Differences in Education, Knowledge, Self-Management Activities, and Health Outcomes for Patients With Heart Failure Cared for Under the Chronic Disease Model: The Improving Chronic Illness Care Evaluation

Investigating the Needs of Caregivers of Patients Suffering from Chronic Diseases: A Mixed-Method Study

Objectives

The objective of this study was to investigate the needs of carers of patients suffering from chronic diseases.

Material and Methods

The present study is a mixed approach, quantitative and qualitative. The study population consisted of 560 caregivers of patients with chronic diseases. The data collection was done with an improvised needs survey questionnaire, which included 57 questions. The questionnaire surveyed carers 'financial needs, social needs, psychological needs, and patients' education needs. The Cronbach-a index of the Patient Needs Survey was 0.956 and that of caregivers was 0.965. Carers' burden of care was assessed with The Zarit Burden Interview scale. The statistical analysis of the data was done with the statistical program IBM SPSS for Windows version 26.0.

Results

The main diseases of the patients were chronic renal failure (22.6%), multiple sclerosis (19%), cancer (19%), diabetes mellitus (7.1%), dementia (6%), and chronic obstructive pulmonary disease (6%). The majority of patients (82.1%) had health problems for more than 24 months. Caregivers provided 12.5 ± 8.3 h of daycare and cared for patients for more than 24 months (73.2%). Caregivers seek information from health professionals (4.41 ± 1.2), need more information (4.11 ± 1.4), feel stressed about the role of caregiver (3.91 ± 1.3), time available for vacation is limited (3.89 ± 1.4), time available for entertainment is limited (3.80 ± 1.3) and they feel intimidated with the role of carer (3.76 ± 1.3). The caregivers' charge was 42.4 ± 19.6. Most caregivers reported moderate to severe burdens.

Conclusion

Caregivers experience a lack of clear and comprehensible information about the treatment that caring patients receive, as well as a lack of ongoing care from health professionals.

Self-management on heart failure: A meta-analysis

BACKGROUND AND AIMS

Heart failure (HF) is a severe public health problem all over the World. Self-management is an effective method to progress self-care ability. However, the role of self-management in heart failure has not been thoroughly elucidated.

METHODS

The research articles related to heart failure were searched by the PubMed, Embase, Cochrane databases, and China National Knowledge Database on articles published through March 2020. The average 95% of confidence intervals (CIs) were used to calculate using random-effects or fixed-effects. Review Manager (version 5.2) was adopted for meta-analysis, sensitivity analysis, and bias analysis.

RESULTS

Eight (8) eligible studies with 1707 patients with HF were included in this analysis. In the Meta-analysis showed significant differences for Self-management (SM) groups in Dutch Heart Failure Knowledge Scale (DHFK) (MD = 1.36, 95%CI [-0.03, 2.75], P = 0.04; I² = 83%), in Self-Care of Heart Failure Index (SCHFI) (MD = 5.51, 95%CI [0.62, 10.40], P = 0.03; I² = 70%), and in Self-Efficacy for Managing Chronic Disease Scale (SEMCDI) (I² = 47%, Z = 5.43, P of over effect < 0.0001) than control groups. One bias is detected as attrition bias, and another one is reporting bias. Sensitivity analysis satisfied the stability of the results.

CONCLUSION

Self-management was associated with significant outcomes in patients with HF through knowledge, attitude, and practice (KAP).

Which Matters for Medical Utilization Equity under Universal Coverage: Insurance System, Region or SES

BACKGROUND

China has achieved universal coverage, with a higher rate of 95% medical insurance. However, huge inequalities are concealed under universal coverage. This article aims to explore the medical insurance utilization disparities over different insurance schemes, regions, and socioeconomic statuses (SES).

METHODS

This study was based on an open-access dataset in 2010, 2012, 2014, and 2016. A longitudinal analysis and separate logistic models were performed.

RESULTS

Urban Employee Basic Medical Insurance (UEBMI) members had an outstanding advantage in specialist visiting over those on the Urban Resident Basic Medical Insurance Scheme (URBMI) (OR = 0.607, p < 0.001) and New Cooperative Medical System (NCMS) (OR = 0.262, p < 0.001). However, in terms of a doctor visiting if a person is sick, the odds of patients in the NCMS receiving a visit were 55.1% ((OR = 1.551; p < 0.05) higher than those on the UEBMI. Compared with west China, the odds of those in the north-east and east were 2.1% (p > 0.05) and 97.2% (OR = 1.972; p < 0.001) higher for seeking medical treatment if sick, and 10.8% (OR = 0.892; p < 0.01) and 42.7% lower (OR = 0.573; p < 0.001) for a specialist visiting. In terms of SES, for each unit of increase in the Standard International Occupational Prestige Scale (SIOPS), the odds of seeking medical treatment decreased by 4.3% (OR = 0.958; p < 0.05), and the odds of a specialist visiting increased by 17.1% (OR = 1.171; p < 0.001) for each unit of the annual income logarithm.

CONCLUSIONS

NCMS members and residents in west China were in a disadvantage status in terms of access to specialists, though had a higher probability of medical care if sick. SES variables were positively correlated with a specialist visiting consistently. We suggest a further focus on healthcare quality in the west and rural areas.

Symptom perception in heart failure - Interventions and outcomes: A scoping review

BACKGROUND

Symptom perception in heart failure has recently been described as essential in the self-care process bridging self-care maintenance and self-care management. Accordingly, symptom perception appears to be critical for improving patient outcomes such as decreased hospital readmission and increased survival.

OBJECTIVES

To explore what interventions have been reported on heart failure symptom perception and to describe outcomes responsive to symptom perception.

DESIGN

We conducted a scoping review using PRISMA Extension for Scoping Reviews.

DATA SOURCES

Structured searches of Medline, PubMed, Embase, CINAHL, PsychINFO, Web of Science, Cochrane, Joanna Briggs Institute and Grey literature databases.

REVIEW METHODS

Two authors independently screened references for eligibility. Eligible articles were written in English, French, German, Swedish, Italian or Spanish and concerned symptom perception in adults with heart failure. Data were extracted and charted in tables by three reviewers. Results were narratively summarized.

RESULTS

We identified 99 eligible studies from 3055 references. Seven interventional studies targeted symptom perception as the single intervention component. Mixed results have been found: while some reported decreased symptom frequency, intensity and distress, enhanced health-related quality of life, improved heart failure self-care maintenance and management as well as a greater ability to mention heart failure symptoms, others found more contacts with healthcare providers or no impact on anxiety, heart failure self-care nor a number of diary reported symptoms. Additional interventional studies included symptom perception as one component of a multi-faceted intervention. Outcomes responsive to symptom perception were improved general and physical health, decreased mortality, heart failure decompensation, as hospital/emergency visits, shorter delays in seeking care, more consistent weight monitoring, improved symptom recognition as well as self-care management, decreased hospital length of stay and decreased costs.

CONCLUSIONS

While many studies allowed to map a comprehensive overview of interventions supporting symptom perception in heart failure as well as responsiveness to outcomes, only a few single component intervention studies targeting symptom perception have been reported and study designs preclude assessing intervention effectiveness. With regard to multiple component interventions, the specific impact of symptom perception interventions on outcomes remains uncertain to date. Well-designed studies are needed to test the effectiveness of symptom perception interventions and to elucidate relationships with outcomes.

Long-term benefits of education by emergency care nurses at discharge of patients with atrial fibrillation

INTRODUCTION AND OBJECTIVE

Health education improves the prognosis of many diseases. A previous study in patients with atrial fibrillation (AF) showed that an educational intervention by nurses at discharge from the emergency room (ER) decreased AF-related complications at 3-month follow-up. Our objective was to determine whether this intervention had a long-term effect.

PATIENTS AND METHODS

A prospective study assessed the outcomes of an intervention carried out upon discharge from the ER. Patients with a diagnosis of AF were randomized into two groups: the intervention group and the control group. The intervention consisted of a basic explanation about the arrhythmia and its treatment, precautions and warning signs, a training to take their pulse, and an individualized informational leaflet. At one year of follow-up, the clinical records for all participants were reviewed. The primary variable was the combined endpoint of AF-related or treatment-related complications and death.

RESULTS

The study included 240 patients (116 intervention and 124 control), mean age 76.1±10.9years. The primary variable was significantly lower in the intervention group (31.9% vs 48.4%; p=0.005).

CONCLUSION

Education by ER nurses at patient discharge helped to decrease AF-related complications at one year of follow-up.

Predicting adherence to use of remote health monitoring systems in a cohort of patients with chronic heart failure

BACKGROUND

It is unclear whether subgroups of patients may benefit from remote monitoring systems (RMS) and what user characteristics and contextual factors determine effective use of RMS in patients with heart failure (HF).

OBJECTIVE

The study was conducted to determine whether certain user characteristics (i.e. personal and clinical variables) predict use of RMS using advanced machine learning software algorithms in patients with HF.

METHODS

This pilot study was a single-arm experimental study with a pre- (baseline) and post- (3 months) design; data from the baseline measures were used for the current data analyses. Sixteen patients provided consent; only 7 patients (mean age 65.8 ± 6.1, range 58-83) accessed the RMS and transmitted daily data (e.g. weight, blood pressure) as instructed during the 12 week study duration.

RESULTS

Baseline demographic and clinical characteristics of users and non-users were comparable for a majority of factors. However, users were more likely to have no HF specialty based care or an automatic internal cardioverter defibrillator. The precision accuracy of decision tree, multilayer perceptron (MLP) and k-Nearest Neighbor (k-NN) classifiers for predicting access to RMS was 87.5%, 90.3%, and 94.5% respectively.

CONCLUSION

Our preliminary data show that a small set of baseline attributes is sufficient to predict subgroups of patients who had a higher likelihood of using RMS. While our findings shed light on potential end-users more likely to benefit from RMS-based interventions, additional research in a larger sample is warranted to explicate the impact of user characteristics on actual use of these technologies.

Effect of Health Literacy on Quality of Life amongst Patients with Ischaemic Heart Disease in Australian General Practice

Background

Appropriate understanding of health information by patients with cardiovascular disease (CVD) is fundamental for better management of risk factors and improved morbidity, which can also benefit their quality of life.

Objectives

To assess the relationship between health literacy and health-related quality of life (HRQoL) in patients with ischaemic heart disease (IHD), and to investigate the role of sociodemographic and clinical variables as possible confounders.

Methods

Cross-sectional study of patients with IHD recruited from a stratified sample of general practices in two Australian states (Queensland and South Australia) between 2007 and 2009. Health literacy was measured using a validated questionnaire and classified as inadequate, marginal, or adequate. Physical and mental components of HRQoL were assessed using the Medical Outcomes Study Short Form (SF12) questionnaire. Analyses were adjusted for confounders (sociodemographic variables, clinical history of IHD, number of CVD comorbidities, and CVD risk factors) using multiple linear regression.

Results

A total sample of 587 patients with IHD (mean age 72.0±8.4 years) was evaluated: 76.8% males, 84.2% retired or pensioner, and 51.4% with up to secondary educational level. Health literacy showed a mean of 39.6±6.7 points, with 14.3% (95%CI 11.8–17.3) classified as inadequate. Scores of the physical component of HRQoL were 39.6 (95%CI 37.1–42.1), 42.1 (95%CI 40.8–43.3) and 44.8 (95%CI 43.3–46.2) for inadequate, marginal, and adequate health literacy, respectively (p-value for trend = 0.001). This association persisted after adjustment for confounders. Health literacy was not associated with the mental component of HRQoL (p-value = 0.482). Advanced age, lower educational level, disadvantaged socioeconomic position, and a larger number of CVD comorbidities adversely affected both, health literacy and HRQoL.

Conclusion

Inadequate health literacy is a contributing factor to poor physical functioning in patients with IHD. Increasing health literacy may improve HRQoL and reduce the impact of IHD among patients with this chronic CVD.

The association between regular symptom monitoring and self-care management in patients with heart failure

BACKGROUND

Symptom monitoring is considered the first step toward self-care management (actions to manage altered symptom status) to avert worsening heart failure (HF). However, empirical evidence demonstrating that symptom monitoring leads to adequate self-care management is lacking. We examined the relationship of adherence to regular symptom monitoring with adequate self-care management in HF patients.

METHODS AND RESULTS

A total of 311 HF patients (60 years, 35% women) were divided into 3 groups by adherence to 2 symptom monitoring behaviors (monitoring daily weights and lower extremity edema). Patients who were adherent to both symptom monitoring behaviors formed the adherent group (15.1%). Those adherent to either of the symptom monitoring behaviors formed the partially adherent group (28.9%). Those adherent to neither of the symptom monitoring behaviors formed the nonadherent group (56.0%). The adjusted odds of performing adequate self-care management were increased by 225% (95% confidence interval, 1.13-4.48) and 344% (95% confidence interval, 1.55-7.62) for the partially adherent and adherent symptom monitoring groups, respectively, compared with the nonadherent group.

CONCLUSION

Adequacy of self-care management was predicted by adherence to symptom monitoring behaviors. This finding suggests that regular symptom monitoring facilitates performance of adequate self-care management, which may contribute to a decrease in preventable hospitalizations in HF.

Factors associated with perceived control and the relationship to quality of life in patients with heart failure

BACKGROUND AND PURPOSE

Health-related quality of life (HRQOL) is as important as survival to patients with heart failure (HF). Perceptions of loss of control are common in HF and negatively affect HRQOL. Knowledge of modifiable factors associated with perceived control could guide the development of interventions to improve perceived control and thus HRQOL. Accordingly, this study examined factors related to perceived control and the relationship between perceived control and HRQOL.

METHODS

Patients (N=232, mean age 61 ± 12, 67% male, 78% Caucasian) provided data on HRQOL (Minnesota Living with Heart Failure questionnaire), perceived control (Control Attitudes Scale-Revised), and factors possibly associated with perceived control (knowledge and barriers (Heart Failure Knowledge and Barriers to Adherence Scale), attitudes (Dietary Sodium Restriction Questionnaire), and social support (Multidimensional Scale of Perceived Social Support)). Patients also provided data on depressive symptoms, which were a covariate of HRQOL. Hierarchical multiple regression analysis was used to analyze the data.

RESULTS

Fewer barriers to following a low sodium diet, more positive attitudes toward following a low sodium diet, and better social support were related to higher perceived control (F=7.54, R(2)=0.17, p<0.001). Perceived control was independently associated with HRQOL, controlling for depressive symptoms, New York Heart Association functional class, age, gender, and all variables possibly associated with perceived control (F=29.67, R(2)=0.55, p<0.001).

CONCLUSIONS

Interventions targeting attitudes and barriers to a low sodium diet and social support may improve perceived control and, in turn, HRQOL.

Factors Associated with Women's Chronic Disease Management: Associations of Healthcare Frustrations, Physician Support, and Self-Care Needs

Previous research emphasizes the importance of reducing healthcare frustrations and enhancing physician supports to help patients engage in recommended healthcare regimens. However, less is known about how these factors are associated with aging women's knowledge about self-care behavior. This study examined the sociodemographics, health indicators, healthcare-related frustrations, and perceptions of physician support associated with middle-aged and older adult females' self-reported need for help to learn how to take better care of their health. Data were analyzed from 287 females with one or more chronic conditions who completed The National Council on Aging (NCOA) Chronic Care Survey. A logistic regression model was developed. Women who were non-White (OR = 2.26, P = 0.049) were more likely to need help learning how to better manage their health. Those who had some college education or more (OR = 0.55, P = 0.044) and lower healthcare-related frustrations (OR = 0.44, P = 0.017) and perceived to have more physician support (OR = 0.49, P = 0.033) were less likely to need help learning how to better manage their health. Findings can inform the planning, implementation, assessment, and dissemination of evidence-based self-management programs for middle-aged and older women within and outside of clinical settings.

Understanding the components of quality improvement collaboratives: a systematic literature review

CONTEXT

In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence-based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level.

METHODS

A systematic search of five major health care databases generated 294 unique articles, twenty-four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi-experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative.

FINDINGS

We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in-person learning sessions, plan-do-study-act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient-level findings were less robust.

CONCLUSIONS

Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient- and provider-level outcomes.

Understanding the components of quality improvement collaboratives: a systematic literature review

CONTEXT

In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence-based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level.

METHODS

A systematic search of five major health care databases generated 294 unique articles, twenty-four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi-experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative.

FINDINGS

We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in-person learning sessions, plan-do-study-act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient-level findings were less robust.

CONCLUSIONS

Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient- and provider-level outcomes.

Effectiveness of an educational program in nursing in the self-care of patients with heart failure: randomized controlled trial

Unblinded randomized controlled clinical trial to evaluate the effectiveness of an educational program in nursing (educational meetings, home visits, telenursing and a printed book) in the improvement of self-care behaviors in patients with heart failure was evaluated. Thirty-three people participated in the intervention group and thirty in the control group. At the beginning and at the end of the study (ninth month), Nancy Artinian's Heart Failure Self-care Behaviors Scale was applied to assess the level of self-care. 66.0% of the intervention group versus 26.6% of the control group improved the self-care score by at least 20% (p<0.001). The Number Needed to Treat was 2.5. The findings suggest that the educational intervention has beneficial effects on the self-care behaviors of people with heart failure.

Patient-reported selective adherence to heart failure self-care recommendations: a prospective cohort study: the Atlanta Cardiomyopathy Consortium

Simultaneous adherence with multiple self-care instructions among heart failure (HF) patients is not well described. Patient-reported adherence to 8 recommendations related to exercise, alcohol, medications, smoking, diet, weight, and symptoms was assessed among 308 HF patients using the Medical Outcomes Study Specific Adherence Scale questionnaire (0="never" to 5="always," maximum score=40). A baseline cumulative score of ≥32/40 (average ≥80%) defined good adherence. Clinical events (death/transplantation/ventricular assist device), resource utilization, functional capacity (6-minute walk distance), and health status (Kansas City Cardiomyopathy Questionnaire [KCCQ]) were compared among patients with and without good adherence. The mean follow-up was 2.0±1.0 years, and adherence ranged from 26.3% (exercise) to 89.9% (medications). A cumulative score indicating good adherence was reported by 35.7%, whereas good adherence with every behavior was reported by 9.1% of patients. Good adherence was associated with fewer hospitalizations (all-cause 87.8 vs 107.6; P=.018; HF 29.6 vs 43.8; P=.007) and hospitalized days (all-cause 422 vs 465; P=.015; HF 228 vs 282; P<.001) per 100-person-years and better health status (KCCQ overall score 70.1±24.6 vs 63.8±22.8; P=.011). Adherence was not associated with clinical events or functional capacity. Patient-reported adherence with HF self-care recommendations is alarmingly low and selective. Good adherence was associated with lower resource utilization and better health status.

Self-management education and support in chronic disease management

With the changing health care environment, prevalence of chronic health conditions, and burgeoning challenges of health literacy, obesity, and homelessness, self-management support provides an opportunity for clinicians to enhance effectiveness and, at the same time, to engage patients to participate in managing their own personal care. This article reviews the differences between patient education and self-management and describes easy-to-use strategies that foster patient self-management and can be used by health care providers in the medical setting. It also highlights the importance of linking patients to nonmedical programs and services in the community.

Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of a randomized controlled trial

OBJECTIVE

To examine the changes in performance on heart failure knowledge assessments administered before and after discharge education.

METHODS

We conducted a randomized controlled trial comparing the effects of a 1-h, one-on-one teaching session with a nurse educator to the standard discharge process in patients with systolic heart failure. Patients completed a 30 point heart failure knowledge questionnaire (HFKQ) prior to and 3 months after the education intervention.

RESULTS

Patients randomized to the nurse education intervention (n=113) demonstrated significantly higher total HFKQ score increases compared to patients receiving the standard discharge process (n=114) (median, IQR 1, 0 to 4 vs 0, -2 to 2, p=0.007). Patients experiencing death or rehospitalization in the subsequent 6 months were found to have significantly lower HFKQ scores (10, 7 to 12 vs 11, 8 to 13, p=0.002) compared to patients without a clinical event.

CONCLUSION

Heart failure nurse education at the time of hospital discharge results in improved patient knowledge and reduced risk of readmission.

PRACTICE IMPLICATIONS

Health care personnel should encourage education sessions for heart failure patients. Resources possibly need to be allocated for nurse led education sessions in heart failure patients as it improves outcomes and knowledge.

Factors associated with delayed care-seeking in hospitalized patients with heart failure

OBJECTIVE

This study sought to evaluate the contributions of symptom recognition and clinical factors to delays in care-seeking.

METHODS

A descriptive correlational study design was used to study 75 patients (mean age, 74.7 years; SD, 10.86 years; range, 40 to 96 years) admitted to a tertiary-care medical center with recurrent symptoms (New York Heart Association classes 2 to 4). The sample was 52% male and 85.3% white. The Heart Failure Somatic Perception Scale (HFSPS) was used to examine symptoms, and additional data were collected on physiologic, social, and demographic factors.

RESULTS

The mean HFSPS score was 37.52 (range, 2 to 74; possible range, 0 to 90). Subjects reported 2 to 16 out of 18 possible symptoms. Durations of individual symptoms ranged from 5 minutes to 8 years, with individual patients describing a variety of symptom combinations and multiple time frames, depending on the specific symptom. Most subjects (80%) reported a mixture of acute and chronic symptoms. A pattern of chronic vs. acute symptoms was associated with proactive vs. emergent care-seeking, respectively. The HFSPS scores did not correlate with care-seeking behavior.

CONCLUSION

Symptom recognition is a complex phenomenon, and few factors differentiate emergent from proactive care-seeking.

What is the value and impact of quality and safety teams? A scoping review

BACKGROUND

The purpose of this study was to conduct a scoping review of the literature about the establishment and impact of quality and safety team initiatives in acute care.

METHODS

Studies were identified through electronic searches of Medline, Embase, CINAHL, PsycINFO, ABI Inform, Cochrane databases. Grey literature and bibliographies were also searched. Qualitative or quantitative studies that occurred in acute care, describing how quality and safety teams were established or implemented, the impact of teams, or the barriers and/or facilitators of teams were included. Two reviewers independently extracted data on study design, sample, interventions, and outcomes. Quality assessment of full text articles was done independently by two reviewers. Studies were categorized according to dimensions of quality.

RESULTS

Of 6,674 articles identified, 99 were included in the study. The heterogeneity of studies and results reported precluded quantitative data analyses. Findings revealed limited information about attributes of successful and unsuccessful team initiatives, barriers and facilitators to team initiatives, unique or combined contribution of selected interventions, or how to effectively establish these teams.

CONCLUSIONS

Not unlike systematic reviews of quality improvement collaboratives, this broad review revealed that while teams reported a number of positive results, there are many methodological issues. This study is unique in utilizing traditional quality assessment and more novel methods of quality assessment and reporting of results (SQUIRE) to appraise studies. Rigorous design, evaluation, and reporting of quality and safety team initiatives are required.

Patient perception versus medical record entry of health-related conditions among patients with heart failure

A shared understanding of medical conditions between patients and their health care providers may improve self-care and outcomes. In this study, the concordance between responses to a medical history self-report (MHSR) form and the corresponding provider documentation in electronic health records (EHRs) of 19 select co-morbidities and habits in 230 patients with heart failure were evaluated. Overall concordance was assessed using the κ statistic, and crude, positive, and negative agreement were determined for each condition. Concordance between MHSR and EHR varied widely for cardiovascular conditions (κ = 0.37 to 0.96), noncardiovascular conditions (κ = 0.06 to 1.00), and habits (κ = 0.26 to 0.69). Less than 80% crude agreement was seen for history of arrhythmias (72%), dyslipidemia (74%), and hypertension (79%) among cardiovascular conditions and lung disease (70%) and peripheral arterial disease (78%) for noncardiovascular conditions. Perfect agreement was observed for only 1 of the 19 conditions (human immunodeficiency virus status). Negative agreement >80% was more frequent than >80% positive agreement for a condition (15 of 19 [79%] vs 8 of 19 [42%], respectively, p = 0.02). Only 20% of patients had concordant MSHRs and EHRs for all 7 cardiovascular conditions; in 40% of patients, concordance was observed for ≤5 conditions. For noncardiovascular conditions, only 28% of MSHR-EHR pairs agreed for all 9 conditions; 37% agreed for ≤7 conditions. Cumulatively, 39% of the pairs matched for ≤15 of 19 conditions. In conclusion, there is significant variation in the perceptions of patients with heart failure compared to providers' records of co-morbidities and habits. The root causes of this variation and its impact on outcomes need further study.

Evidence that consumers are skeptical about evidence-based health care

We undertook focus groups, interviews, and an online survey with health care consumers as part of a recent project to assist purchasers in communicating more effectively about health care evidence and quality. Most of the consumers were ages 18-64; had health insurance through a current employer; and had taken part in making decisions about health insurance coverage for themselves, their spouse, or someone else. We found many of these consumers' beliefs, values, and knowledge to be at odds with what policy makers prescribe as evidence-based health care. Few consumers understood terms such as "medical evidence" or "quality guidelines." Most believed that more care meant higher-quality, better care. The gaps in knowledge and misconceptions point to serious challenges in engaging consumers in evidence-based decision making.

Improving chronic illness care: findings from a national study of care management processes in large physician practices

The use of evidence-based care management processes (CMPs) in physician practice is an important component of delivery-system reform.The authors used data from a 2006-2007 national study of large physician organizations-medical groups and independent practice associations (IPAs) to determine the extent to which organizations use CMPs, and to identify external (market) influences and organizational capabilities associated with CMP use. The study found that physician organizations use about half of recommended CMPs, most commonly disease registries, specially trained patient educators, and performance feedback to physicians. Physician organizations that reported participating in quality improvement programs, having a patient-centered focus, and being owned by a hospital or health maintenance organization used more CMPs. IPAs and very large medical groups used more CMPs than smaller groups. Organizations externally evaluated on quality measures used more CMPs than other organizations. These findings can inform efforts to stimulate the adoption of best practices for chronic illness care.

Using Qualitative Research to Inform the Development of a Comprehensive Outcomes Assessment for Asthma

BACKGROUND: Qualitative research can inform the development of asthma patient-reported outcome (PRO) measures and user-friendly technologies through defining measurement constructs, identifying potential limitations in measurement and sources of response error, and evaluating usability. OBJECTIVE: The goal of the current study was to inform the development of a comprehensive asthma PRO assessment with input from patients and clinical experts. METHOD: Self-reported adult asthma sufferers recruited from a 3,000 member New England-area research panel participated in either one of three focus groups (N=21) or individual cognitive item debriefing interviews (N=20) to discuss how asthma impacts their health-related quality of life (HRQOL), and provide feedback on a preliminary set of asthma impact survey items and prototype patient report. Focus groups and cognitive interviews were conducted using traditional research principles (e.g., semi-structured interview guide, probing, and think aloud techniques). An Expert Advisory Panel (N=12) including asthma clinical specialists and measurement professionals was convened to review results from the focus group and cognitive interview studies and make recommendations for final survey and report development. RESULTS: Domains of health impacted by asthma included physical (recreation, play, competitive sports, and exercise), social (activities, family relationships), emotional (anger, upset, frustration, anxiety, worry), sleep, role (recreational/leisure activities; work), and sexual functioning. Most items in the impact survey were easily understood, covered important content, and included relevant response options. Items with contradictory examples and multiple concepts were difficult to comprehend. Suggestions were made to expand survey content by including additional items on physical and sexual functioning, sleep, self-consciousness, stigma, and finances. Reports were considered useful and participants saw value in sharing the results with their doctor. Graphic presentation of scores was not always understood; participants preferred tabular presentation of score levels with associated interpretative text. Display of inverse scores for different measures (higher scores equaling better health on one scale and worse health on another) shown on a single page was confusing. The score history section of the report was seen as helpful for monitoring progress over time, particularly for those recently diagnosed with asthma. Expert panelists agreed that displaying inverse scores in a single summary report may be confusing to patients and providers. They also stressed the importance of comprehensive interpretation guidelines for patients, with an emphasis on what they should do next based on scores. Panelists made recommendations for provider and aggregate-level reports (e.g., "red flags" to indicate significant score changes or cut-points of significance; identification of subgroups that have scored poorly or recently gotten worse). CONCLUSION: Incorporating input from patients, clinicians, and measurement experts in the early stages of product development should improve the construct validity of this PRO measure and enhance its practical application in healthcare.

Disease insight and treatment perception of men on active surveillance for early prostate cancer

STUDY TYPE

Survey (prospective cohort).

LEVEL OF EVIDENCE

1b.

OBJECTIVE

To investigate the levels of knowledge of prostate cancer and the perception of active surveillance (AS) in men on AS, as AS for early prostate cancer instead of radical treatment might partly solve the over-treatment dilemma in this disease, but might be experienced as a complex and contradictory strategy by patients.

PATIENTS AND METHODS

In all, 150 Dutch men recently diagnosed with early prostate cancer participating in a prospective protocol-based AS programme (PRIAS study) received questionnaires, including a 15-item measure on their general knowledge of prostate cancer, and open-ended questions on the most important disadvantages and advantages of AS, and on the specific perception of AS. We assessed knowledge scores and explored potentially associated factors, the stated (dis)advantages and specific perceptions.

RESULTS

The questionnaire response rate was 86% (129/150). Participants provided correct answers to a median (interquartile range) of 13 (12-14) of 15 (87%) knowledge items. Younger and higher educated men had higher knowledge scores. In line with a priori hypotheses, the most frequently reported advantage and disadvantage of AS were the delay of side-effects and the risk of disease progression, respectively. Specific negative experiences included the feeling of losing control over treatment decisions, distress at follow-up visits, and the desire for a more active participation in disease management. No conceptually wrong understandings or expectations of AS were identified.

CONCLUSIONS

We found adequate knowledge of prostate cancer levels and realistic perceptions of the AS strategy in patients with early prostate cancer and on AS. These findings suggest adequate counselling by the physician or patient self-education.

Structured chronic primary care and health-related quality of life in chronic heart failure

BACKGROUND

Structured care is proposed as a lever for improving care for patients with chronic conditions. The purpose of this study was to explore the associations of structured care characteristics, derived from the Chronic Care Model, with health-related quality of life (HRQOL) and optimal clinical management in chronic heart failure (CHF) patients in primary care, as well as the association between optimal management and HRQOL.

METHODS

Cross-sectional observational study using multi-level random-coefficient analyses of a representative sample of 357 patients diagnosed with CHF from 42 primary care practices in the Netherlands. We combined individual medical record data with patient and physician questionnaires.

RESULTS

There was large variation in the levels and presence of structured care elements. A 91% of physicians indicated that next appointments for CHF patients were made immediately after visits, while 11% indicated that reminders on CHF management were periodically received in their practice. Few associations were found between the organizational characteristics and optimal treatment or HRQOL. Optimal pharmacological treatment related to better quality of life (beta = -11.5, P < .0001). Also, more lifestyle advice was given in practices with an appointment system allowing contact with more than one professional during the encounter (beta = 1.0, P = .04).

CONCLUSION

HRQOL and treatment quality in CHF patients were not consistently associated with characteristics of structured care in primary care practices.

Psychological, social and spiritual distress at the end of life in heart failure patients

PURPOSE OF REVIEW

Chronic heart failure patients have palliative care needs that include psychosocial and spiritual support, particularly towards the end of life, when breathlessness and resultant immobility become increasingly severe. This review informs clinicians of the importance of understanding, assessing and managing patients' psychosocial and spiritual needs.

RECENT FINDINGS

The high prevalence of depression (9-77.5%) among chronic heart failure patients is well documented. Clinical assessment and treatment of depression and anxiety are key to good patient care, although no model for assessment has been agreed. Evidence suggests that social support and spiritual belief are important coping resources, but there is a dearth of research into social and spiritual distress in chronic heart failure. Patients rarely access social services support, and family carers experience considerable burden. Little is known about how psychosocial and spiritual variables influence each other, and the impact of social and spiritual distress on outcomes such as quality of life.

SUMMARY

We hope this review will inform cardiac and palliative care staff about the prevalence of psychosocial and spiritual distress in advanced chronic heart failure, and highlight the importance of their assessment and management. There is an urgent need for research in this field, including the rigorous development and evaluation of service models and nonpharmacological interventions.

"They diagnosed bad heart": a qualitative exploration of patients' knowledge about and experiences with heart failure

BACKGROUND

Patient education is central to the management of individuals with heart failure; therefore, it is important to know what these patients understand and experience both clinically and personally.

OBJECTIVES

This study qualitatively explored patients' knowledge regarding a heart failure diagnosis, their understanding of their cardiac care providers' treatment recommendations, and their views concerning the impact of heart failure on their daily lives and prognosis.

METHODS

A qualitative study was conducted whereby data were collected through 25 telephone interviews with adults being followed for heart failure at a Veterans Affairs medical center. Subjects were interviewed using semistructured open-ended questions. Audiotaped responses were analyzed using grounded theory methods.

RESULTS

The majority of participants were elderly, male, and white, and had New York Heart Association class II disease. Participants without angina typically experienced a lengthy and difficult diagnostic delay, with symptoms misattributed to comorbid diseases. Most understood the importance of self-monitoring and adhering to physician recommendations, and their discussions of life-changing effects typically focused on loss of physical functioning and decreased quality of life. Although participants wanted to know their prognosis, most had not received information about it or about advance care planning.

CONCLUSION

Patients require opportunities for enhanced communication with physicians and health care team members during the challenging diagnostic period and subsequently need more information about their medical condition and prognosis.

Meeting the communication and information needs of chronic heart failure patients

There is a lack of evidence on how best to meet policy guidance in fulfilling the information needs of patients with chronic heart failure (CHF) and their families. We aimed to generate guidance for appropriate information provision to CHF patients and their families through a cross-sectional qualitative methodology with constant comparison of emergent themes. Participants were 20 CHF patients (New York Heart Association Functional Classification III, III-IV, and IV); 11 family carers; six palliative care staff; and six cardiology staff. Patients and carers severely lacked understanding of CHF and its symptoms. None had discussed disease progression or advanced care planning with staff. Although patients expected honest discussion of disease implications, data from clinicians described an unwillingness to disclose poor prognosis. We identified four types of barriers to the discussion of disease progression: disease-specific; patient-specific; specialism-specific; and staff time and resources. This is the first study to integrate cardiology, palliative care, and patient and family views to develop feasible recommendations on meeting information needs. Three recommendations for hospital-based clinical practice were generated from the data: (1) improved methods of providing information; (2) introduction of mutual education and joint working; and (3) development of care pathways and referral criteria.

Gender differences in and factors related to self-care behaviors: a cross-sectional, correlational study of patients with heart failure

BACKGROUND

Although self-care may reduce exacerbations of heart failure, reported rates of effective self-care in patients with heart failure are low. Modifiable factors, including psychosocial status, knowledge, and physical factors, are thought to influence heart failure self-care, but little is known about their combined impact on self-care.

OBJECTIVES

The objective of this study was to identify factors related to self-care behaviors in patients with heart failure.

DESIGN

A cross-sectional, correlational study design was used.

PARTICIPANTS AND SETTINGS

One hundred twenty-two patients (77 men and 45 women, mean age 60+/-12 years old, 66% New York Heart Association functional class III/IV) were recruited from the outpatient clinics of an academic medical center and two community hospitals.

METHODS

Data on self-care behaviors (Self-Care of Heart Failure Index), depressive symptoms, perceived control, self-care confidence, knowledge, functional status, and social support were collected. Factors related to self-care were examined using hierarchical multiple regression.

RESULTS

Mean self-care behavior scores were less than 70 indicating the majority of men and women with HF did not consistently engage in self-care behaviors. Higher self-care confidence and perceived control and better heart failure management knowledge were associated with better self-care (r2=.25, p<.001). Higher perceived control and better knowledge were related to better self-care behaviors in men (r2=.18, p=.001), while higher self-care confidence and poorer functional status were related to better self-care behaviors in women (r2=.35, p<.001).

CONCLUSION

This study demonstrates the substantial impact of modifiable factors such as confidence in one's self-care abilities, perceived control, and knowledge on self-care behaviors. This study demonstrates that there are gender differences in factors affecting self-care, even though at baseline men and women have similar knowledge levels, physical, psychological, and behavioral status. Effective interventions focusing on modifiable factors and the unique characteristics of men and women should be provided to improve self-care behaviors in patients with heart failure.

Inside the health disparities collaboratives: a detailed exploration of quality improvement at community health centers

BACKGROUND

Quality improvement collaboratives (QICs) based on the Chronic Care Model (CCM) are widely used models for improving medical care, but there has been little information to date about the specific projects undertaken by participants in these collaboratives and their outcomes.

OBJECTIVES

To describe initiatives undertaken by community health centers (CHCs) participating in QICs (the Health Disparities Collaboratives) for asthma, cardiovascular disease, or diabetes, and to determine whether particular features of these initiatives were associated with improvement in health care processes or outcomes.

RESEARCH DESIGN

Observational cohort study.

DATA SOURCES/STUDY SETTING

Reports of quality improvement (QI) activities and clinical data from 40 CHCs participating in Health Disparities Collaboratives, 2000-2002.

MEASURES

Clinical quality scores based on indicators of chronic disease care.

RESULTS

Participating CHCs undertook an average of 44 QI activities per center (range, 8-84). These interventions were distributed broadly throughout the elements of the CCM, with particular emphasis on patient registry development and linkages to the surrounding community. Fifty-three percent of the interventions were fully institutionalized and 28% were evaluated by the centers. We found no relationships between improvement in quality and markers of QI activity quantity, intensity, or CCM category.

CONCLUSIONS

Organizations participating in QICs fully integrate the CCM components into their QI activities. However, it remains unclear how specific activities pursued under the guidance of the CCM and QICs contribute to quality improvement.

What do we know about adherence and self-care?

Despite advances in healthcare, heart failure patients continue to experience complications that could have been prevented or treated. This occurs because the only way that a therapeutic or preventive regimen can be effective, assuming that the patient's condition has been accurately diagnosed and appropriately treated, is if the patient implements self-care behaviors and adheres to the treatment regimen. However, it is widely accepted that this does not occur in many or even most instances. This article provides an overview of the current evidence related to adherence and self-care behaviors among heart failure patients and describes the state of the science on interventions developed and tested to enhance self-care maintenance in this population. Our review of literature shows that effective interventions integrate strategies that motivate, empower, and encourage patients to make informed decisions and assume responsibility for self-care. Gaps in current evidence support the need for additional research on ways to improve adherence and self-care for patients who are at an increased risk of poor adherence, including those with cognitive and functional impairments and low health literacy.

Impact of provider self-management education, patient self-efficacy, and health status on patient adherence in heart failure in a Veterans Administration population

To address the need for more information on predictors of adherence to heart failure (HF) self-management regimens, this study analyzed surveys completed by 259 HF patients receiving care at 2 Veterans Affairs hospitals in 2003. Linear multivariable regression models were used to examine general health status, HF-specific health status (Kansas City Cardiomyopathy Questionnaire) self-management education, and self-efficacy as predictors of self-reported adherence to salt intake and exercise regimens. Self-management education was provided most often for salt restriction (87%) followed by exercise (78%). In multivariable regression analyses, education about salt restriction (P=.01), weight reduction (P=.0004), self-efficacy (P=.03), and health status (P=.003) were significantly associated with patient-reported adherence to salt restriction. In a similar model, self-efficacy (P=.006) and health status (P< or = .0001), but not exercise education, were significantly associated with patient-reported exercise adherence. Findings suggest that provider interventions may lead to improved adherence with HF self-management and thus improvements in patients' health.

Prostate cancer knowledge among low income minority men

PURPOSE

We identified sociodemographic characteristics that predict poor disease understanding in low income, uninsured men with prostate cancer.

MATERIALS AND METHODS

A total of 399 low income, uninsured men with prostate cancer participating in the Men's Health Survey done by researchers at University of California-Los Angeles Jonsson Comprehensive Cancer Center completed questionnaires assessing their knowledge of prostate cancer. Logistic regression was used to identify sociodemographic factors, eg age, education level, language preference, ethnicity and relationship status, associated with poor prostate cancer knowledge.

RESULTS

Most subjects were Latino (54% or 213 of 399), spoke English (53% or 213 of 399) and had a high school education or less (86% or 344 of 399). In the multivariate model increasing age (p<0.014) and less than a high school education (p<0.012) were associated with lower knowledge of disease, while Latino ethnicity and relationship status were not.

CONCLUSIONS

Among low income men with prostate cancer increasing age and less formal education were associated with lower knowledge of disease. Further study is needed to determine the roles of language preference and ethnicity in the understanding of the disease in patients with prostate cancer.

Making Systemwide Improvements in Health Care

Over the past 10 years, Jönköping County in Sweden has made impressive progress in improving its health care system. The motor of improvement work is Qulturum, an innovation and learning center within the health system. Qulturum has no responsibilities for clinical or administrative functions; its sole mission is improvement work. Qulturum's improvement strategy is based on 3 principles: (1) Learning is key to improvement, (2) Improvement needs to be broad and deep, and (3) Improvement must be both bottom-up and top-down. Based on these principles, Jönköping County has achieved timely access to primary and specialty care, has improved the care of a number of chronic conditions, and has accomplished these goals without increases in expenditures. The United States could benefit by instituting Qulturum-like centers of learning and innovation within health systems.

An HIV Collaborative in the VHA: Do Advanced HIT and One-Day Sessions Change the Collaborative Experience?

BACKGROUND

Many organizations participate in quality collaboratives, yet the return on investment of the associated time and costs is unclear.

METHOD

Semistructured interviews, surveys, and direct observation were used to assess experiences, improvement activities, and costs associated with participation in a year-long modified Institute for Healthcare Improvement-style collaborative designed to improve HIV care within the Veterans Health Administration. All nine sites had access to automated patient registries and semi-automated clinical measure reports; five sites also received computerized clinical reminders. Three one-day learning sessions were conducted.

RESULTS

Participants reported that burden was small and value high, although many suggested that more time for peer-to peer learning would have been helpful. Teams averaged five quality improvement activities per site and most reported improvements in HIV care processes. The average annual cost per site was dollars 28,000 but costs varied considerably by site.

DISCUSSION

Shortened learning sessions and the incorporation of health information technology can reduce some of the costs and burdens associated with collaboratives, yet peer-to-peer interaction and local organizational factors remain important to ensuring perceived effectiveness of collaboratives.