Review Article

Gaps in Heart Failure Care: The Need for Effective Communication and Health Literacy-concordant Patient Education

Register or Login to View PDF Permissions
Permissions× For commercial reprint enquiries please contact Springer Healthcare: ReprintsWarehouse@springernature.com.

For permissions and non-commercial reprint enquiries, please visit Copyright.com to start a request.

For author reprints, please email rob.barclay@radcliffe-group.com.
Information image

  • Views: 456

  • Likes: 1

  • Downloads: 60

  • Read time: 14m 29s
Average (ratings)
No ratings
Your rating

Abstract

Heart failure (HF) care has increased in complexity over the past decade, with a higher number of interventions and medications offered to patients as part of routine HF care. Studies have consistently shown poor patient understanding of their HF diagnosis and treatment plans, impacting their overall outcomes. Effective communication and literacy-concordant patient education are two key players in comprehensive disease understanding. However, wide variability in HF patient education and the usage of literacy-discordant material have resulted in ineffective patient education, further contributing to fragmented patient understanding of their HF diagnosis. Innovative interventions targeting communication strategies and education delivery methods could significantly alter care delivery and improve multiple domains in HF care.

Keywords

Heart failure, patient education, health literacy, communication, disease understanding,

Received:

Accepted:

Published online:

DOI: https://doi.org/10.15420/usc.2024.55

Disclosure: AY is on the US Cardiology Review editorial board; this did not influence peer review. All other authors have no conflicts of interest to declare.

Correspondence: Zara Latif, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, MA 02114, US. E: zlatif@mgh.harvard.edu

Copyright:

© The Author(s). This work is open access and is licensed under CC-BY-NC 4.0. Users may copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

Heart failure (HF) is the leading cause of readmissions among Medicare patients in the US, with persistently high mortality rates.1,2 Readmission rates among HF patients have not significantly improved, despite advances in HF management.3 Patients with HF have multiple comorbidities, complex medication regimens, and high symptom burden.4 While medications are a cornerstone in HF treatment, HF care also depends on adequate patient knowledge and self-management, yet studies have shown limited disease understanding among patients with HF.5 Self-management has been defined as the daily tasks patients perform to manage their condition, including symptom monitoring, adhering to treatment plans, and following lifestyle adjustments.6 Although the complexity of HF care has increased over the past decade, there has not been a similar evolution in HF patient education to ensure patient understanding of their disease.

Health literacy has been the focus of recent literature in HF, given the critical role it plays in HF care.7 Health literacy has been defined as the degree to which individuals find, understand, and use information and services to inform health-related decisions and actions for themselves and others.8 In this paper, we aim to provide a comprehensive overview of the critical gaps in HF care, spanning communication, disease understanding, and patient education. We also discuss future innovative interventions that can be employed to improve care delivery to HF patients.

Patient Understanding of Heart Failure

Numerous studies have highlighted HF patients’ limited understanding of their HF diagnosis.9 In a qualitative study of HF patients, 13 out of 17 patients had a lack of knowledge related to their HF diagnosis, treatment plan, and self-management.10 Some patients in the study had a superficial knowledge of HF, and attributed their lack of knowledge to the strong focus of the medical encounters on medication adjustments. The gaps in patient understanding of HF diagnosis have been shown to originate very early in the disease course. In a meta-synthesis of 25 qualitative studies, several studies highlighted that HF patients were initially confused about the meaning of their new HF diagnosis, given the language used by providers.11 The term ‘heart failure’ has also been challenged in recent years, as it is often misleading to patients and carries significant psychological distress.12 Organizations, such as the Heart Failure Society of America, have advocated for reframing the diagnosis as ‘heart function’ to allow for better patient understanding of their condition.

In an analysis of 73 qualitative and mixed methods studies of patients with HF, patients attributed their HF symptoms to other conditions, such as stress, viral illness, medication side-effects, old age, or deconditioning.5,13,14 Additionally, some studies have shown that patients viewed HF as an acute condition that is curable, and in which they are able to eventually stop their medications. These studies highlight the lack of foundational knowledge among HF patients, with subsequent consequences on their treatment decisions and self-care routines.5,14 Complex HF treatment regimens have resulted in HF patients feeling overwhelmed by self-care, with 20–46% displaying poor treatment adherence behavior in one study.15

Patients’ insufficient understanding of HF included poor understanding of guideline-directed medical therapy (GDMT). In a study by Samsky et al., HF patients reported lack of familiarity with HF GDMT, such as angiotensin receptor-neprilysin inhibitor and mineralocorticoid receptor antagonist. Only 25% of the survey respondents were familiar with angiotensin receptor-neprilysin inhibitor.16 These results are likely due to multiple challenges on both patient and provider levels, including under prescription of GDMT and limited patient knowledge of their GDMT regimens. In addition, patients also reported concerns over the efficacy and safety of the medications. In the CHAMP-HF trial, a significant proportion of GDMT discontinuation was due to patient request.17,18 Lack of adequate patient understanding has been hypothesized to impact patients’ decisions to accept GDMT and continue taking all four classes of medications.

Patients’ limited knowledge of their disease persisted even after a HF admission. In a scoping review of pre-discharge knowledge in patients hospitalized with HF, patients had low knowledge of the causes and proper management of HF.19 Patients in the study who had higher knowledge displayed higher compliance with daily weight and fluid restriction; additionally, they had higher self-care scores. Factors associated with low levels of HF knowledge included inadequate health literacy and being on a higher number of medications.19

In another study exploring discharge education among HF patients with readmissions, patients in the study commonly shared that they understood discharge instructions, but later shared in the interviews several behaviors that were inconsistent with their discharge instructions.20 Moreover, there appear to be significant differences among HF phenotypes. In a survey study of 787 patients with confirmed HF, only 37% were aware of their HF diagnosis, and patients with HF with reduced ejection fraction were more aware of their diagnosis than those with HF with preserved ejection fraction.21

Inadequate patient knowledge of their disease and treatment results in an incomplete understanding of their prognosis. In a study to determine concordance between HF patients’ estimates of their prognosis and their physicians’ estimates, 84% of patients reported prognosis >1 year, while their physicians estimated prognosis <1 year.22 These studies underscore the current state of some of our HF patients, which spans multiple domains, including a lack of understanding of the etiology, treatment plan, and prognosis. Such critical gaps in knowledge will require multipronged interventions focused on implementing methods for effective communication and testing innovative information delivery methods that integrate patients’ perspectives and experiences.

Patient Education in Heart Failure: Unanswered Questions

HF patient education has been shown to be effective in improving multiple outcomes, including lowering the risk of rehospitalizations, fewer hospitalized days, and improved adherence to self-care measures.23,24 Currently, HF education is a shared responsibility among all members of the HF team; however, perceptions appear to differ regarding the key player in delivering HF education to patients. In a qualitative study of 15 cardiologists, 35 general medicine doctors, and eight HF nurses, cardiologists provided limited education to patients, but it was mainly HF nurses who provided patient education and considered patient education a core component of their role.25 In one study, only 50% of HF patients received complete instructions for diet, weight monitoring, activity level, worsening symptoms, follow-up appointment, and medication management at hospital discharge.26

Nurse-led HF education has been shown to be an effective measure for improving patients’ knowledge of their disease. In a randomized controlled trial of 223 HF patients who received a 1-h one-to-one teaching session with a nurse educator compared with a standard discharge process, patients receiving a 1-h dedicated discharge education session had a lower risk of rehospitalizations or deaths compared with controls (RR 0.65; 95% CI [0.45–0.93]; p=0.018).23 The results were similarly shown in a systematic review of randomized controlled trials of nurse-led one-to-one HF education, where the authors showed that nurse-led education sessions for adults with HF contributed to a reduction in hospital admissions and readmissions in addition to improvement in quality of life.27

While hospital discharge education is routine in most medical centers, the focus of current discharge education is on medication changes and medical appointments. There is no uniform guidance on topics covered for HF discharge education, length of education sessions, or who should deliver education sessions. Dedicated HF educators similar to those for other chronic diseases, such as diabetes, are not currently part of most medical centers. This in turn creates a diffusion of responsibility on who should provide HF education and what material is covered during discharge education sessions. HF nurses often deliver HF education to patients at the time of hospital discharge; however, given the lack of standardization in terms of topics covered and length of sessions, there is a wide variety in patients’ experiences depending on medical centers.

Innovative HF education techniques, including interactive iPad-based applications in addition to routine education, have been tested. In a randomized investigator-blinded study of 126 HF patients focused on HF education, where patients received nurse practitioner education plus interactive tablet application or nurse practitioner education alone, there was no significant difference in 30-day readmissions. However, patients felt that nurse practitioners plus iPad application offered better explanation of their care, and they had better understanding of medication side-effects compared with controls.28

Educational interventions focused on medications counseling that use pharmacy students and residents have also been studied, and have shown promising results. In a study of 86 HF patients who received discharge education focused on HF medications by pharmacy students, there was no difference in readmission rates. However, pharmacy students counseling HF patients were able to uncover 34 medication errors, one medication error for every 2.5 patients counseled. Importantly, 89% of patients who received counseling agreed that they had a better understanding of their medications after speaking to a pharmacy student/resident.29

Nurse educators are crucial in assisting patients with successful self-adherence through HF education related to diet modifications, fluid restrictions, symptom monitoring with knowledge focusing on decompensation, and overall lifestyle changes.30 Studies have shown that those with HF who better understood the medical plan established by their healthcare team had better understanding of HF, including the importance of medication adherence to improve symptoms.31–34 Providing patients with an understanding of fundamental HF care can enhance self-care, decrease HF hospitalizations, and increase medication adherence.35,36

Health Literacy and Heart Failure: The Overlooked Barrier to Care Delivery

Approximately one in four HF patients has inadequate health literacy.37 Studies have shown a gap in understanding the information given, and the action–response required among patients with HF.13,38 HF is a complex disease, and highly dependent on the collaborative work between the medical team and patients.39,40 The pathophysiology of HF imposes excessive demands on individual patients, including the requirement to comprehend, interpret, and adhere to complex medical regimens; monitor symptoms, salt intake, and weight daily; and attend outpatient follow-up with multiple providers and specialties.39 Self-care constitutes a significant and crucial aspect of HF management, and given the complexity of disease, health literacy and education are critical components of care.39–41

Health literacy is key to knowledge acquisition of cardiovascular disease, management of medications, physician–patient communication, and adherence to healthcare.41 However, low health literacy is an important healthcare disparity associated with the social determinants of health, and is an invisible barrier that impacts individual healthcare costs and public health.41 Yet, health providers continue to overestimate the health literacy of patients, using medical terminology that far exceeds patient comprehension, and missing opportunities for simplifying treatment regimens and education, which limits patient engagement.40,42

Previous studies have shown the importance of health literacy in self-care in patients with HF. In a cross-sectional study of 998 patients in which 172 had HF, the prevalence of limited health literacy was higher in patients with HF (27%) compared with those without HF (15%).43 Even when accounting for key sociodemographic factors, including age, sex, race, income, marital status, and insurance, HF remained significantly associated with low health literacy. Patients with limited literacy in this study were likely to be older, male, and from lower-income groups, findings that have been shown in subsequent studies.40,43 However, when adjusting for education, the association was no longer significant. In this study, education was considered a likely mediator between health literacy and HF.43

Among Medicare patients with chronic diseases, one study found 24% of patients had inadequate health literacy, and 12% of patients had marginal health literacy. Low health literacy has been associated with limited disease knowledge.44 More recent studies have shown an association between low literacy and mortality (HR 1.32; 95% CI [1.05–1.66]; p=0.02) after acute HF hospitalization, but no association with 90-day rehospitalizations or emergency visits.40 In one study, the prevalence of low health literacy among patients hospitalized for acute HF was 23.5%.40 These findings suggest that low health literacy among HF patients is highly prevalent, which should be taken into consideration when discussing disease or designing any HF patient education materials.

Health literacy in HF not only impacts outcomes after discharge, but can also influence quality of life. In one study, 605 patients with symptomatic HF were recruited from four academic centers to assess the relationship between health literacy levels and HF-related knowledge, self-efficacy, self-care behaviors, and quality of life. The results showed 37% of the cohort had low health literacy. Patients with low literacy were more likely to report New York Heart Association class III–IV HF symptoms (40 versus 26%; p<0.001), scored lower on HF general knowledge (mean score 5.5 versus 6.2), demonstrated lower self-efficacy (4.1 versus 5.0), achieved a lower HF behavioral score (4.2 versus 5.3), and were less likely to own a scale at home or obtain daily weight measurements. The authors postulated that low literacy is associated with poor knowledge retention, impacting HF management and care, which may potentially mediate poor outcomes in HF.39

Chen et al. found health literacy was associated with longitudinal HF knowledge, with no impact on self-care or self-efficacy.42 The authors found that clinic-based HF education improved HF knowledge in individuals with adequate health literacy compared with those with low health literacy. It is possible that traditional clinic-based HF education is discordant with patients’ literacy levels, making it challenging for them to process, retain, and apply educational materials that impact self-care.41,45 In a recent study evaluating the readability and accessibility of online educational materials for HF patients, the authors found that most websites for HF education (government, public, or private) have a median readability level between the 9th and 12th grade.46 Professional organizations, however, such as the American Medical Association, recommend that materials for patient education be written at the 6th grade reading level to improve comprehension.47,48 These studies highlight the discrepancy between the education provided to HF patients and their literacy level. To improve HF knowledge and patient engagement, targeted approaches to HF education should take into account the known low health literacy levels among patients, target the recommended readability level for education material, and focus on patient-identified topics of interest.

Whether targeted HF self-management education programs for patients with low literacy levels can improve HF knowledge and outcomes was studied in a randomized controlled trial by DeWalt et al., who enrolled 123 patients, 41% of whom had low literacy levels.49 At the end of 12 months, the study demonstrated that patients in the intervention arm who received the education program were significantly more likely to have their daily weight measured (79 versus 29%; p<0.0001). Overall, the intervention resulted in reduced hospitalization and death rates. In their sensitivity analysis for outcomes by literacy levels, the authors observed a larger difference in reduction of the primary outcomes for patients with low literacy levels (incidence rate ratio 0.39; 95% CI [0.16–0.91]) compared with higher literacy levels (incidence rate ratio 0.56; 95% CI [0.3–1.04]). This study demonstrated that a self-management program designed for patients with HF and low literacy improved the outcomes of hospitalization and death. Additionally, there were improvements in self-care behaviors, and patients were empowered with knowledge to adjust diuretics doses as necessary, thereby reducing the barriers to contacting providers for changes in baseline weights.49

Lessons can be gleaned from the use of education-concordant materials by patients with low literacy in the management of other chronic diseases. For primary care patients with hypertension, diabetes, and HF, the use of flash card aids and smartphone-activated videos on prescription medications improved medication adherence among low-literacy patients.50 For patients with diabetes, a study found increased barriers to electronic health enrollment, with higher odds of never using the patient portal among low-literacy patients, even with internet access (OR 1.4; 95% CI [1.2–1.8]).51 In a small pilot study of ethnically diverse HF patients, the use of language-free, graphic illustrations for HF education improved HF knowledge and self-care.52 A larger randomized controlled trial with 605 patients showed that providing longitudinal, telephone-based, literacy-sensitive training support for patients after HF hospitalization was associated with a lower incidence of HF hospitalization (incidence rate ratio 0.53; 95% CI [0.25–1.12]) among patients with lower literacy, and improved overall quality of life.53

Potential solutions to address the issues that stem from the high prevalence of low health literacy among HF patients include allocating resources to public health initiatives to improve HF knowledge, in addition to developing literacy-concordant education and self-care material. Conducting pragmatic and implementation trials to determine the best models to improve patient education among this patient population, with a particular focus on at-risk populations, such as older adults, minoritized populations, and patients with less than a college education, can pave the path for enhanced care delivery and will likely result in improved outcomes. Implementing national initiatives used in patient education for other chronic illnesses, such as diabetes, is a feasible next step.

Table 1: Overview of Current Communication and Education Challenges in Heart Failure Care.

Article image
Download

Figure 1: Summary of Multilayered Interventions to Address the Critical Gaps in Heart Failure Patient Education and Disease Understanding

Article image
Download

Conclusion

With studies showing significant gaps in patients’ knowledge, heterogeneity in patient education programs, and low health literacy among HF patients, it is imperative to redesign the way we communicate and educate patients about HF (Table 1). Effective communication and improvement in patient education are tightly intertwined, and several interventions targeting these areas could significantly change care delivery to HF patients (Figure 1). Needs-assessment using qualitative studies can provide enlightening information regarding the needs of patients and can guide the optimal design for interventions. Programs similar to the DECIDE-LVAD, which integrated patients’ input along every step in the design of decision aids, will ensure buy-in from patients and broad usage by patients.54 Such interventions also showed effectiveness among HF patients with low health literacy.55 With persistently high HF mortality and readmission rates, it is critical to address the neglected aspects in our care delivery to HF patients, such as effective communication and patient education.

References

  1. Jiang H, Barrett M. Healthcare Cost and Utilization Project (HCUP). Statistical Brief #307. Clinical Conditions With Frequent, Costly Hospital Readmissions by Payer, 2020. Rockville, MD: Agency for Healthcare Research and Quality, 2024. https://hcup-us.ahrq.gov/reports/statbriefs/SB307-508.pdf (accessed November 24, 2025).
  2. Siddiqi TJ, Khan Minhas AM, Greene SJ, et al. Trends in heart failure-related mortality among older adults in the United States from 1999–2019. JACC Heart Fail 2022;10:851–9. 
    Crossref | PubMed
  3. Bozkurt B, Ahmad T, Alexander K, et al. HF STATS 2024: heart failure epidemiology and outcomes statistics: an updated 2024 report from the Heart Failure Society of America. J Card Fail 2025;31:66–116. 
    Crossref | PubMed
  4. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation 2022;145:e895–1032. 
    Crossref | PubMed
  5. Daley C, Al-Abdulmunem M, Holden RJ. Knowledge among patients with heart failure: a narrative synthesis of qualitative research. Heart Lung 2019;48:477–85. 
    Crossref | PubMed
  6. Lainscak M, Blue L, Clark AL, et al. Self-care management of heart failure: practical recommendations from the Patient Care Committee of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2011;13:115–26. 
    Crossref | PubMed
  7. Ionescu R, Allen LA, Breathett K, et al. Health literacy in heart failure. JACC Adv 2025;4:101608. 
    Crossref | PubMed
  8. US Department of Health and Human Services. Health Literacy in Healthy People 2030. 2025. https://odphp.health.gov/healthypeople/priority-areas/health-literacy-healthy-people-2030 (accessed July 8, 2025).
  9. Latif Z, Makuvire TT, Feder SL, et al. Gaps in care delivery for patients with heart failure: a qualitative study of patients with multiple readmissions. J Hosp Med 2025:jhm.70051. 
    Crossref | PubMed
  10. Nordfonn OK, Morken IM, Bru LE, Husebø AML. Patients’ experience with heart failure treatment and self-care—a qualitative study exploring the burden of treatment. J Clin Nurs 2019;28:1782–93. 
    Crossref | PubMed
  11. Olano-Lizarraga M, Oroviogoicoechea C, Errasti-Ibarrondo B, Saracíbar-Razquin M. The personal experience of living with chronic heart failure: a qualitative meta-synthesis of the literature. J Clin Nurs 2016;25:2413–29. 
    Crossref | PubMed
  12. Boulos PK, Burgin G, Johnson-Koenke R, Flint KM. ‘My Amazing Heart’: a patient’s simple request to change outdated heart failure labels. Circ: Heart Failure 2022;15:e008679. 
    Crossref | PubMed
  13. Rogers AE, Addington-Hall JM, Abery AJ, et al. Knowledge and communication difficulties for patients with chronic heart failure: qualitative study. BMJ 2000;321:605–7. 
    Crossref | PubMed
  14. Heo S, Moser DK, Lennie TA, et al. Patients’ beliefs about causes and consequences of heart failure symptoms. West J Nurs Res 2019;41:1623–41. 
    Crossref | PubMed
  15. Riegel B, Lee CS, Albert N, et al. From novice to expert: confidence and activity status determine heart failure self-care performance. Nurs Res 2011;60:132–8. 
    Crossref | PubMed
  16. Samsky MD, Lin L, Greene SJ, et al. Patient perceptions and familiarity with medical therapy for heart failure. JAMA Cardiol 2020;5:292–9. 
    Crossref | PubMed
  17. Greene SJ, Butler J, Albert NM, et al. Medical therapy for heart failure with reduced ejection fraction. J Am Coll Cardiol 2018;72:351–66. 
    Crossref | PubMed
  18. Greene SJ, Fonarow GC, DeVore AD, et al. Titration of medical therapy for heart failure with reduced ejection fraction. J Am Coll Cardiol 2019;73:2365–83. 
    Crossref | PubMed
  19. Nozawa M, Hotta S, Tanaka M. Actual status of pre-discharge knowledge of hospitalised patients with heart failure and measurement tools to assess said knowledge: a scoping review. Heart Lung 2024;64:46–54. 
    Crossref | PubMed
  20. Gatto D, Newcomb P. Impressions of conventional bedside discharge teaching among readmitted heart failure patients. J Nurs Adm 2022;52:479–85. 
    Crossref | PubMed
  21. Shropshire SJ, Fabbri M, Manemann SM, et al. Patient awareness of heart failure diagnosis: a community study. J Am Heart Assoc 2023;12:e029284. 
    Crossref | PubMed
  22. Gelfman LP, Mather H, McKendrick K, et al. Non-concordance between patient and clinician estimates of prognosis in advanced heart failure. J Card Fail 2021;27:700–5. 
    Crossref | PubMed
  23. Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation 2005;111:179–85. 
    Crossref | PubMed
  24. Meng K, Musekamp G, Schuler M, et al. The impact of a self-management patient education program for patients with chronic heart failure undergoing inpatient cardiac rehabilitation. Patient Educ Couns 2016;99:1190–7. 
    Crossref | PubMed
  25. Baldewijns K, Boyne J, Rohde C, et al. What kind of patient education and self-care support do patients with heart failure receive, and by whom? Implementation of the ESC guidelines for heart failure in three European regions. Heart Lung 2023;57:25–30. 
    Crossref | PubMed
  26. Boren SA, Wakefield BJ, Gunlock TL, Wakefield DS. Heart failure self-management education: a systematic review of the evidence. Int J Evid-Based Healthc 2009;7:159–68. 
    Crossref | PubMed
  27. Rice H, Say R, Betihavas V. The effect of nurse-led education on hospitalization, readmission, quality of life and cost in adults with heart failure. A systematic review. Patient Educ Couns 2018;101:363–74. 
    Crossref | PubMed
  28. Breathett K, Maffett S, Foraker RE, et al. Pilot randomized controlled trial to reduce readmission for heart failure using novel tablet and nurse practitioner education. Am J Med 2018;131:974–8. 
    Crossref | PubMed
  29. Szkiladz A, Carey K, Ackerbauer K, et al. Impact of pharmacy student and resident-led discharge counseling on heart failure patients. J Pharm Pract 2013;26:574–9. 
    Crossref | PubMed
  30. Jaarsma T, Hill L, Bayes-Genis A, et al. Self-care of heart failure patients: practical management recommendations from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2021;23:157–74. 
    Crossref | PubMed
  31. Eimer S, Mahmoodi-Shan GR, Abdollahi AA. The effect of self-care education on adherence to treatment in elderly patients with heart failure: a randomized clinical trial. Iran J Nurs Midwif Res 2023;28:610–5. 
    Crossref | PubMed
  32. Tinoco JMVP, Figueiredo LDS, Flores PVP, et al. Effectiveness of health education in the self-care and adherence of patients with heart failure: a meta-analysis. Rev Lat Am Enfermagem 2021;29:e3389. 
    Crossref | PubMed
  33. Van Der Wal MHL, Jaarsma T, Moser DK, et al. Compliance in heart failure patients: the importance of knowledge and beliefs. Eur Heart J 2006;27:434–40. 
    Crossref | PubMed
  34. Riegel B, Moser DK, Anker SD, et al. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation 2009;120:1141–63. 
    Crossref | PubMed
  35. Cotie LM, Pakosh M, Ghisi GLM. Inpatient vs. outpatient: a systematic review of information needs throughout the heart failure patient Journey. J Clin Med 2024;13:1085. 
    Crossref | PubMed
  36. Stahlman S, Huizar-Garcia S, Lipscomb J, et al. Implementation of a heart failure educational intervention for patients with recent admissions for acute decompensated heart failure. Front Cardiovasc Med 2023;10:1133988. 
    Crossref | PubMed
  37. Fabbri M, Murad MH, Wennberg AM, et al. Health literacy and outcomes among patients with heart failure. JACC Heart Fail 2020;8:451–60. 
    Crossref | PubMed
  38. Ni H, Nauman D, Burgess D, et al. Factors influencing knowledge of and adherence to self-care among patients with heart failure. Arch Intern Med 1999;159:1613–9. 
    Crossref | PubMed
  39. Macabasco-O’Connell A, DeWalt DA, Broucksou KA, et al. Relationship between literacy, knowledge, self-care behaviors, and heart failure-related quality of life among patients with heart failure. J Gen Intern Med 2011;26:979–86. 
    Crossref | PubMed
  40. McNaughton CD, Cawthon C, Kripalani S, et al. Health literacy and mortality: a cohort study of patients hospitalized for acute heart failure. J Am Heart Assoc 2015;4:e001799. 
    Crossref | PubMed
  41. Magnani JW, Mujahid MS, Aronow HD, et al. Health literacy and cardiovascular disease: fundamental relevance to primary and secondary prevention: a scientific statement from the American Heart Association. Circulation 2018;138:e48–74. 
    Crossref | PubMed
  42. Chen AMH, Yehle KS, Albert NM, et al. Health literacy influences heart failure knowledge attainment but not self-efficacy for self-care or adherence to self-care over time. Nurs Res Pract 2013;2013:353290. 
    Crossref | PubMed
  43. Laramee AS, Morris N, Littenberg B. Relationship of literacy and heart failure in adults with diabetes. BMC Health Serv Res 2007;7:98. 
    Crossref | PubMed
  44. Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns 2003;51:267–75. 
    Crossref | PubMed
  45. Kapoor K, George P, Evans MC, et al. Health literacy: readability of ACC/AHA online patient education material. Cardiology 2017;138:36–40. 
    Crossref | PubMed
  46. Sharma S, Latif Z, Makuvire TT, et al. Readability and accessibility of patient education materials for heart failure in the United States. J Card Fail 2025;31:154–7. 
    Crossref | PubMed
  47. Mishra V, Dexter JP. Comparison of readability of official public health information about COVID-19 on Websites of international agencies and the governments of 15 countries. JAMA Netw Open 2020;3:e2018033. 
    Crossref | PubMed
  48. Wasir AS, Volgman AS, Jolly M. Assessing readability and comprehension of web-based patient education materials by American Heart Association (AHA) and CardioSmart online platform by American College of Cardiology (ACC): how useful are these websites for patient understanding? Am Heart J Plus 2023;32:100308. 
    Crossref | PubMed
  49. DeWalt DA, Malone RM, Bryant ME, et al. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res 2006;6:30. 
    Crossref | PubMed
  50. Yeung DL, Alvarez KS, Quinones ME, et al. Low-health literacy flashcards & mobile video reinforcement to improve medication adherence in patients on oral diabetes, heart failure, and hypertension medications. J Am Pharm Assoc (2003) 2017;57:30–7. 
    Crossref | PubMed
  51. Sarkar U, Karter AJ, Liu JY, et al. The literacy divide: health literacy and the use of an Internet-based patient portal in an integrated health system—results from the diabetes study of northern California (DISTANCE). J Health Commun 2010;15(Suppl 2):183–96. 
    Crossref | PubMed
  52. Dickson VV, Chyun D, Caridi C, et al. Low literacy self-care management patient education for a multi-lingual heart failure population: results of a pilot study. Appl Nurs Res 2016;29:122–4. 
    Crossref | PubMed
  53. DeWalt DA, Schillinger D, Ruo B, et al. Multisite randomized trial of a single-session versus multisession literacy-sensitive self-care intervention for patients with heart failure. Circulation 2012;125:2854–62. 
    Crossref | PubMed
  54. Allen LA, McIlvennan CK, Thompson JS, et al. Effectiveness of an intervention supporting shared decision making for destination therapy left ventricular assist device: the DECIDE-LVAD randomized clinical trial. JAMA Intern Med 2018;178:520–9. 
    Crossref | PubMed
  55. Raymer DS, Allen LA, Chaussee EL, et al. Health literacy in patients considering a left ventricular assist device: findings from the DECIDE-LVAD trial. J Card Fail 2022;28:1318–25. 
    Crossref | PubMed
Next Volume Article