it would be a good moment to establish strong alliances with community nursing, which is also promoting goals such as self-care.
In summary, the authors are right in affirming that their results may be relevant for planning future heart failure units. In our humble opinion, it is necessary to standardize interventions through a health plan or program that overcomes the barriers between patients and their treatment.