Development and Validation of A Frusemide Card to Guide Self-Titration of Oral Frusemide in the Outpatient Setting
Main Article Content
Abstract
Background: Heart failure (HF) causes frequent hospitalisations due to fluid congestion. Patient-friendly self-titration tools are scarce. This study developed and validated a “Frusemide Card” to support safe outpatient dose adjustment.
Methods: This cross-sectional development and validation study was conducted in two phases. Phase 1 involved developing the Frusemide Card through evidence-based content construction and graphical design. Phase 2 included content validation by six experts (four cardiologists, two pharmacists) using the Content Validity Index (CVI) and Content Validity Ratio (CVR), followed by face validation among 20 HF patients in two sequential cohorts using the Face Validity Index (FVI). Content validity included four domains: relevance, clarity, essentiality, and patient instructions. Face validation assessed clarity and comprehension to determine overall acceptance.
Results: Expert validation showed perfect agreement for relevance and essentiality (I-CVI, CVR, and S-CVI/UA = 1.00). Clarity for domains 2–4 was acceptable (I-CVI ≥ 0.83), but domain 1 scored lower (I-CVI = 0.50), reducing the universal agreement (S-CVI/UA = 0.25), though average clarity was acceptable (S-CVI/Ave = 0.79). The first patient cohort reported good average clarity (S-FVI/Ave = 0.90) but low universal agreement (S-FVI/UA = 0.25). Following revisions based on feedback, the second patient cohort confirmed excellent clarity and acceptance, achieving perfect validity across all domains (I-FVI and S-FVI = 1.00).
Conclusion: The Frusemide Card showed strong content and face validity, suggesting that it could be a useful tool for guiding the safe self-titration of oral frusemide in outpatient HF management.
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
Shahim B, Kapelios CJ, Savarese G, Lund LH. Global public health burden of heart failure: an updated review. Card Fail Rev. 2023;9:e11. https://doi.org/10.15420/cfr.2023.05
Savarese G, Lund LH. Global public health burden of heart failure. Card Fail Rev. 2017;3(1):7–11. https://doi.org/10.15420/cfr.2016:25:2
National Heart Association of Malaysia. Clinical practice guidelines management of heart failure 2023 5th edition. [Internet]. Kuala Lumpur: National Heart Association of Malaysia; 2023. [Retrieved 2025 Aug 20]. Available at: https://www.acadmed.org.my/CPGdl/CPG%20Management%20of%20Heart%20Failure%20(5th%20Edition).pdf
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–3726. https://doi.org/10.1093/eurheartj/ehab368
Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, 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. J Am Coll Cardiol. 2022;79(17):e263–e421. https://doi.org/10.1016/j.jacc.2021.12.012
Platz E, Jhund PS, Claggett BL, Pfeffer MA, Swedberg K, Granger CB, et al. Prevalence and prognostic importance of precipitating factors leading to heart failure hospitalization: recurrent hospitalizations and mortality. Eur J Heart Fail. 2018;20(2):295–303. https://doi.org/10.1002/ejhf.901
Haboub M, Mounssif A, Khaldi M, Mechal H, Drighil A, Habbal R. Clinical, paraclinical, therapeutic features of acute decompensated heart failure in a Moroccan population. Sci Rep. 2025;15(1):20799. https://doi.org/10.1038/s41598-025-09363-7
Harkness K, Spaling MA, Currie K, Strachan PH, Clark AM. A systematic review of patient heart failure self-care strategies. J Cardiovasc Nurs. 2015;30(2):121–135. https://doi.org/10.1097/JCN.0000000000000118
Riegel B, Lee CS, Dickson VV. Self care in patients with chronic heart failure. Nat Rev Cardiol. 2011;8(11):644–654. https://doi.org/10.1038/nrcardio.2011.95
DeWalt DA, Malone RM, Bryant ME, Kosnar MC, Corr KE, Rothman RL, 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(1):30. https://doi.org/10.1186/1472-6963-6-30
Magdy JS, McVeigh J, Indraratna P. Diuretics in the management of chronic heart failure: when and how. Aust Prescr. 2022;45(6):200–204. https://doi.org/10.18773/austprescr.2022.069
Mullens W, Damman K, Harjola V, Mebazaa A, Brunner-La Rocca H, Martens P, et al. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019;21(2):137–155. https://doi.org/10.1002/ejhf.1369
Prasun MA, Kocheril AG, Klass PH, Dunlap SH, Piano MR. The effects of a sliding scale diuretic titration protocol in patients with heart failure. J Cardiovasc Nurs. 2005;20(1):62–70. https://doi.org/10.1097/00005082-200501000-00012
Veilleux RP, Wight JN, Cannon A, Whalen M, Bachman D. Home diuretic protocol for heart failure: partnering with home health to improve outcomes and reduce readmissions. Perm J. 2014;18(3):44–48. https://doi.org/10.7812/TPP/14-013
Feijó MK, Ruschel KB, Bernardes D, Ferro EB, Rohde LE, Biolo A, et al. Effects of a diuretic adjustment algorithm protocol on heart failure admissions: a randomized clinical trial. J Telemed Telecare. 2021;27(5):288–297. https://doi.org/10.1177/1357633X211009640
Tsang L, Pahk M, Fang T, Hansen M, Bucci C. Validation of a diuretic sliding scale for patients discharged with heart failure. Can J Cardiol. 2013;29(10):S196. https://doi.org/10.1016/j.cjca.2013.07.317
Barsuk JH, Gordon RA, Cohen ER, Cotts WG, Malkenson D, Yancy CW, et al. A diuretic protocol increases volume removal and reduces readmissions among hospitalized patients with acute decompensated heart failure. Congest Heart Fail. 2013;19(2):53–60. https://doi.org/10.1111/chf.12020
Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev. 2010;(8):CD007228. https://doi.org/10.1002/14651858.CD007228.pub2
Piano MR, Prasun MA, Stamos T, Groo V. Flexible diuretic titration in chronic heart failure: where is the evidence? J Card Fail. 2011;17(11):944–954. https://doi.org/10.1016/j.cardfail.2011.10.001. Erratum in: J Card Fail. 2011;18(2):172. https://doi.org/10.1016/j.cardfail.2012.01.012
Farizan NH, Sutan R, Mani KKC. Development and validation of a survey instrument on drowning prevention and water safety among parents of primary school children. J Clin Diagn Res. 2019;13(5):LC01–LC06. https://doi.org/10.7860/JCDR/2019/40100.12817
Zamanzadeh V, Ghahramanian A, Rassouli M, Abbaszadeh A, Alavi-Majd H, Nikanfar AR. Design and implementation content validity study: development of an instrument for measuring patient-centered communication. J Caring Sci. 2015;4(2):165–178. https://doi.org/10.15171/jcs.2015.017
Almanasreh E, Moles R, Chen TF. Evaluation of methods used for estimating content validity. Res Social Adm Pharm. 2019;15(2):214–221. https://doi.org/10.1016/j.sapharm.2018.03.066
Yusoff MSB. ABC of content validation and content validity index calculation. Educ Med J. 2019;11(2):49–54. https://doi.org/10.21315/eimj2019.11.2.6
Mat Said NA, Bujang SM, Buang NA, Siraj@Ramli HH, Awang Besar MN. Critical thinking transfer practice instrument: a content validity calculation steps based on expert panel evaluation. Educ Med J. 2022;14(3):61–74. https://doi.org/10.21315/eimj2022.14.3.5
Allen MS, Robson DA, Iliescu D. Face validity: a critical but ignored component of scale construction in psychological assessment. Eur J Psychol Assess. 2023;39(3):153–156. https://psycnet.apa.org/doi/10.1027/1015-5759/a000777
Yusoff MSB. ABC of response process validation and face validity index calculation. Educ Med J. 2019;11(3):55–61. https://doi.org/10.21315/eimj2019.11.3.6
Nieminen MS, Brutsaert D, Dickstein K, Drexler H, Follath F, Harjola VP, et al. EuroHeart Failure Survey II (EHFS II): a survey on hospitalized acute heart failure patients: description of population. Eur Heart J. 2006;27(22):2725–2736. https://doi.org/10.1093/eurheartj/ehl193
Wu L, Rodriguez M, El Hachem K, Krittanawong C. Diuretic treatment in heart failure: a practical guide for clinicians. J Clin Med. 2024;13(15):4470. https://doi.org/10.3390/jcm13154470
Fonarow GC, Stevenson LW, Walden JA, Livingston NA, Steimle AE, Hamilton MA, et al. Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol. 1997;30(3):725–732. https://doi.org/10.1016/s0735-1097(97)00208-8
Jaarsma T, Hill L, Bayes-Genis A, La Rocca HB, Castiello T, Čelutkienė J, 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(1):157–174. https://doi.org/10.1002/ejhf.2008
McAlister FA, Stewart S, Ferrua S, McMurray JJJV. Multidisciplinary strategies for the management of heart failure patients at high risk for admission. J Am Coll Cardiol. 2004;44(4):810–819. https://doi.org/10.1016/j.jacc.2004.05.055
NSW Agency for Clinical Innovation. Flexible diuretic regimen clinical practice guide [Internet]. Sydney: ACI; 2024. [Retrieved 2025 Aug 25]. Available at: https://aci.health.nsw.gov.au/networks/cardiac/resources/flexible-diuretic-regimen
NSW Agency for Clinical Innovation. Flexible diuretic action plan for heart failure [Internet]. Sydney: ACI; 2024. [Retrieved 2025 Aug 25]. Available at: https://aci.health.nsw.gov.au/networks/cardiac/resources/flexible-diuretic-regimen
Furosemide oral sliding scale for heart failure outpatients. Considerations for assessing and managing hypovolemia/volume depletion, with goal of achieving euvolemia [Internet]. Saskatchewan, Canada: University of Saskatchewan; 2020. [Retrieved 2025 Aug 25]. Available at: https://www.rxfiles.ca/rxfiles/uploads/documents/hf-furosemideslidingscale.pdf