Comparative Evaluation of Health-Related Quality of Life Questionnaires in Patients With Heart Failure Undergoing Cardiac Rehabilitation: A Psychometric Study

The effect of trans-theoretical model stage-matched intervention on medication adherence in hypertensive patients

Introduction

Hypertension is a chronic condition that requires active patient management and awareness of treatment strategies. This study aimed to evaluate the effectiveness of an intervention program grounded in the Transtheoretical Model (TTM) of behavior change for improving treatment adherence among hypertensive patients.

Materials and methods

This study conducted at the Nukan Comprehensive Rural Health Center in Kermanshah, Iran, 120 participants were selected according to specific inclusion criteria. Demographic data and responses to 20 hypertension-related behavior questions were collected via a questionnaire. Participants were categorized into non-adherence (pre-contemplation, contemplation, preparation stages) and adherence categories (action and maintenance stages) based on self-reported medication adherence, with 60 individuals in each group. Each group was then randomly divided into intervention and control subgroups. The educational intervention consisted of four 45 min sessions grounded in TTM constructs regarding to health-related behaviors including Physical activity, salt and oil intake, and fruit and vegetable consumption, and medication adherence. Three months post-intervention, a follow-up questionnaire evaluated the educational impact on treatment adherence. The McNemar test and Chi-square test were utilized to analyze effects across the intervention, control, and pre- and post-intervention groups.

Results

The participants had a mean age of 58.09 years (SD = 11.85). Three months after the intervention, the non-adherence intervention group showed significant progress in transitioning to the action and maintenance stages across all physical activity behaviors, as well as in salt, oil, fruit and vegetable intake, and medication adherence (P < 0.005). In the adherence intervention group, after the intervention, the number of hypertensive patients who fell into the action and maintenance categories according to all lifestyle variables increased, but the change was not significant. Concerning blood pressure, the intervention group had a significant reduction in mean systolic blood pressure (142.88 ± 20.87 vs. 141.00 ± 18.52; p = 0.015), but the decrease in mean diastolic blood pressure was not significant (88.17 ± 10.30 vs. 87.58 ± 9.70; p = 0.154). No significant changes in systolic or diastolic blood pressure were observed in the control or in intervention groups within the adherence category.

Conclusion

This research highlights the potential benefits of applying the TTM to tailor interventions for hypertensive patients with poor treatment adherence, suggesting that such an approach can enhance the efficacy of health education interventions.

Measurement properties of utility-based health-related quality of life measures in cardiac rehabilitation and secondary prevention programs: a systematic review

PURPOSE

To identify utility-based patient-reported outcome measures (PROMs) for assessing health-related quality of life (HRQoL) in cardiac rehabilitation and secondary prevention programs (CR) and appraise existing evidence on their measurement properties. Secondly, to link their items to the International Classification of Functioning Disability and Health (ICF) and the International Consortium of Health Outcome Measures (ICHOM) domains for cardiovascular disease (CVD).

METHODS

Eight databases were searched. The review followed the COSMIN and JBI guidelines for measurement properties systematic reviews and PRISMA 2020 reporting guidelines. Non-experimental and observational empirical studies of patients ≥ 18 years of age with CVD undergoing CR and assessed quality of life (QoL) or HRQoL using utility-based PROMs or one accompanied by health state utilities were included.

RESULTS

Nine PROMs were identified with evidence on measurement properties for three measures: the German translations of SF-12, EQ-5D-5L, and MacNew heart disease HRQoL questionnaire. There was moderate quality evidence for responsiveness and hypothesis testing of the SF-12 and EQ-5D-5L, and high-quality evidence for responsiveness and hypothesis testing for the MacNew. All items of SF-12 and EQ-5D were linked to ICF categories, but four items of the MacNew were not classified or defined. All the PROM domains were mapped onto similar constructs from the ICHOM global sets.

CONCLUSION

Three utility-based PROMs validated in CR were identified: the German versions of the EQ-5D and SF-12 and the MacNew questionnaire. These PROMs are linked to a breadth of ICF categories and all ICHOM global sets. Additional validation studies of PROMs in CR are required.

The effect of health literacy intervention on adherence to medication of uncontrolled hypertensive patients using the M-health

BACKGROUND

Given that patients' medication adherence is regarded as the major part of disease control and improving health literacy can be effective in promoting adherence to healthy behaviors, the present study aimed to investigate the effect of health literacy intervention based on the medication adherence among uncontrolled hypertensive patients using mobile health (M-health).

METHODS

An interventional study with a quasi-experimental design, was conducted on 118 uncontrolled hypertensive patients. Participants were randomly divided into the intervention (n = 59) and control (n = 59) groups using blocked randomization. In the intervention group, a mobile health (M-health) program was designed using programmed instruction to improve patients' health literacy over a period of 3 months. Data was collected by administering health literacy and medication adherence questionnaires to participants before and after the intervention. The analysis involved using the independent sample t-test to compare the variables before and after the study.

RESULTS

Before the intervention, the total score of health literacy was 33.34 and 33.14 in the intervention and control groups, respectively. After the intervention, it increased to 40.36 and 34.20 in the intervention and control groups, respectively, which was statistically significant in the intervention group (p = 0.01). Moreover, the medication adherence score of the intervention group significantly increased after the intervention. Both systolic and diastolic blood pressure decreased in the intervention group. However, it should be noted that the decrease in systolic blood pressure by 148.98 was statistically significant, while the decrease observed in diastolic blood pressure in the intervention group was not statistically significant (p = 0.08).

CONCLUSION

The application of programmed instruction through M-Health has shown a positive effect on the health literacy of uncontrolled hypertensive patients. In addition to detecting and treating patients, it is important to prioritize the improvement of health literacy in terms of medication adherence and the adoption of healthy behaviors.

Relationship of spiritual wellbeing with life expectancy and quality of life for patients living with heart failure

Aim: Spirituality is a crucial dimension in human health. However, it is often overlooked in patients with heart failure (HF) in Iran. Thus, the purpose of this study was to determine the relationship between spiritual wellbeing, life expectancy and quality-of-life (QOL) in patients with HF. Methods: This cross-sectional study was performed with 150 HF patients, who were enrolled through convenience sampling. Data were collected using a questionnaire comprising four parts: the Minnesota Living with Heart Failure Questionnaire, Schneider's life expectancy instrument, Ellison's and Paulotzin's (1982) Spiritual Well-Being Scale, and a demographic checklist. SPSS software was used for data analysis. Results: In this study, mean and standard deviation of QOL, life expectancy and spiritual wellbeing were 41.82±19.17, 30.20±4.58 and 87.80±5.28 respectively. There was a significant relationship between spiritual wellbeing and quality of life (r=-0.633, P<0.001) and also life expectancy (r=0.544, P<0.001). Quality of life and life expectancy were significantly higher in men than in women. Linear regression tests showed that the existential and religious dimensions of spirituality could influence 44.9% of the QOL variance (F=54.54, P<0.001) and increased values of existential spirituality would improve QOL by an average of 3.45 units. Improving life expectancy also raised QOL by 14.0% (F=21.26, P<0.001). This study also demonstrated that life expectancy is impacted by spiritual health, with a variance of 34.2%, in which the role of existential-spiritual health is of particular significance (t=7.10, P<0.001). Conclusion: The results revealed that spiritual wellbeing, especially the existential type, enhances life expectancy and quality-of-life among HF patients. Therefore, it is recommended that healthcare professionals design a comprehensive and supportive care model for the promotion of spiritual wellbeing in HF patients.

Validation and Psychometric Properties of the Minnesota Living With Heart Failure Questionnaire in Individuals With Coronary Artery Disease in Lithuania

BACKGROUND

Health-related quality of life (HRQoL) is known to be impaired in individuals with coronary artery disease (CAD), especially in those after a recent acute coronary syndrome (ACS). Heart failure (HF) is a common burden in this population that significantly contributes to worsening HRQoL. To accurately measure the level of HRQoL in individuals with CAD after ACS, disease-specific scales, such as the Minnesota living with heart failure questionnaire (MLHFQ), are recommended. Nevertheless, to date, there has not been a study that would comprehensively evaluate the psychometric properties of the MLHFQ in a large sample of individuals with CAD after ACS. The debate regarding the internal structure of MLHFQ is also still present. Hence, this study aimed to translate the MLHFQ and evaluate its internal structure, reliability/precision, and validity in individuals with CAD following ACS in Lithuania.

METHODS

In the cross-sectional study, 1,083 participants (70% men, age M = 58, SD = 9) were evaluated for sociodemographic and clinical characteristics. HRQoL was measured using the MLHFQ and the Short Form-36 health survey (SF-36). In addition, exercise capacity (EC) was also evaluated in the study patients, using a standardized computer-driven bicycle ergometer.

RESULTS

The internal consistency of the MLHFQ subscales (0.79-0.88) was found to be good. Confirmatory factor analysis (CFA) provided the support for the three-factor model ("physical domain," "social domain," and "emotional domain") of the MLHFQ and showed acceptable fit [comparative fit indices (CFI) = 0.894; goodness-of-fit (GFI) = 0.898; non-normal fit index (NFI) = 0.879, and root mean square error of approximation (RMSEA) = 0.073]. Regarding convergent evidence, significant associations were found between the MLHFQ domains and the SF-36 domains and EC (r's range 0.11-0.58).

CONCLUSION

The current study completed cultural validation and provided further information on the psychometric characteristics of the MLHFQ in Lithuania, suggesting MLHFQ as a valid and reliable instrument to measure HRQoL. The Lithuanian version of MLHFQ is best described by a three-factor solution, measuring physical, social, and emotional dimensions of HRQoL among individuals with CAD following ACS.

Predictors of long-term HRQOL following cardiac surgery: a 5-year follow-up study

Background

The study aimed to evaluate the long-term change of health-related quality of life (HRQOL) and to identify predictors of HRQOL 5 years after cardiac surgery.

Methods

Consecutive adult patients, undergoing elective cardiac surgery were enrolled in the study. HRQOL was measured using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire before and 5-years after cardiac surgery. A multivariate latent change modeling approach was used for data analysis.

Results

210 participants (30.5% female) were reached at 5-year follow-up and included in final data analysis. The study revealed, after controlling for gender effects, a significant long-term positive change, in physical functioning (PF, M_slope = 19.79, p < 0.001), social functioning (SF, M_slope = 17.27, p < 0.001), vitality (VT, M_slope = 6.309, p < 0.001) and mental health (MH, M_slope = 8.40, p < .001) in the total sample. Lower education was associated with an increase in PF (M_slope = 24.09, p < 0.001) and VT (M_slope = 8.39, p < 0.001), more complicated surgery (other than the coronary artery bypass graft (CABG) predicted increase in general health (GH, M_slope = 6.76, p = 0.005). Arrhythmia was a significant predictor for lower pre- and post-operative VT and SF.

Conclusions

Overall HRQOL in our sample improved from baseline to five years postoperatively. Further studies including larger patient groups are needed to confirm these findings.

Psychometric Properties of the Persian Version of Cardiovascular Management Self-efficacy Scale

BACKGROUND

Self-efficacy plays a major role in the management of cardiovascular disease (CVD). The original Cardiovascular Management Self-efficacy Scale (CMSS) was developed in 2016 in Italian patients with CVD; however, no such scale exists for Iranian patients with CVD.

OBJECTIVE

We translated the CMSS into Persian and assessed its validity, reliability, and psychometric properties in Iranian patients with CVD.

METHODS

This study was conducted for 4 months in 2017 on a group of consenting patients with CVD (N = 363) recruited from a cardiovascular hospital in Kermanshah, Iran. The reliability of the Persian CMSS was evaluated. We assessed validity, including face, content, construct, convergent, divergent, and discriminate validity, using the General Self-efficacy Scale, the Hospital Anxiety and Depression Scale, and the 36-item Short Form Health Survey Scale. Known-group validity was assessed among patients with high blood pressure.

RESULTS

The Persian CMSS had acceptable face and content validity. No floor or ceiling effects were found for the total scale. Cronbach α was calculated as .68. Test-retest reliability was confirmed by intraclass correlation coefficient (ICC1,3 = 0.98, P < .001). Using exploratory factor analysis, 3 subscales were identified, similar to the original version. Significant correlations were found between the Persian CMSS and both the General Self-efficacy Scale (r = 0.94, P < .001) and Hospital Anxiety and Depression Scale (r = -0.35, P < .05). Self-efficacy measured using the Persian CMSS was statistically different between 2 levels of patients' health status (P < .05). Patients with hypertension had a lower level of self-efficacy than those in the healthy group (P < .05).

CONCLUSIONS

The Persian version of CMSS provides a practical, reliable, and valid scale for evaluating self-efficacy in the clinical management of Persian Iranian patients with CVD.

Quality of life and outcomes in heart failure patients with ejection fractions in different ranges

AIMS

Guidelines divide patients with heart failure (HF) into 3 distinct groups based on left ventricular ejection fraction (LVEF) We used the Minnesota Living with Heart Failure Questionnaire (MLHFQ) to quantify the health-related quality of life in patients with HF.

METHODS

Patients were stratified into three cohorts: preserved LVEF (>50%), mid-range LVEF (40-49%) and reduced LVEF (<40%). The MLHFQ scores were evaluated using one-way ANOVA, and differences were observed among the groups. The association of New York Heart Association (NYHA) class with the physical scores was analyzed by Spearman's correlation analysis. The predictive utility of the total MLHFQ scores was assessed with Kaplan-Meier curves for death and HF-related hospitalization. The Cox proportional hazards model was used to identify the risk factors for prognosis. Internal reliability was assessed with Cronbach's α.

RESULTS

There were significant differences in the total MLHFQ scores and the MLHFQ subscale scores among the three groups (p<0.05). MLHFQ domains demonstrated high internal consistency among the three groups (Cronbach's α = 0.92, 0.96 and 0.93). The MLHFQ physical subscale scores were significantly associated with NYHA class in HFrEF (r = 0.59, p<0.001) and HFmrEF patients (r = 0.537, p<0.001). The survival analysis indicated that there was a significant difference among the three groups regarding high MLHFQ scores (p = 0.038). In the groups with low MLHFQ scores, the HFmrEF group exhibited significantly increased rates of death and HF-related hospitalization compared with the HFpEF group (p = 0.035).

CONCLUSIONS

The features and clinical outcomes varied among heart failure patients with different EF values. The MLHFQ appears to be a valid and reliable measurement of health status and offers excellent prognostic ability.

The effect of an educational program based on Roy's adaptation model on the quality of life of patients suffering from heart failure: A clinical trial study

AIM

Heart failure is a progressive, debilitating disease with exacerbated physical and psychological symptoms that reduces the quality of life of patients. Nursing intervention based on nursing theories could help in the adaptation of patients to the disease and improving quality of life. The aim of this study was to determine the effect of an educational program based on Roy's adaptation model on the quality of life of patients with heart failure.

METHODS AND MATERIAL

In this randomized controlled trial, 76 patients with heart failure were allocated to either the intervention or control group through a blocked randomization method. The data were collected between May and October 2017. The intervention group received oral and written educational programs for 4 weeks. Minnesota quality-of-life questionnaire and Roy's adaptation model-based evaluation form was completed at the beginning of the trial, and 1 month after the completion of the study.

RESULTS

Intervention patients showed statistically significantly improved scores on the physiologic, role function, independence-interdependence dimensions and the total score of Roy's adaptation model over time compared with control patients (p < .05). The mean score of all of the three quality-of-life dimensions and total score of quality of life increased significantly (p < .05).

CONCLUSION

The study results help nursing staff detect the stimuli and the behaviors of patients with heart failure. Roy's adaptation model can be used as a standard practice to increase adaptation to the disease and improving quality of life.

Outcomes of spironolactone treatment in patients in Northeast China suffering from heart failure with mid-range ejection fraction

AIM

The treatment effects of spironolactone on heart failure with reduced (HFrEF LVEF <40%) and preserved (HFpEF LVEF ≥50%) ejection fraction are well characterized. It is not clear whether heart failure patients with mid-range ejection fraction (HFmrEF, LVEF 40-49%) benefit from spironolactone. The present study aims to evaluate the efficacy of spironolactone in HFmrEF patients.

METHOD

This study compared a high dosage of spironolactone (50 mg daily), a low dosage of spironolactone (25 mg daily), and an untreated group for the prevention of major adverse cardiovascular events (MACE) in 279 patients admitted to hospital diagnosed with HFmrEF.

RESULTS

With a mean follow-up duration of 1 year, the death and HF-rehospitalization rate demonstrated significantly lower incidence in those taking spironolactone, compared with the untreated group (21.3% vs 34.5%, p = .014, respectively). Further analysis showed no difference between two spironolactone groups (21.8% vs 20.7%, p = .861). Kaplan-Meier analysis of outcome-free survival illustrated a significant difference in survival rate among three groups (log-rank testing, p = .045). Compared with the baseline level, patients receiving 25 mg spironolactone had a lower physical score (p < .05) at 1-year follow-up. MLHFQ total scores in the two spironolactone groups markedly improved compared with the untreated group (p < .001); similar results were observed in the MLHFQ physical scores (p = .025, .001, respectively) and emotional sub-scale (p = .023, .011, respectively); however, paired comparison between the two spironolactone groups showed no difference.

CONCLUSIONS

In patients with HFmrEF, treatment with spironolactone significantly reduced the incidence of the primary composite outcomes of all-cause death, and rehospitalization for the management of heart failure compared with placebo, and a high dosage of spironolactone did not show trends of reduction in MACE.

Responsiveness and minimal clinically important difference of the Minnesota living with heart failure questionnaire

Background

The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is one of the most widely used health-related quality of life questionnaires for patients with heart failure (HF). The objective of the present study was to explore the responsiveness of the MLHFQ by estimating the minimal detectable change (MDC) and the minimal clinically important difference (MCID) in Spain.

Methods

Patients hospitalized for HF in the participating hospitals completed the MLHFQ at baseline and 6 months, plus anchor questions at 6 months. To study responsiveness, patients were classified as having “improved”, remained “the same” or “worsened”, using anchor questions. We used the standardized effect size (SES), and standardized response mean (SRM) to measure the magnitude of the changes scores and calculate the MDC and MCID.

Results

Overall, 1211 patients completed the baseline and follow-up questionnaires 6 months after discharge. The mean changes in all MLHFQ domains followed a trend (P < 0.0001) with larger gains in quality of life among patients classified as “improved”, smaller gains among those classified as “the same”, and losses among those classified as “worsened”. The SES and SRM responsiveness parameters in the “improved” group were ≥ 0.80 on nearly all scales. Among patients classified as “worsened”, effect sizes were < 0.40, while among patients classified as “the same”, the values ranged from 0.24 to 0.52. The MDC ranged from 7.27 to 16.96. The MCID based on patients whose response to the anchor question was “somewhat better”, ranged from 3.59 to 19.14 points.

Conclusions

All of these results suggest that all domains of the MLHFQ have a good sensitivity to change in the population studied.

The impact of heart rate on patients diagnosed with heart failure with mid-range ejection fraction

OBJECTIVE

The relationship between prognosis and heart rate remains unclear among patients diagnosed with heart failure with mid-range ejection fraction (HFmrEF). The aim of the present study was to assess the effect of heart rate in this group of patients.

METHODS

Of the 197 patients diagnosed with HFmrEF, 92 had a heart rate <70 beats/min (bpm), and 105 had a heart rate ≥70 bpm. We analyzed the outcomes including all-cause death and HF-related hospitalization and evaluated the quality of life.

RESULTS

The outcome demonstrated a lower incidence in patients with heart rate <70 bpm. The outcome-free survival illustrated significant difference in survival rate (p=0.045). The Minnesota Living with Heart Failure Questionnaire total scores and physical subscale in the lower heart rate group decreased compared with the heart rate ≥70 bpm group (p=0.048 and p=0.03, respectively). In the following analysis of patients with sinus rhythm, beta blockers showed great positive effects on patients with heart rate <70 bpm (p=0.046), as for the quality of life in patients with beta blocker, heart rate <70 bpm showed lower total and physical scores (p=0.025 and p=0.017, respectively).

CONCLUSION

Our results showed that heart rate is an important prognostic factor in patients with HFmrEF. Patients with heart rate <70 bpm was related with a lower risk of outcomes and better quality of life. Beta blockers reduced the outcome rate in patients with sinus rhythm.

2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.