Individual and family self-management for high-risk gastrointestinal bleeding in older adults

Abstract

BACKGROUND

Promoting evidence-based practice and quality improvement based on the individual and family self-management theory (IFSMT) in chronic disease management may help reduce the incidence of gastrointestinal bleeding.

AIM

To explore implementation strategies for evidence-based practice and quality improvement based on IFSMT in chronic disease management for older patients at high risk of gastrointestinal bleeding, thereby providing a reference for chronic disease management programs for such patients and improving their prognosis.

METHODS

A total of 150 older patients at high risk of gastrointestinal bleeding who were admitted to the Department of General Medicine, Affiliated Hospital of Nantong University, from January 2022 to January 2025 were enrolled and randomly divided into two groups using a random number table method. The control group (n = 75) received routine chronic disease management, while the observation group (n = 75) received a continuous quality improvement model of evidence-based chronic disease management based on IFSMT. Self-management ability, health behaviors, psychological status, rebleeding rate, and other indicators were compared between the two groups.

RESULTS

After the intervention, the score of the Self-Management Ability Scale-Short Form in the observation group was 73.51 ± 5.20, which was higher than 68.73 ± 5.16 in the control group. The anxiety and depression scores were lower in the observation group than in the control group. The medication compliance score was 7.10 ± 0.48 in the observation group, which was higher than 6.38 ± 0.51 in the control group. Disease uncertainty and family self-burden were lower and health management behaviors were better in the observation group (P < 0.05). After 12 months of follow-up, the rebleeding rate in the observation group was 1.33%, which was significantly lower than the rate of 10.67% (8/75) in the control group (P < 0.05).

CONCLUSION

Establishing an IFSMT-based continuous quality improvement model for evidence-based chronic disease management can improve patients' self-management ability, relieve anxiety and depression, enhance medication compliance, and reduce the rebleeding rate. Therefore, this model may be clinically useful.

Key Words: Older patients; High-risk gastrointestinal bleeding; Chronic disease management; Individual and family self-management; Evidence-based practice; Quality improvement

Core Tip: This study applied an evidence-based chronic disease management quality improvement based on the individual and family self-management theory to 150 older patients at high-risk gastrointestinal bleeding. The model significantly improved patients’ self-management ability and reduced anxiety, depression, and the rebleeding rate, suggesting its clinically valuable.

INTRODUCTION

Gastrointestinal bleeding is a common gastrointestinal emergency mainly caused by vascular lesions, systemic diseases involving the digestive tract, mechanical injury, and other factors[1]. Older patients are at particularly high risk of gastrointestinal bleeding. In particular, patients with coronary heart disease, liver cirrhosis, long-term use of antiplatelet or anticoagulant drugs, or a history of peptic ulcers have a further increased risk of gastrointestinal bleeding[2]. A study[3] showed that the incidence of major gastrointestinal bleeding in patients receiving long-term proton pump inhibitor therapy was 0.7%, which was significantly higher than that in patients not receiving proton pump inhibitors. Moreover, gastrointestinal bleeding is a leading cause of death among hospitalized patients. For high-risk patients, the rebleeding rate within 72 hours after endoscopic treatment can be as high as 25%, which seriously endangers patients' lives[4]. Therefore, clinical management and intervention should be strengthened for older patients at high risk of gastrointestinal disease to reduce the recurrence rate of bleeding.

Chronic disease management refers to the continuous monitoring, evaluation, and comprehensive management of chronic non-communicable diseases and their risk factors, with the aim of delaying disease progression and reducing patients' medical burden[5]. However, older patients at high risk of gastrointestinal bleeding often present with multiple comorbidities, a long disease course, poor compliance, and insufficient disease-related knowledge. In addition, the chronic disease management system remains imperfect, which affects management outcomes.

The individual and family self-management theory (IFSMT) holds that individual self-management behavior includes three components: Context, process, and outcome, and emphasizes that individual, family, and social environmental factors should be comprehensively considered in chronic disease management[6]. At present, the IFSMT has achieved good results in chronic disease management. However, when nurses implement it, they need to consider not only patients' biomedical needs but also their psychosocial needs, which highlights the need for stronger evidence-based practice, application strategies, standardized application pathways, and quality improvement plans for IFSMT implementation.

Based on the above background, this study explored strategies for evidence-based practice and quality improvement based on IFSMT in the chronic disease management of older patients at high risk of gastrointestinal bleeding, aiming to provide a reference for chronic disease management programs of such patients. The results are reported as follows.

MATERIALS AND METHODS

General information

A total of 150 older patients at high risk of gastrointestinal bleeding who were admitted to the Department of General Medicine, Affiliated Hospital of Nantong University, from January 2022 to January 2025 were selected and randomly divided into the control group (n = 75) and the observation group (n = 75) using the random number table method. The baseline characteristics of the two groups were comparable (P > 0.05), as shown in Table 1.

Table 1 Comparison of general data between the two groups.

Item	Observation group (n = 75)	Control group (n = 75)	χ2/t	P value
Gender			0.440	0.507
Male	46	42
Female	29	33
Age (years)	72.08 ± 3.39	71.42 ± 3.28	1.212	0.228
Medication use			0.466	0.926
Antiplatelet agents	28	25
Nonsteroidal anti-inflammatory drugs	17	18
Anticoagulants	11	10
None	19	22
Comorbidities			0.450	0.799
Hypertension with diabetes	26	28
Coronary heart disease	16	18
Peptic ulcer	33	29
Complicated with gastrointestinal tumor	4	2	0.174	0.677
Education level			0.883	0.643
Primary school or below	50	48
Junior high school	21	20
Senior high school or above	4	7

Inclusion and exclusion criteria

Inclusion criteria: (1) Age ≥ 60 years; (2) Meeting the criteria for high-risk gastrointestinal bleeding[7]: Presence of ≥ 1 underlying disease; long-term use of nonsteroidal anti-inflammatory drugs, antiplatelet agents, or similar medications; or a history of peptic ulcer, gastrointestinal tumor, or related conditions; (3) Controlled disease status and stable vital signs; (4) Good compliance and ability to cooperate with chronic disease management; (5) Basic communication and cognitive abilities; and (6) Provision or written informed consent after being informed about the study.

Exclusion criteria: (1) Hemorrhage caused by esophagogastric variceal rupture; (2) Hematological or immunodeficiency diseases; (3) Severe hepatic or renal insufficiency, cardiocerebrovascular disease, infectious diseases, or malignant tumors; (4) Gastrointestinal bleeding caused by invasive procedures or trauma; (5) Cognitive impairment or mental disorders; or (6) Poor compliance.

Random sequences were generated by an independent statistician using a computer-generated random number table. Allocation was concealed using sequentially numbered, opaque, sealed envelopes. Outcome assessors were blinded to group assignment. The sample size was calculated based on the expected difference in rebleeding rates between groups. Assuming an alpha level of 0.05, statistical power of 80%, and an expected reduction in the rebleeding rate after the intervention, the minimum required sample size was calculated. Considering a potential dropout rate of approximately 10%, 75 patients were finally recruited into each group.

Methods

The control group received routine chronic disease management. Medical staff provided patients with the Guidelines for Rehabilitation of Gastrointestinal Bleeding and used oral education to explain the pathogenesis, risk factors, medication use, preventive measures, self-management behaviors, and contraindications related to gastrointestinal bleeding. Patients were instructed regarding reasonable diet and preventive measures for complications. They were warned of bleeding-related symptoms, such as hematemesis, melena, dizziness, and fatigue, and were informed about emergency treatment measures. After discharge, follow-up was conducted via telephone, WeChat, and outpatient review to inquire about the improvement of the disease, medication use, diet, sleep, and related conditions. Patients were reminded to undergo regular follow-up examinations and seek immediate medical treatment if discomfort or bleeding signs occurred.

In the observation group, an evidence-based practice and continuous quality improvement model for chronic disease management was constructed based on IFSMT in addition to routine management.

The average intervention time was approximately 20-30 minutes per patient per follow-up, and multidisciplinary consultation was triggered only when specific problems were identified.

All randomized patients were included in the intention-to-treat analysis. During the 12-month follow-up, no patients were lost to follow-up.

Establishment of an evidence-based practice team for chronic disease management: The team consisted of 1 head nurse, 2 general practitioners, 2 gastroenterologists serving as instructors, 4 specialized nurses, 1 nutritionist, 1 pharmacist, and 1 psychological counselor. All members received standardized training before the intervention and mastered relevant knowledge of gastrointestinal bleeding, first aid methods, preventive measures, and precautions. They were also trained in the IFSMT theory, evidence-based practice, continuous quality improvement theories, and operational procedures, and all passed the assessment. Responsibilities were assigned as follows: The head nurse served as the team leader and was responsible for supervising and coordinating nursing management; the gastroenterologists were in charge of disease monitoring and treatment plan adjustment; the general practitioners formulated and supervised continuous medical and health services for patients; the pharmacists provided medication guidance; the nutritionists offered nutritional guidance; the specialized nurses implemented management practice, health education, and follow-up management; and the psychological counselors provided psychological counseling.

Evidence-based retrieval: This study adopted an evidence-based practice approach guided by the IFSMT. Literature retrieval was conducted in PubMed, CNKI, Wanfang Database, and VIP Database using the keywords “gastrointestinal bleeding”, “IFSMT theory”, “chronic disease management”, and “elderly patients”. Relevant literature published in recent years was screened to identify evidence supporting the intervention components. The retrieved literature was reviewed and integrated by the research team. The quality and applicability of the evidence were considered during the formulation of the intervention protocol. The final evidence-based chronic disease management model was developed by combining available research evidence, expert consultation, and the clinical context of our hospital. Since this study focused on evidence translation and quality improvement rather than systematic evidence synthesis, no formal systematic review or meta-analysis was performed.

Context dimension: After admission, baseline data of patients were collected in detail by team members. Combined with motivational interviews, a comprehensive assessment was performed to evaluate patients’ understanding of the disease, medication use, diet, attitude toward treatment, family status, and social support. According to each patient’s disease characteristics, comorbidities, and medication use, the risk of bleeding was evaluated using the Blatchford score. Patients were classified into low-risk (0-2 points), moderate-risk (3-5 points), and high-risk (≥ 6 points) groups, and stratified management was implemented accordingly.

Process dimension: (1) Disease knowledge management: On the basis of routine education, patients were informed about the pathogenesis, risk factors, treatment regimens, medication use and mechanisms, daily diet, and self-management of gastrointestinal bleeding through multimedia animation videos, model demonstrations, PPT lectures, and brochures. They were taught to accurately identify signs of bleeding and adopt self-prevention strategies, thereby improving their understanding of gastrointestinal bleeding; (2) Self-management behavior guidance: The importance of self-health management and the relationship between personal behavior and bleeding recurrence were explained to patients using Power Point, model demonstrations, video playback, and on-site demonstrations. Medication administration and adverse reaction monitoring were demonstrated. Daily diet guidance was provided via one-on-one food models and dietary guidelines, with patients advised to avoid spicy, irritating, overheated, and hard foods. Patients were instructed to self-monitor for symptoms of bleeding, including stool color and consistency, as well as dizziness, fatigue, and hematemesis. They were also advised to quit smoking and drinking, maintain regular schedules, and take medications on time. Through one-on-one communication, nurses evaluated patients’ understanding of the disease, actively guided them to recognize the benefits of maintaining stable disease control, and corrected misconceptions and inappropriate behaviors; (3) Family collaborative intervention: Nurses provided health education to patients’ family members and invited them to join a WeChat group, where relevant knowledge of gastrointestinal bleeding and the effects of unhealthy behaviors on disease progression were regularly shared. Family care responsibilities were clarified, including assisting with and supervising medication use, monitoring disease conditions, overseeing diet and daily routines, correcting unhealthy behaviors, identifying bleeding signs, and implementing emergency measures. Family members were guided to provide adequate psychological support and emotional companionship to relieve patients’ psychological burden and build confidence in recovery; (4) Psychological intervention: Psychological counselors assessed patients’ psychological status and relieved their psychological burden through psychological counseling and family emotional support. Patients were taught mindfulness therapy, meditation, relaxation training, and emotion diversion techniques to reduce negative emotions. Peer support activities were regularly held to encourage patients to share treatment and rehabilitation experiences. Patients with good performance were praised and affirmed; for those with poor recovery, underlying reasons were analyzed, and targeted improvement strategies were proposed. Before discharge, an experience-sharing meeting was held, during which successfully recovered patients shared their experiences to further enhance patients’ confidence in rehabilitation; (5) Risk-stratified intervention: For low-risk patients, the intervention focused on health education and family supervision. The impact of unhealthy behaviors on bleeding was explained, and patients were guided to maintain regular schedules and reasonable diets. Questions raised by patients were answered patiently. Outpatient follow-up examinations were scheduled regularly after discharge, with follow-up once a month. For moderate-risk patients, vital signs were closely monitored, and rebleeding prevention was strengthened. First-aid medications were prepared, and medication guidance, dietary instruction, and psychological counseling were provided. Follow-up was conducted every 2 weeks after discharge. For high-risk patients, preparations were made for massive bleeding, shock rescue, and complication prevention. Blood pressure, heart rate, and other vital signs were intensively monitored. One-on-one follow-up management was implemented once a week to closely monitor disease progression and adjust the management plan in a timely manner; and (6) Follow-up management: A WeChat-based health management follow-up platform was established, and patients and their families were invited to join the group. Nurses regularly posted health education materials on gastrointestinal bleeding and promptly answered questions in the group. Short videos about gastrointestinal bleeding were produced and shared weekly via Douyin and WeChat for patients and family members to view. Follow-up was conducted once a week to evaluate bleeding signs, medication adherence, disease improvement, and dietary compliance. Any abnormal conditions were addressed immediately, and patients were advised to receive prompt symptomatic treatment in the hospital.

Outcome dimension and continuous quality improvement: Medication adherence, diet and daily routine, smoking cessation, and alcohol abstinence were evaluated monthly, and disease improvement and rebleeding risk were investigated. Feedback from family members was collected to assess patient and family satisfaction with the management program, which was then adjusted accordingly. The implementation of management components and improvement measures was inspected monthly, management effectiveness was evaluated, existing problems were analyzed, and quality inspection reports were generated. Effective and well-implemented measures were incorporated into the chronic disease management protocol. For measures that failed to achieve the expected outcomes, underlying causes were analyzed, and revised strategies were proposed for the next round of management, forming a continuous optimization cycle. Both groups received the intervention for 6 consecutive months.

Observation indicators

Self-management behavior: The Self-Management Ability Scale-Short Form[8] was used before and after the intervention. The scale contains 18 items, each scored from 1 to 5 points, with a total score of 90 points; higher scores indicate better self-management behavior.

Psychological status: The Hospital Anxiety and Depression Scale[9] was used to assess anxiety and depression before and after the intervention. Each subscale includes 7 items, scored from 0 to 3 points; higher scores indicate more severe anxiety and depression.

Medication adherence: The Morisky Medication Adherence Scale[10] was used before and after the intervention. The scale includes 8 items, scored 1 for “yes” and 0 for “no”, with a total score of 8 points; higher scores indicate better medication adherence.

Uncertainty in illness: The Mishel Uncertainty in Illness Scale[11] was used before and after the intervention and includes ambiguity (13 items), complexity (7 items), unpredictability (5 items), and inconsistency (7 items). Each item is scored from 1 to 5 points; higher scores indicate stronger illness uncertainty.

Family caregiver burden: The Zarit Caregiver Burden Interview[12] was used before and after the intervention and includes personal burden (12 items) and role burden (10 items). Each item is scored from 0 to 4 points; higher total scores indicate heavier caregiver burden.

Health management behavior: The Self-Rated Abilities for Health Practices Scale[13] was used before and after the intervention. The scale contains 28 items, each scored from 1 to 5 points, with a total score of 140 points; higher scores indicate better health management behavior.

Rebleeding rate: The occurrence of rebleeding was recorded within 12 months after discharge.

Statistical analysis

SPSS 26.0 statistical software was used for data analysis. Measurement data that conformed to normal distribution were expressed as the mean ± SD. Independent-samples t-test and paired-samples t-test were used for between-group and within-group comparisons, respectively. Enumeration data were expressed as rates (%) and analyzed using the χ² test. A value of P < 0.05 was considered statistically significant.

RESULTS

Self-management behavior

Before the intervention, there was no significant difference in self-management behavior between the two groups (P > 0.05). After the intervention, self-management behavior improved in both groups, and the score in the observation group was higher than that in the control group (P < 0.05), as shown in Table 2.

Table 2 Comparison of Self-Management Ability Scale-Short Form scores for self-management behaviors between the two groups (score, mean ± SD).

Group	Before Intervention	After Intervention	t value	P value
Observation group (n = 75)	48.86 ± 6.69	73.51 ± 5.20	25.194	< 0.001
Control group (n = 75)	50.17 ± 7.39	68.73 ± 5.16	17.833	< 0.001
t value	1.138	5.561	-	-
P value	0.257	< 0.001	-	-

Psychological status

Before the intervention, there was no significant difference in psychological status between the two groups (P > 0.05). After the intervention, anxiety and depression were alleviated in both groups, and the scores in the observation group were lower than those in the control group (P < 0.05), as shown in Table 3.

Table 3 Comparison of Hospital Anxiety and Depression Scale scores between the two groups (point, mean ± SD).

Group	Anxiety		Depression
	Before	After	Before	After
Observation group (n = 75)	12.08 ± 2.17	5.39 ± 1.04	11.41 ± 2.14	4.82 ± 1.01
Control group (n = 75)	11.87 ± 2.26	6.75 ± 1.08	10.96 ± 2.38	5.91 ± 1.13
t value	0.580	7.855	1.218	6.228
P value	0.562	< 0.001a	0.225	< 0.001a

^aP < 0.05 vs the same group before intervention.

Medication adherence

Before the intervention, there was no significant difference in medication adherence between the two groups (P > 0.05). After the intervention, medication adherence improved in both groups, with a greater increase in the observation group (P < 0.05), as shown in Table 4.

Table 4 Comparison of Morisky compliance between the two groups (point, mean ± SD).

Group	Before intervention	After intervention	t value	P value
Observation group (n = 75)	4.68 ± 1.01	7.10 ± 0.48	18.741	< 0.001
Control group (n = 75)	4.82 ± 1.03	6.38 ± 0.51	11.754	< 0.001
t value	0.840	8.903	-	-
P value	0.402	< 0.001	-	-

Uncertainty in illness

Before the intervention, there was no significant difference in uncertainty in illness between the two groups (P > 0.05). After the intervention, uncertainty in illness decreased in both groups, and the score in the observation group was lower than that in the control group (P < 0.05), as shown in Table 5.

Table 5 Comparison of disease uncertainty between the two groups (point, mean ± SD).

Group	Uncertainty		Complexity		Unpredictability		Inconsistency
	Before	After	Before	After	Before	After	Before	After
Observation group (n = 75)	36.71 ± 3.25	52.47 ± 3.68	16.67 ± 2.18	26.80 ± 2.40	11.76 ± 1.86	18.82 ± 1.47	17.83 ± 2.36	25.76 ± 2.81
Control group (n = 75)	37.36 ± 3.60	46.71 ± 4.15	17.10 ± 2.64	21.76 ± 2.39	12.08 ± 2.03	15.60 ± 1.54	18.29 ± 2.43	22.37 ± 2.49
t value	1.161	8.993	1.088	12.887	1.007	13.098	1.176	7.820
P value	0.248	< 0.001a	0.279	< 0.001a	0.316	< 0.001a	0.241	< 0.001a

^aP < 0.05 vs the baseline level before intervention in the same group.

Family caregiver burden

Before the intervention, there was no significant difference in family caregiver burden between the two groups (P > 0.05). After the intervention, caregiver burden was reduced in both groups, with a greater decrease in the observation group (P < 0.05), as shown in Table 6.

Table 6 Comparison of family caregiving burden between the two groups (point, mean ± SD).

Group	Individual burden		Role burden
	Before	After	Before	After
Observation group (n = 75)	33.14 ± 3.39	16.74 ± 2.73	28.60 ± 3.14	14.47 ± 2.54
Control group (n = 75)	32.75 ± 3.51	19.95 ± 3.18	27.76 ± 3.39	17.39 ± 2.95
t value	0.692	6.633	1.574	6.496
P value	0.490	< 0.001a	0.118	< 0.001a

^aP < 0.05 vs the same group before intervention.

Health management behavior

Before the intervention, there was no significant difference in health management behavior between the two groups (P > 0.05). After the intervention, health management behavior was improved in both groups, with a greater increase in the observation group compared with the control group (P < 0.05), as shown in Table 7.

Table 7 Comparison of health management behaviors between the two groups (point, mean ± SD).

Group	Before	After	t value	P value
Observation group (n = 75)	78.68 ± 8.36	118.74 ± 6.64	32.496	< 0.001
Control group (n = 75)	81.49 ± 9.81	102.47 ± 7.13	14.982	< 0.001
t value	1.888	14.462
P value	0.061	< 0.001

Rebleeding rate

During the 12-month follow-up, rebleeding occurred in 1 patient (1.33%) in the observation group and 8 patients (10.67%) in the control group. The intervention was associated with a lower risk of rebleeding (RR = 0.13, 95%CI: 0.01-1.08). The absolute risk difference was -9.34% (95%CI: -16.8% to -1.9%).

DISCUSSION

Gastrointestinal bleeding is a common clinical emergency, characterized mainly by hematemesis and melena. In severe cases, hemorrhagic shock may even occur, endangering patients’ lives. For older patients at high risk of gastrointestinal bleeding, risk factors such as advanced age, multiple comorbidities, and long-term use of nonsteroidal anti-inflammatory drugs or antiplatelet agents can increase the risk of both initial and recurrent gastrointestinal bleeding[14]. Therefore, reducing rebleeding after discharge and improving patients’ self-management ability may help regulate health behaviors, minimizing the impact of adverse factors on the disease, and promoting a better prognosis.

Chronic disease management is a basic health management service developed to meet the health needs of older adults and improve their quality of life. However, because of the complexity of geriatric diseases, limited medical resources and conditions across different regions, and the lack of standardized chronic disease management protocols, a more standardized and systematic chronic disease management program is needed. The IFSMT identifies risk and protective factors during individual self-management and proposes corresponding strategies to promote changes in patients’ health behaviors and improve their prognosis[15]. Therefore, integrating IFSMT with evidence-based practice and continuous quality improvement can enhance the scientific rigor and practical applicability of chronic disease management.

The present study showed that after intervention, the observation group exhibited significantly higher self-management ability, medication adherence, and health management behaviors than the control group (P < 0.05). These results indicate that an IFSMT-based evidence-based practice and continuous quality improvement model for chronic disease management can effectively improve patients’ self-management ability, standardize their health behaviors, and enhance medication adherence. Rias et al[16] reported that health education based on IFSMT improved self-management ability and reduced diabetes distress in patients with diabetes mellitus. The underlying mechanism may be as follows: The combination of IFSMT and evidence-based practice fully considers the influences of individual, family, and social environmental factors on self-management behaviors in chronic disease care. Through the context dimension, the biopsychosocial characteristics of patients and potential effects of family environment on self-management and health behaviors are evaluated. Based on evidence-based practice and previous studies investigating factors related to the psychological, family, and social functions of patients with gastrointestinal bleeding, a reliable basis is provided for subsequent chronic disease management[17]. In the process dimension, patients and their families receive education on disease knowledge, which improves their understanding of the pathogenesis, risk factors, medication, self-prevention strategies, and warning signs of gastrointestinal bleeding. Compliance recommendations are offered to help patients adjust their lifestyles and establish healthy behaviors[18]. In addition, risk-stratified nursing interventions based on disease severity can enhance disease management and reduce the incidence of gastrointestinal bleeding[19]. Furthermore, professional and comprehensive follow-up management and guidance via internet-based information platforms further standardize health behaviors and strengthen self-management ability[20]. In the outcome dimension, clarifying the impact of health behaviors on clinical outcomes increases treatment confidence and encourages patients to abandon unhealthy lifestyles. Combined with continuous quality improvement, chronic disease management becomes a dynamic and sustained process, which improves the management level for high-risk gastrointestinal bleeding and lowers bleeding risk[21].

After 12 months of follow-up, the rebleeding rate in the observation group was 1.33%, which was significantly lower than the rate of 10.67% in the control group. This finding suggests that the IFSMT-based evidence-based and continuous quality improvement model may reduce post-discharge rebleeding. The mechanism may involve improved lifestyle behaviors, reduced exposure to adverse triggers for gastrointestinal bleeding, and improved self-management and accurate medication use, all of which contribute to a lower risk of rebleeding.

Patients with high-risk gastrointestinal bleeding often experience anxiety, depression, tension, and other negative emotions due to a long disease course and multiple comorbidities. The sudden and severe nature of the disease also leads to varying degrees of illness uncertainty and increased psychological stress. Moreover, insufficient disease-related knowledge and impaired self-management in older patients further increase caregiver burden[22,23]. The present study demonstrated that after the intervention, the observation group had significantly lower negative emotions, illness uncertainty, and family caregiver burden than the control group (P < 0.05). This suggests that the model can alleviate negative emotions, enhance disease-related knowledge, and reduce caregiver burden. During the process dimension of IFSMT, targeted psychological interventions, including counseling, family support, relaxation training, and peer support, help divert negative emotions and strengthen rehabilitation confidence. Health education for family members improves their understanding of the disease and mastery of care skills, thereby relieving caregiver burden and facilitating disease recovery[24,25]. Informal feedback obtained during follow-up suggested that patients and their families perceived improved confidence in disease management and a better understanding of gastrointestinal bleeding prevention strategies after participating in peer support activities and experience-sharing sessions. These observations may help explain the improvement observed in psychological status and self-management outcomes, although further qualitative studies are needed to explore patients’ experiences in depth.

Although all dimensions of illness uncertainty improved significantly after the intervention, the magnitude of improvement varied among the dimensions. Complexity showed a relatively greater improvement, which may be attributed to structured disease education, medication guidance, and risk stratification, all of which directly improved patients’ understanding of disease management. However, unpredictability showed a relatively smaller improvement, possibly because recurrent gastrointestinal bleeding is influenced by multiple uncontrollable factors, including age-related physiological changes, comorbidities, and medication-related risks. Therefore, future interventions should further strengthen individualized risk prediction and early warning strategies. The intervention involved multidisciplinary participation, including physicians, nurses, pharmacists, nutritionists, and psychological counselors. Although this model requires additional healthcare resources, the intervention was designed with risk stratification to improve feasibility. High-intensity follow-up was mainly provided for high-risk patients, whereas lower-risk patients received nurse-led management. Future studies incorporating formal health economic evaluations are needed to determine whether reductions in rebleeding events, hospitalization, and emergency procedures can offset the implementation costs.

Several limitations should be acknowledged in this study. First, this was a single-center randomized controlled study with a relatively limited sample size and a short- to medium-term follow-up period. Although significant improvements were observed after the intervention, the generalizability of these findings to other healthcare settings requires further validation through multicenter studies with larger samples and longer follow-up periods. Second, this study focused on evidence translation and the development of an evidence-based chronic disease management program rather than on a systematic review or formal evidence synthesis. Therefore, although relevant literature was retrieved and integrated to support the intervention design, a formal systematic review, meta-analysis, or evidence grading process was not conducted. Future studies may further strengthen the evidence base through systematic evidence synthesis. Third, the IFSMT-based intervention involved multidisciplinary participation and relatively intensive follow-up, which may require additional healthcare resources. Although the intervention demonstrated clinical benefits, this study did not include a formal health economic evaluation. Future research should assess the cost-effectiveness and implementation feasibility of this model in different clinical environments. Fourth, although informal feedback from patients and family members during follow-up suggested improved confidence and disease awareness, formal qualitative interviews and thematic analyses were not performed. Therefore, future qualitative studies are needed to further explore patients’ experiences and the mechanisms underlying behavioral changes. Fifth, due to the nature of the behavioral intervention, blinding of patients and intervention providers was not feasible. Although efforts were made to reduce measurement bias through standardized assessment procedures, subjective outcomes such as anxiety, depression, and self-management ability may still have been influenced by participants’ perceptions. Finally, medication-related factors may influence the risk of recurrent bleeding. In this study, baseline medication information was collected by major categories, including antiplatelet agents, anticoagulants, and nonsteroidal anti-inflammatory drugs. However, detailed information regarding specific medications, dosages, and medication adjustments, such as aspirin, clopidogrel, warfarin/direct oral anticoagulants, and proton pump inhibitor use, was not fully analyzed, which should be addressed in future studies.

CONCLUSION

The IFSMT-based evidence-based chronic disease management model demonstrated significant improvements in self-management ability, psychological status, medication adherence, illness uncertainty, family caregiver burden, and rebleeding outcomes among older patients at high risk of gastrointestinal bleeding. However, this study was conducted in a single center with a relatively short- to medium-term follow-up period. Further multicenter randomized controlled studies with longer follow-up periods are required to confirm the long-term effectiveness, cost-effectiveness, and feasibility of widespread clinical implementation.