Health literacy and the patient with heart failure--implications for patient care and research: a consensus statement of the Heart Failure Society of America

Psychometric evaluation of the Arabic version of the heart failure-specific health literacy scale in a socio-politically challenged setting

INTRODUCTION

Low levels of formal education among Lebanese people with HF were reported. Additionally, limited discharge education is provided to this population. Therefore, it was necessary to evaluate the health literacy levels among this population following the translation of the heart failure-specific health literacy scale into Arabic and to evaluate its psychometric properties in the Lebanese setting.

METHODS

A cross-sectional design conducted on participants from the community with confirmed cases of heart failure. A research team was trained for data collection. Following securing participants' consents, baseline sociodemographic characteristics and the Arabic version of the heart failure-specific health literacy scale were administered. Data collection took place between June and December 2022. A pilot sample analysis was done to confirm homogeneity between the English and the Arabic versions. Exploratory and confirmatory factor analysis were performed to evaluate content and construct validity of the scale. Cronbach alpha was done to evaluate reliability.

RESULTS

The pilot analysis confirmed homogeneity of the items of the Arabic and English versions of the scale. The final sample of 343 participants was randomly divided to two parts for each of the exploratory factor analysis and confirmatory factor analysis. The mean age was 64 years with the majority being male participants. In terms of exploratory factor analysis, the three subscales of the literacy scale explained 60% of the variance. The best acceptable fit was found on 11 items of the scale after dropping the 10th item from the analysis. The Cronbach alpha of the scale was 0.68.

CONCLUSION

The Arabic version of the heart failure-specific health literacy scale was evaluated to be a valid and reliable tool. Further analysis should be done on the dropped item, and correlations should be done with significant variables such as self-care.

REPORTING METHOD

STROBE checklist.

PATIENT/PUBLIC CONTRIBUTION

No patient/public contribution.

CONTRIBUTION TO THE WIDER GLOBAL COMMUNITY

Participants with heart failure were shown to have low levels of literacy in Lebanon. Additionally, low literacy levels are also common among Lebanese older adults living in high income, Western Countries. Therefore, this valid and reliable scale can be used to evaluate health literacy among people with heart failure in Lebanon and among Lebanese and other Arabic-speaking older adults globally.

Impact of Digital Health Technology on Quality of Life in Patients With Heart Failure

BACKGROUND

Digital health tools may improve quality of life (QoL) in patients with heart failure (HF) by promoting self-care, knowledge, and engagement.

OBJECTIVES

This study evaluates the effect of 3 digital technologies on QoL in patients with HF.

METHODS

A total of 182 patients were randomized to usual care or one of the technologies promoting self-care: Bodyport (cardiac scale), Conversa (conversational platform), or Noom (smartphone application). The primary outcome was 90-day change in QoL, as assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary Score (OSS).

RESULTS

A total of 151 participants (83%) completed their 90-day surveys. The median age of enrolled participants was 61 years (IQR: 53-69 years), and 37.9% were women. No group had any significant change in KCCQ OSS or improvement relative to usual care. However, symptoms and physical function at 90 days, as assessed by the Total Symptom Score (TSS) and Clinical Summary Score (CSS), were significantly improved in the Noom group relative to usual care: TSS median change of +4.2 points (IQR -1 to +16.7) vs -1 points (IQR: -13.5 to +7.8; P = 0.006); CSS median change of +2.8 points (IQR: -1 to +14.6) vs -3.1 points (IQR: -10.2 to +3; P = 0.002).

CONCLUSIONS

Three digital interventions showed no independent effect on QoL as assessed by the KCCQ OSS. However, participants randomized to the Noom technology demonstrated improved KCCQ TSS and CSS relative to usual care. Although digital tools may be an important component of longitudinal care for patients with HF, larger studies are needed to better understand their effectiveness and optimal deployment. (Evaluating Efficacy of Digital Health Technology in the Treatment of Congestive Heart Failure; NCT04394754).

Patient Awareness of Heart Failure Diagnosis: A Community Study

Background Heart failure (HF) is a complex disease that contributes to a high number of hospitalizations, deaths, and economic health care costs each year. However, among patients with HF, there is a lack of awareness of their HF diagnosis that has not been fully examined. Methods and Results Residents from 3 counties of southeast Minnesota with a first-ever International Classification of Diseases, Ninth Revision (ICD-9) code 428 or Tenth Revision (ICD-10) code I50 between January 1, 2013 and March 31, 2016 (N=2461) were prospectively surveyed to measure HF self-awareness. A total of 1114 patients returned the survey (response rate, 45%), and 787 had validated HF upon medical record review. Among these 787 patients with HF (mean age, 76 years; 53% men), 37% (n=293) were aware of their HF diagnosis. After adjustment, being a woman (odds ratio [OR], 1.56 [95% CI, 1.10-2.22]), having HF with reduced ejection fraction (OR, 1.58 [95% CI, 1.13-2.22]), attending the HF clinic (OR, 4.07 [95% CI, 2.25-7.36]), and having coronary artery disease (OR, 1.65 [95% CI, 1.16-2.37]) were all associated with increased awareness of an HF diagnosis. Conversely, having diabetes was associated with decreased awareness of an HF diagnosis (adjusted OR, 0.69 [95% CI, 0.50-0.95]). Conclusions Awareness of an HF diagnosis is low in a community population of patients with HF. Strategies to improve patient awareness of their diagnosis should be implemented to improve self-care behaviors and outcomes in patients with HF.

Transitional Care in Patients with Heart Failure: A Concept Analysis Using Rogers' Evolutionary Approach

Objective

The purpose of this study was to clarify the concept of transitional care in patients with heart failure.

Background

Transitional care is increasingly being applied in patients with heart failure, but the concept of transitional care in heart failure patients is not uniform and confused with other definitions, which limits further research and practice on transitional care for these patients.

Design

Rodgers' evolutionary concept analysis.

Methods

A comprehensive literature search was conducted using the PUBMED, EMBASE, EBSCO, Chinese Biological Medicine (CBM), CNKI, and WANFANG databases (up to January 26, 2023). We used Rodgers' evolutionary concept analysis method to identify related concepts, attributes, antecedents, and consequences of transitional care in patients with heart failure.

Results

A total of 33 articles were included. The following attributes belonging to transitional care in patients with heart failure were extracted from the literature: self-care, multidisciplinary collaboration, and information transmission. The antecedents were patients' health status, the health literacy of patients and caregivers, the role functions of the main implementer and social and medical resources. Consequences were separated into two categories: patient-centered health outcomes (all-cause mortality, health-related quality of life, discharge preparedness, self-care behaviors, satisfaction of patients) and healthcare utilization outcomes (hospital readmission, length of hospital stay, emergency department visits).

Conclusion

This study found that transitional care in heart failure patients is a systemic care process during a vulnerable period that improves patient self-management and coordination between hospital resources and social support systems for continuous management to promote smooth patient transitions between different locations. This concept analysis will inform healthcare providers in designing evidence-based interventions and quality improvement strategies to ensure that transition processes lead to desired outcomes. In addition, this study will also be helpful for developing specific assessment tools to identify patients with HF who need transitional care.

[Protocolo para la evaluación de una intervención de alfabetización en salud sobre morbimortalidad y calidad de vida en pacientes con insuficiencia cardíaca.]

OBJECTIVE

Heart failure (HF) is a complex clinical syndrome that impairs the ability to achieve proper filling or ejection, in which patients have typical symptoms and signs. It is a major Public Health problem with a high incidence and prevalence associated with high morbidity and mortality. The management of the patient with HF is complex, requiring in its treatment the work of specialized multidisciplinary teams in which the management of cardiac-healthy habits and self-care will play a leading role. Knowing the health literacy (HL) level of patients is a fundamental piece that will help us to provide a holistic attention, based on individual needs, promoting in this way the empowerment of the patient. Our aim will be to evaluate the effectiveness of an HL intervention for improving quality of life and decreasing morbidity/mortality.

METHODS

A two-arm randomized controlled clinical trial will be conducted, with concealment of randomization. Patients with diagnosis of HF attended in cardiology and internal medicine consultations of 5 hospitals in Spain will be included.

Relationship Between Health Literacy, Quality of Life, and Treatment Adherence in Patients with Acute Coronary Syndrome

BACKGROUND

Acute coronary syndrome is a significant global health concern that can affect patients' health outcomes and quality of life. In addition, adherence to treatment and health literacy can affect health outcomes.

OBJECTIVE

This study aimed to investigate the relationship between treatment adherence, health literacy, and quality of life among patients with acute coronary syndrome.

METHODS

This cross-sectional study was conducted on 407 patients in Iran from April 2019 to November 2019. Patients were selected by convenience sampling method. Data were collected using demographic questionnaire, World Health Organization Quality of Life Brief Version, Adherence to Treatment Questionnaire, and Health Literacy for Iranian Adults questionnaire. SPSS 25 was used for statistical analysis.

RESULTS

Based on descriptive statistics in this study, most of the participants had good treatment adherence level (56.5%); 28.7% of the participants had insufficient health literacy level. The mean score of quality of life was 51.41 ± 12.03, which was greater than the midpoint of the questionnaire. Furthermore, Pearson's correlation coefficient showed a negative association between health literacy, treatment adherence (r = -0.167, p < .01), and quality of life (r = -0.153, p < .01), and a positive association between treatment adherence and quality of life (r = 0.169, p < .01).

CONCLUSION

The results of the current study showed a negative relationship between health literacy, quality of life, and treatment adherence among patients with acute coronary syndrome. [HLRP: Health Literacy Research and Practice. 2023;7(2):e71-e79.].

Health literacy and prognosis of heart failure: a prospective propensity-matched study in the community

AIMS

Health literacy (HL), the ability to obtain and understand health information, is critical to self-care in chronic disorders. A low HL is common among these patients and has been associated with a worse prognosis. Nevertheless, the relationship between HL and the prognosis of heart failure (HF) with reduced (HFrEF) vs. preserved (HFpEF) ejection fraction remains unsettled. To analyse the relationship between HL and the prognosis of patients with incident HFrEF and HFpEF.

METHODS AND RESULTS

Prospective study over 10 years (2010-19) on 6444 patients diagnosed with incident HF. The main outcomes were mortality, hospitalizations, and visits to emergency services. The independent relationship between HL and the prognosis, stratifying patients for cardiovascular comorbidity after propensity score-matching was analysed.After matching 5355 HF patients, 1785 with low HL (874 with HFrEF and 911 with HFpEF) vs. 3570 with adequate HL (1748 with HFrEF and 1822 with HFpEF), during a median follow-up of 5.41 years, 3874 patients died (72.3%) and 3699 patients were hospitalized (69.1%). After adjustment for potential confounders, an adequate HL was associated with a lower all-cause and cardiovascular mortality, less hospitalizations, and less 30-day readmissions [relative risk (RR) for HF <0.72 (0.66-0.86), RR for HFrEF <0.69 (0.63-0.95), and RR for HFpEF <0.62 (0.55-0.88), P < 0.001 in all cases], both for patients with HFrEF and HFpEF. Analyses of recurrent hospitalizations gave larger HL effects than time-to-first-event analyses.

CONCLUSIONS

In this propensity-matched study, a low HL is associated with a worse prognosis of patients with incident HFrEF and HFpEF.

Impact of health literacy in patients with cardiovascular diseases: A systematic review and meta-analysis

OBJECTIVE

To clarify the impacts of health literacy on mortality, readmission, and quality of life (QOL) in the secondary or tertiary prevention of cardiovascular diseases (CVD) through a meta-analysis.

METHODS

Six electronic databases were searched on June 11, 2020. Observational studies involving patients with CVD, health literacy as an exposure factor and mortality, readmission, or QOL as outcomes were included in this study. Two researchers screened the retrieved articles and extracted data independently. The meta-analysis calculated the pooled relative risk of mortality and readmission. We also assessed the body of evidence based on Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Following screening of 1616 studies, 16 observational studies were included. The mean rate of low health literacy was 32.8%. All studies focusing on QOL showed significant impacts of health literacy. Pooled relative risk was 1.621 (95% confidence interval: 1.089-2.412) for mortality and 1.184 (95% confidence interval: 1.035-1.355) for readmission, indicating significant effects of health literacy. GRADE assessment showed "LOW" certainty for each outcome.

CONCLUSION

Low health literacy was significantly associated with increased mortality and hospital readmission and decreased QOL in patients with CVD.

PRACTICE IMPLICATIONS

Considering low health literacy in clinical practice is very important to improve prognosis of CVD patients.

The importance of health literacy for self-management: A scoping review of reviews

OBJECTIVES

Self-management of chronic diseases is rather complex, especially for patients with limited health literacy. In this review, we aim to disentangle the specific difficulties patients with limited health literacy face in relation to self-management and their associated needs with respect to self-management support.

METHODS

We performed a literature search in five databases. We used a broad definition of health literacy and self-management was categorized into four types of activities: medical management, changing lifestyle, communicating and navigating through the health care system and coping. Included reviews described the relationship between health literacy and different domains of self-management and were published after 2010.

RESULTS

A total of 28 reviews were included. Some clear difficulties of patients with limited health literacy emerged, predominantly in the area of medical management (especially adherence), communication and knowledge. Other associations between health literacy and self-management were inconclusive. Barriers from the patients' perspective described mainly medical management and the communication and navigation of the health care system.

DISCUSSION

Patients with limited health literacy experience difficulties with specific domains of self-management. For a better understanding of the relationship between health literacy and self-management, a broader conceptualization of health literacy is warranted, including both cognitive and behavioural aspects.

Relationship between Health Literacy and Knowledge, Compliance with Bowel Preparation, and Bowel Cleanliness in Older Patients Undergoing Colonoscopy

Compared to young adults, it is difficult for the older people with relatively low health literacy to perform proper bowel preparation for a colonoscopy. This study aims to identify the relationship between knowledge, compliance with bowel preparation, and bowel cleanliness with health literacy in older patients undergoing colonoscopy. The participants were 110 older people undergoing colonoscopy, recruited from an endoscopy hospital in G metropolitan city, South Korea. Data obtained from a structured questionnaire that included items on health literacy and knowledge of and compliance with bowel preparation, and the Aronchick bowel cleanliness scale. The data were analyzed using descriptive statistics, χ-test, Pearson's correlation, t-test, and ANCOVA. Participants who were younger and those with a higher education level and better economic status had a statistically significantly higher health literacy level. Older people with a health literacy level of 7 points and above had a higher knowledge level and bowel cleanliness index, a showed better compliance with bowel preparation. The results highlight the need for developing a customized education intervention program that can improve health literacy for successful bowel preparation and examination of the older population undergoing colonoscopy.

Effect of nurse-led hospital-to-home transitional care interventions on mortality and psychosocial outcomes in adults with heart failure: a meta-analysis

AIMS

To determine the effectiveness and dose-response of nurse-led hospital-to-home transitional care interventions (TCIs) on patient mortality and psychosocial outcomes of health-related quality of life (HRQoL), self-care behaviours, and emotional well-being in adults hospitalized with heart failure (HF) and to recognize pertinent characteristics that potentially affect the overall effectiveness.

METHODS AND RESULTS

Relevant studies were identified through electronic database searches, including MEDLINE, Embase, CINAHL, and Cochrane Library from January 2000 until January 2021. Two independent authors performed study selection, data abstraction, and risk-of-bias assessment. When appropriate, we used random-effects meta-analysis to derive pooled effect estimates, investigated dose-response relationships, and ran meta-regressions to locate the source of heterogeneity. A total of 27 studies with 7635 participants were included. Our findings revealed that nurse-led hospital-to-home TCIs reduced the risk of all-cause mortality by 21% [risk ratio = 0.79; 95% confidence interval (CI) 0.68-0.92; P = 0.003] and improved HRQoL (mean difference = -3.29; 95% CI -6.51 to -0.07; P = 0.04) compared to usual care, but non-significant effects were found for emotional well-being. The narrative summary of evidence for self-care behaviours showed positive intervention effects. Meta-regression did not find any covariates that were significantly related to mortality or HRQoL. Dose-response analysis showed that mortality risk was reduced with increased intensity and complexity of the nurse-led TCIs.

CONCLUSION

Generally, nurse-led hospital-to-home TCIs may play a beneficial role in decreasing mortality, and improving HRQoL and self-care behaviours for adults with HF. Additional studies are warranted to characterize the optimal nurse-led TCIs for HF management.

Public Health Literacy, Knowledge, and Awareness Regarding Antibiotic Use and Antimicrobial Resistance during the COVID-19 Pandemic: A Cross-Sectional Study

Multi-drug-resistant (MDR) organisms pose a global threat to modern medicine, which has grown as a result of irrational antibiotic use and misuse. This study aimed to assess general public knowledge in Jordan and awareness of antibiotics and antibiotic resistance during the COVID-19 pandemic. A cross-sectional study was carried out utilizing the WHO multicountry public awareness survey. The study population was composed mainly of social media users, and a total of 1213 participants completed the online survey. According to the findings, more than half of the participants were well versed in antibiotic use and resistance. Those with adequate health literacy were found to better understand antibiotics (OR = 1.37, p = 0.017) and antibiotic resistance (OR = 1.46, p = 0.003). The vast majority (88.5%) recognized at least one antibiotic resistance term; however, 53.2% believed that antibiotic resistance is a problem in other nations. The participants in this study reported using antibiotics incorrectly, believing that they were treating sore throats, colds, and flu. The participants were well aware of antibiotic resistance solutions and their consequences on health. Age, education, health literacy, and antibiotic knowledge were found to be substantially (p < 0.05) associated with greater awareness of antibiotic resistance. The findings highlight the need for antimicrobial resistance education campaigns, health literacy, and antibiotic stewardship initiatives.

Association of health literacy and medication adherence with health-related quality of life (HRQoL) in patients with ischemic heart disease

BACKGROUND

Medication Adherence (MA) and Health Related Quality of Life (HRQoL) are two inter-connected concepts, co-influenced by Health Literacy (HL), with significant impact on patient management and care. Thus, we aimed to estimate the association of HL and MA with HRQoL in IHD patients.

METHODS

Cross-sectional study of 251 IHD patients recruited from Lahore over 6 months period. HL, MA and HRQoL was assessed using validated questionnaires; 16-items of HL, Morisky Green Levine Scale (MGLS) and SF-12, respectively. Chi-square for significance, logistic-regression for association and linear regression for predictions were used.

RESULTS

IHD patients; males (p = 0.0001), having secondary-higher education (p = 0.0001), middle/upper class (p = 0.0001) and employed (p = 0.005) had adequate HL, and were more likely to be adherent (OR; 4.3, p = 0.014). Both physical (PCS-12) and mental (MCS-12) component scores of HRQoL for age, gender, education, area of residence, employment and MA were significantly higher in patients with adequate HL. In multinomial regression, improved PCS-12 scores tend to be higher in subjects having secondary-higher education (OR; 3.5, p = 0.067), employed (OR; 6.1, p = 0.002) and adherent (OR; 2.95, p = 0.218), while MCS-12 scores tend to be higher in patients < 65 years (OR; 2.2, p = 0.032), employed (OR; 3, p = 0.002) and adherent (OR; 4, p = 0.004). In adjusted model, HL (β;0.383, p = 0.0001) and MA (β; - 0.133, p = 0.018) were significantly associated with PCS-12, and MCS-12 with MA (β; - 0.161, p = 0.009) only.

CONCLUSION

Data suggested that adequate HL was significantly associated with adherence and both physical and mental dimensions of HRQoL were higher in IHD patients with adequate HL. Besides, HL and MA are independent predictors of HRQoL in IHD patients.

Assessing the facilities and healthcare services for heart failure: Taiwan versus European countries

BACKGROUND/PURPOSE

The present study was designed to evaluate the local cardiology infrastructure and services for heart failure (HF) care in Taiwan hospitals and to compare the HF care with the hospitals in European countries.

METHODS

Available data from a total of 98 medical centers and regional hospitals in Taiwan were analyzed. Each facility was given a single copy of the questionnaire between September and December 2019, and service records were extracted from the National Health Insurance Database. European data were adopted from the 2017 European Society of Cardiology Atlas.

RESULTS

The number of cardiologists per million populations in Taiwan was 57.4, and it was lower than the European median (72.8). The median percentages of interventional and electrophysiologists among cardiologists were 64% and 15% in Taiwan, which were both higher than the European median values (12% and 5%, respectively). The accessibility rates to implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) in Taiwan were both higher (3.4 and 3.0 centers per million populations) comparing to those in European countries (median 1.6 and 1.5 centers per million populations). Comparing to 67 hospitals without HF care teams in Taiwan, 31 hospitals (31.6%) with HF teams have significantly more cardiology staff, enhanced procedural capabilities with more alternatives on oral or intravenous HF relevant medications.

CONCLUSION

Our analysis clearly demonstrated discrepancies in cardiology subspecialties and CRT/ICD accessibilities between European countries and Taiwan. Variations in HF-focused services and facilities plus HF-directed medications have demonstrated significant differences among Taiwanese hospitals with or without HF care team.

The effectiveness of transitional care interventions for adult people with heart failure on patient-centered health outcomes: A systematic review and meta-analysis including dose-response relationship

BACKGROUND

Transitional care interventions that bridge the care gap from hospital to home have proven to be effective in lessening the burden of healthcare systems by reducing hospital readmissions. Yet, the effects of transitional care interventions on patient-centered health outcomes of mortality, quality of life, and emotional distress remains unclear.

OBJECTIVES

To evaluate the effectiveness and dose-response of transitional care interventions on patient-centered health outcomes of mortality, quality of life, and emotional distress among individuals with heart failure and to identify the trial-level characteristics potentially affecting the overall effectiveness.

DESIGN

Systematic review with random-effects meta-analysis, meta-regression, and dose-response analysis of randomized controlled trials comparing transitional care interventions with usual care in adult people hospitalized with heart failure.

DATA SOURCES

Electronic databases including MEDLINE, Embase, Cochrane Library, and CINAHL were systematically searched from January 1, 2000 to June 31, 2020.

REVIEW METHODS

Authors independently reviewed the retrieved articles based on inclusion and exclusion criteria, extracted data, and assessed risk of bias using the Cochrane risk-of-bias tool version 2.0. We pooled data from each study using random-effects meta-analysis and performed meta-regression to explore the impact of pre-specified trial-level factors. Dose-response meta-analysis was conducted to examine the relationship between the intensity (i.e., frequency and duration of interventions) and complexity (i.e., number of intervention components) of transitional care interventions and the treatment effects.

RESULTS

Data were synthesized from 42 trials covering a total of 10,784 people with heart failure. Comparing to usual care, transitional care interventions achieved pooled evidence of a mean 18% risk reduction on mortality (0.82, 95% CI 0.71 to 0.95, P = 0.009) and better improvement in quality of life (-4.37, 95% CI -7.20 to -1.54, P = 0.002). There were insufficient data to determine with certainty the effects on anxiety and depression. Meta-regression showed greater efficacy in trials that delivered the intervention by a multidisciplinary team. Dose-response analyses demonstrated that mortality and quality of life were improved with increased intensity and complexity of the transitional care interventions.

CONCLUSIONS

Transitional care interventions were effective in reducing mortality and improving quality of life for adult people with heart failure. The effects on emotional distress were inconclusive due to insufficient data, highlighting the need for further research.

REGISTRATION NUMBER

CRD42019132732.

Social determinants and cardiovascular care: A focus on vulnerable populations and the Jamaica experience

The concept of social determinants of health (SDOH) describes the complex interplay of social, economic, cultural, and environmental forces that influence health and illness and result in health inequities in society. In cardiovascular disease (CVD), SDOH play a significant role in contributing to the severe morbidity and mortality that various cardiovascular diseases inflict on our societies. The components of SDOH include wealth/income, employment status, education, social interactions/support, access to medical care (including mental health services), housing, transportation, physical environment (including availability of green space, water/sanitation, air pollution, noise pollution), work environment, access to good nutrition, social and community networks, access to technology and data, exposure to crime/social disorder/violence, exposure to adverse law enforcement/bad governance, and cultural norms. Leveraging reliable SDOH data is critical to addressing healthcare needs of the community. At‐risk populations must be connected to the appropriate resources needed to overcome these barriers to access to achieve better health outcomes. This review explores this theme with a focus on several vulnerable populations and offers possible strategies to reduce these inequalities. The Heart Institute of the Caribbean (HIC) was founded in 2005 to improve access to quality medical and cardiovascular services, made available to everyone regardless of their socioeconomic status. HIC has encountered and learned to navigate a myriad structural, institutional, socio‐economic, cultural, and behavioral barriers to appropriate CVD care for vulnerable populations in Jamaica and the wider Caribbean. The successes attained and the lessons learned by HIC can be replicated in other nations to address social determinants that impede cardiovascular and medical care in vulnerable populations and may alleviate the access gap in high‐quality care in developing countries and in underserved and marginalized communities in developed countries.

The Effect of Cognitive-Behavioral Training Versus Conventional Training on Self-care and Depression Severity in Heart Failure Patients with Depression: A Randomized Clinical Trial

Introduction: Psychological factors including depression and anxiety are the most critical risk factors in the treatment and prognosis of heart failure which should be addressed in treatment and care programs. The purpose of this study was to examine the effect of cognitive-behavioral training (CBT) on depression severity and self-care ability of patients with heart failure.

Methods: This study was a randomized clinical trial that carried out on 80 patients with heart failure who had been hospitalized in 2018. The participants were divided into the CBT group (n= 40) and the conventional training (CT) group (n= 40), randomly. Data were collected using Beck Depression Inventory (BDI) and the Self-Care of Heart Failure Index (SCHFI) version 6.2 before and 8 weeks after the educational interventions. Data were analyzed in SPSS 21 using paired t-test, independent t-test, chi-square test, and covariance analysis.

Results: The mean score of self-care in the CBT group turned out to be significantly higher than the CT group after receiving the intervention. Also, the mean depression score of the CBT group 26.95 (5.53) after intervention was significantly lower than the CT group 36.04 (8.45).

Conclusion: Cognitive-behavioral intervention, compared with conventional training, had a greater positive impact on improving self-care and alleviating the severity of depression symptoms. Therefore, it is recommended that the principles of cognitive-behavioral therapy be integrated into routine educational programs.

The Effectiveness of Transitional Care Interventions on Health Care Utilization in Patients Discharged From the Hospital With Heart Failure: A Systematic Review and Meta-Analysis

OBJECTIVES

Heart failure (HF) heavily burdens the global health system. Transitional care interventions attempt to streamline the hospital-to-home transition to ease the burden. This systematic review and meta-analysis aimed to evaluate the effectiveness of transitional care interventions on health care utilization after hospitalization for HF.

DESIGN

Systematic review and meta-analysis including dose-response relationship.

SETTING AND PARTICIPANTS

Randomized controlled trials (RCTs) of transitional care interventions vs usual care in older patients discharged from the hospital with HF.

METHODS

Electronic databases including MEDLINE, Embase, Cochrane Library, and CINAHL, were systematically searched from January 2009 to October 2019 to locate relevant systematic reviews or meta-analyses. The original RCTs included in the review articles were identified, and an additional search for recently published RCTs was performed from January 2014 to June 2020. This systematic review focused on health care utilization outcomes, including hospital readmissions for HF or any cause, emergency department (ED) visits, and length of hospital stay (LOS).

RESULTS

Data were summarized from 38 RCTs covering 10,871 patients. Pooled evidence suggested a mean 11% [risk ratio (RR) 0.89, 95% confidence interval (CI) 0.82, 0.97] and 22% (RR 0.78, 95% CI 0.68, 0.89) risk reduction on all-cause and HF-specific readmissions, but no significant reduction (RR 0.94, 95% CI 0.83, 1.07) on ED visits. Findings were mixed for LOS. Subgroup analysis by different types of transitional care interventions indicated that multidisciplinary interventions currently have the best evidence for reducing readmissions up to 6 months post the index HF hospitalization. In addition, we observed an inverse linear dose-response relationship between intervention intensity (ie, frequency and duration of interventions) and complexity (ie, number of intervention components) and the risk of HF readmissions.

CONCLUSIONS AND IMPLICATIONS

Transitional care interventions for hospitalized patients with HF reduced all-cause and HF-specific readmissions, but did not decrease ED visits. Multidisciplinary interventions are highly recommended if adequate resources are available.

Health literacy and quality of life in hospitalized heart failure patients: a cross-sectional study

INTRODUCTION

Heart Failure (HF) treatment may be improved by good knowledge of the disease (Health Literacy) that, despite the well-established role on improving self-care, preventing complications and avoiding worse outcomes, has little evidence on affecting QoL of HF patients. Therefore, the objective of the present study was to evaluate the impact of Health Literacy on QoL in hospitalized HF patients.

METHODOLOGY

A cross-sectional exploratory study was conducted with HF patients hospitalized at a public cardiological hospital. Health Literacy was assessed using the "Questionnaire about Heart Failure Patients' Knowledge of Disease" and QoL using the "Minnesota Living with Heart Failure Questionnaire" (MLHFQ). The association between Health Literacy and QoL was assessed by linear regression (P<0.05).

RESULTS

50 patients were included in the study; the mean Health Literacy score was 34.2 ± 15.1 (the majority presenting acceptable or better knowledge). The mean MLHFQ score was 73.5 ± 19.8. The one-year hospital readmission rate (β=+3.8; P=0.009) and the patients' Health Literacy score (β=-0.4; P=0.024) or good knowledge category (β=-20.2; P=0.016) were independently associated with QoL.

CONCLUSION

While the readmission rate was inversely associated with QoL, the better the HF knowledge the better QoL in hospitalized HF patients.

The Impact of Nurse-Led Cardiac Rehabilitation on Quality of Life and Biophysiological Parameters in Patients With Heart Failure: A Randomized Clinical Trial

BACKGROUND

Cardiovascular diseases are the leading cause of mortality in the Indian subcontinent, accounting for 38% of deaths annually. One cardiovascular disease in particular, heart failure, is a growing public health problem both in India and worldwide.

PURPOSE

Heart failure is a chronic, progressive disease with increasing rates of incidence and prevalence. This study was conducted to determine the influence of a nurse-led cardiac rehabilitation program on quality of life and biophysiological parameters in patients with chronic heart failure. In this study, it was hypothesized that participants in the cardiac rehabilitation program would report significantly more-positive changes in quality of life and biophysiological parameters than their peers who did not participate in this program.

METHODS

In this randomized controlled trial, the participants were patients with chronic heart failure who had been admitted to a tertiary care hospital in India. The participants assigned to the intervention group received both nurse-led cardiac rehabilitation and routine care. In addition, intervention group participants received a booklet on cardiac rehabilitation, Healthy Way to Healthy Heart, at discharge and fortnightly telephone reminders about good cardiac rehabilitation practices. A standard questionnaire was used to collect targeted information on participants' general and disease-specific quality of life at 1 and 3 months postintervention. Biophysiological parameters such as body mass index, blood pressure, and serum cholesterol values were also measured.

RESULTS

Two thirds of the participants in each group (65% in the intervention group and 66% in the control group) were between 51 and 70 years old. The mean score for the mental component summary of generic quality of life steadily decreased in the control group and steadily increased in the intervention group at the first and second posttests.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Nurses working in cardiology units play a pivotal role in educating and managing the health status of patients with heart failure. Providing cardiac rehabilitation to patients with heart failure benefits the quality of life of these patients. Nurses working in cardiology units should encourage patients with heart failure to practice cardiac rehabilitation for a longer period to further improve their quality of life.

SiTe iC: A telemonitoring system for heart failure patients

In the last years, multidisciplinary post-discharge treatment programs, such as telemonitoring, have been promoted as a strategy for Heart Failure (HF) management. However, the distinctive requirements that a telemonitoring system should have, have not been clearly identified. To this aim, the most relevant requirements for telemonitoring of HF patients are derived from evidence-based Clinical Practice Guidelines (CPGs) for HF management. The main objective of this work is to present a prototype of a telemonitoring system for HF patients, named SiTe iC, that has been developed based on the identified requirements, highlighting its design and evaluation. A first prototype of the system was designed and programmed. It consists of an mHealth app for HF patients, a website for physicians who monitor patients, and a server which runs an Application Programming Interface to allow communication between the app and the website. The system was thoroughly assessed through a clinical trial that demonstrates that telemonitoring using SiTe iC actually improves patients self-care when compared to usual care and it has the potential to avoid patient re-hospitalizations. This study demonstrated that the identified functional requirements for telemonitoring systems are relevant. In addition, thanks to SiTe iC, HF patients would take a more active role in their disease management by improving self-care.

Health literacy and its predictors among urban and rural adults in Bijar County

BACKGROUND AND PURPOSE

The World Health Organization has identified health literacy (HL) as one of the most important determinants of people's health. Therefore, this research aimed to investigate the status of HL and its predictors.

MATERIALS AND METHODS

This research was a cross-sectional study that was performed on 600 adults in Bijar County, Iran. Cluster sampling was used to select the samples. Data were collected using the questionnaire of HL for Iranian adults. Data were analyzed using one-way analysis of variance, Student's t-test, and multiple linear regression in SPSS 21.

RESULTS

The mean score of HL was 3.6 out of 5; 69% and 29% of the samples had a moderate-to-high health status, respectively. Among the dimensions of HL, the highest and the lowest means were perception (3.94) and evaluation (3.21), respectively. Based on the multiple regression results, the variables (gender - B = -0.142, confidence interval [CI]: -0.409 to -0.011, P = 0.39; education level - B = 0.391, CI: 0.149-0.287, P = 0.00; and income level - B = 0.203, CI: 0.00-0.00, P = 0.01) were significantly positively associated with HL.

CONCLUSION

The results of this study can be applied to educational interventions through media and radio-television to increase public awareness. Education is also strongly recommended in terms of demographic variables and characteristics to promote HL in the society.

Factors Associated with Low Awareness of Heart Failure in the General Population of Korea

Background and Objectives

Factors associated with low heart failure (HF) awareness have not been well-evaluated. This study was conducted to find out which demographic features would be associated with low HF awareness in the general population of Korea.

Methods

A telephone interview was conducted with 1,032 adults (58 years and 50.6% were male) across the country. Based on answer to 15 questions about HF, we scored from 0 to 15 points (mean, 7.53±2.75; median, 8; interquartile range, 6–9). A score of <8 was defined as low HF awareness, and a score of ≥8 was defined as high HF awareness.

Results

A total of 478 subjects (46.3%) had low HF awareness. HF awareness scores were 5.18±1.85 and 9.55±1.50 in subjects of low and high HF awareness groups, respectively. Subjects with low HF awareness were older, more female-dominant, more diabetic, lower educational and house hold income levels, and more frequently living in rural areas, compared to those with high HF awareness (p<0.05 for each). In multivariable logistic regression analyses, older age (≥67 years: odds ratio [OR], 1.61; 95% confidence interval [CI], 1.16–2.19; p=0.004), female sex (OR, 1.33; 95% CI, 1.02–1.73; p=0.034) and low educational level (high school graduate or less vs. college graduate: OR, 2.38; 95% CI, 1.75–3.22; p<0.001) were significantly associated with low HF awareness even after controlling for potential confounders.

Conclusions

Older age, female sex, and lower level of education were independently associated with low HF awareness in the general Korean population. More attention and education are needed for these vulnerable groups to improve HF awareness.

Predictors of rehospitalization for community-dwelling older adults with chronic heart failure: A structural equation model

AIMS

To examine the effects of health literacy, activities of daily living, frailty and self-care on rehospitalization for older adults with chronic heart failure using a structural equation model.

DESIGN

This was a cross-sectional study.

METHODS

Two hundred and seventy-one older patients with chronic heart failure were recruited using a convenience sampling method from three community healthcare centres in Guangzhou, Southern China. The data were collected using a questionnaire survey between April 2018 and October 2018 by three research assistants.

FINDINGS

The proposed model revealed a good fit to the data (χ² /d.f. = 2.39, root mean square error of approximation = 0.06, goodness of fit index = 0.93, comparative fit index = 0.91, normed fit index = 0.91). Health literacy (β = 0.21), activities of daily living (β = 0.43), frailty (β = 0.29) and self-care (β = 0.40) directly affected the rehospitalization of older patients with chronic heart failure. Health literacy (β = 0.19), activities of daily living (β = 0.36) and frailty (β = 0.33) indirectly affected rehospitalization through self-care. Frailty (β = 0.16) indirectly affected rehospitalization by activities of daily living. Activities of daily living had the highest direct and total effects on rehospitalization; the effect values were 0.43 and 0.57, respectively.

CONCLUSION

Community-dwelling older adults with chronic heart failure who had limited health literacy, frailty, declined activities of daily living and lower self-care were eligible for rehospitalization. Self-care and activities of daily living were considered mediators between rehospitalization and its predictors. A future longitudinal study is required to validate the results.

IMPACT

Tailored and targeted measures aiming to enhance self-care and activities of daily living have been developed for older patients with chronic heart failure because they are not only predictors but also mediators. Assessment of health literacy level of this population is the first step before developing health education. Frailty of patients with chronic heart failure should be reduced to a minimum level.

Enablers and obstacles to implementing remote monitoring technology in cardiac care: A report from an interactive workshop

An ageing population and chronic disease are putting pressure on the Irish health system. The field of eHealth is rapidly evolving and has the potential to become an important component of healthcare, but there appears to be a gap currently between research in this field and the integration of eHealth technology into clinical practice. During the eHealth Ireland Ecosystem Conference held in April 2018, a workshop was conducted to explore the barriers and facilitators to the adoption of eHealth technology, particularly remote monitoring systems in community and home cardiac care. Participants included clinicians, academic researchers, technologists, patient advocates, policy makers, and representatives from the health service. The conversations in the workshop pivoted around why technology systems in cardiac care rarely moved beyond the research project stage and what can be done to address this issue. The discussions in the workshop focused around the lack of funding available, the need for reimbursement models, the lack of awareness about remote monitoring, the angst about who is responsible for the data generated, the design of systems, regulatory standards, and the increasing demand on services, education, and patient empowerment.

Determinants of Self-Care in Patients With Heart Failure: Observations From a Developing Country in the Middle East

Introduction: Self-care is recognized as a means for improving outcomes of heart failure (HF), yet studies have not addressed what predicts successful self-care in collectivist cultures like Lebanon. Methodology: Self-care was measured, using the Arabic Self-Care of HF index, in 100 participants with HF (76% males; mean age 67.59) recruited from a tertiary medical center. Results: Self-care was suboptimal, with mean scores of 67.26, 66.96, and 69.5 for self-care maintenance, management, and confidence. Better HF knowledge, social support, and self-care confidence and lower New York Heart Association score predicted better self-care maintenance. Better knowledge, social support, and self-care maintenance, no recent hospitalization, and being unemployed predicted better self-care confidence. Better self-care confidence, maintenance, and HF knowledge predicted better self-care management. Discussion: HF self-care in Lebanon is suboptimal. Nurses need to identify facilitators of and barriers to self-care particular to this population. Interventions targeting HF knowledge, confidence, and caregiver support are expected to improve self-care in Lebanese patients.

Functional Health Literacy in chronic cardiovascular patients

Functional Health Literacy (FHL) is the ability to retrieve, process and understand information in order to make appropriate decisions regarding self-care, defined by the World Health Organization as a social determinant of health. Its evaluation is important especially between patients with noncommunicable chronic diseases, given the need of permanent health care. This paper aims to evaluate the FHL in patients with chronic cardiovascular diseases and possible implications to the understanding of the disease and medical instructions and adherence to the measures proposed by health professionals. This is a cross-sectional and quantitative study with the application of tool S-TOFHLA and a structured questionnaire on 345 patients of a cardiovascular disease outpatient service in Juiz de Fora. Less than a half (49.3%) of the sample showed adequate FHL. Satisfactory FHL was associated with lower ageand higher schooling. Lower FHL evidenced that it can influence the impaired comprehension of the disease and medical instructions and the rare habit to question professionals. A high prevalence of inadequate FHL was identified in our sample and was associated with the impaired understanding of the disease and medical instructions, showing the need to streamline medical communication in this group.

Knowledge among patients with heart failure: A narrative synthesis of qualitative research

BACKGROUND

Patients' knowledge of heart failure (HF) is integral to improved outcomes. However, the HF literature has not adequately explored the nature of patients' knowledge of HF as part of their lived experience.

OBJECTIVES

We aimed to characterize the nature of patients' knowledge of HF, in the context of living with the disease.

METHODS

We conducted a narrative synthesis of qualitative studies that addressed patients' knowledge of HF. Studies were systematically searched and retrieved from MEDLINE, CINAHL, PsycINFO and PsycARTICLES databases. Findings were synthesized using an iterative coding process carried out by multiple analysts and reported following Enhancing Transparency in the Reporting of Qualitative Health Research (ENTREQ) criteria.

RESULTS

Analysis of 73 eligible articles produced five themes: the content that comprises HF knowledge; development of HF knowledge over time; application of HF knowledge for decision making; communication of information between clinicians and patients; and patients' experience of knowledge.

CONCLUSION

The nature of patients' knowledge of HF is both explicit and implicit, dynamic, and personal. This multidimensional model of knowledge-in-context calls for equally multidimensional research and intervention design.

A multi-component, family-focused and literacy-sensitive intervention to improve medication adherence in patients with heart failure-A randomized controlled trial

BACKGROUND

Medication nonadherence is prevalent and links to serious outcomes (e.g., rehospitalization/death) in heart failure (HF) patients; therefore, an urgent need exists for an intervention to improve and sustain adherence after intervention completion.

OBJECTIVES

To test the efficacy of a multi-component, family-focused, literacy-sensitive (FamLit) intervention on medication adherence in HF patients.

METHODS

Forty-three HF patients and their care partners were enrolled and randomized to receive FamLit or attention-only intervention, including an in-person session at baseline and bi-weekly phone boosters for 3 months. We measured medication adherence from baseline to 3-month post-intervention using the Medication Event Monitoring System.

RESULTS

After 3-month intervention, intervention patients had significantly better medication adherence than control patients. At 6 months (3-months post-intervention), intervention effect on adherence was sustained in the FamLit intervention group, while adherence decreased in the control group.

CONCLUSION

Incorporating care partner support and providing an easy-to-understand intervention to patients-care partners may improve/sustain adherence.

Influence of depression and gender on symptom burden among patients with advanced heart failure: Insight from the pain assessment, incidence and nature in heart failure study

INTRODUCTION

Patients with advanced heart failure (HF) experience many burdensome symptoms that increase patient suffering.

METHODS

Comparative secondary analysis of 347 patients with advanced HF. Symptom burden was measured with the Memorial Symptom Assessment Scale-HF. Depression was measured using the Patient Health Questionnaire-9.

RESULTS

Mean number of symptoms was 13.6. The three most frequent symptoms were non-cardiac pain, shortness of breath, and lack of energy. Patients with depression reported higher symptom burden. Symptom burden differed when compared by gender. Women reported higher symptom burden for other pain, dry mouth, swelling of the arms and legs, sweats, feeling nervous, nausea, and vomiting. Men reported higher symptom burden with sexual problems.

CONCLUSIONS

Given the high rates of symptoms and distress, interventions are needed to alleviate the symptom burden of patients with advanced HF. Reported symptom burden in patients with advanced heart failure was higher when depressive symptoms were present. Women reported varied number and severity of symptoms than men.

[Benefits of integrated care delivery system for heart failure: A case study of Intermountain Healthcare (USA)]

BACKGROUND

Among chronic diseases, heart failure is a top public health priority both in France and in the United States. If progress is possible in France, the experience from Intermountain Healthcare (IH), in the United States can be a source of significant experimentations.

AIM

To identify the teaching of the clinical integration of the specialists in the field of heart failure with the primary care sector which could be useful in France.

METHODS

This research is based on the qualitative analysis of data resulting from the work between experts, of bibliographical research, and of some groupings by item corresponding to the objectives of the Triple Aim from the Institute for Healthcare Improvement (IHI).

RESULTS

The program of the integrated care delivery system for heart failure of Intermountain Healthcare reaches the objectives of the Triple Aim from the IHI, that is to say, the enhancement of the health of the population, improving quality of care and the satisfaction of the user, and the reduction of the cost of care. This program also enhances the Chronic Care Model by integrating a team of specialists in the field of heart failure, building up a pluridisciplinary team focused on the need of both the patients and their families. This creates a multidisciplinary care delivery system for heart failure which is global, protocolized, stratified, planned and followed. The prevention and the ambulatory care integrating the specialized care of second stage to the care of first stage are developed. The users and their families are co-responsible for their health. The systematic evaluation is based on the specific indicators.

DISCUSSION

This program improves the effectiveness of care while improving organizational efficiency resulting in savings for IH Health Plan (SelectHealth). It also enhances the equality of access to better healthcare and health for the entire population.

Concurrent validity and acceptability of health literacy measures of adults hospitalized with heart failure

OBJECTIVES

To test concurrent validity and acceptability of the Single Item Literacy Screener (SILS), Test of Functional Health Literacy (S-TOFHLA) and the Newest Vital Sign (NVS) in hospitalized adults with heart failure (HF).

BACKGROUND

Health literacy is not routinely evaluated in adults hospitalized with HF. Low health literacy is linked to poor HF self-care and hospital readmissions.

METHODS

SILS, NVS and S-TOFHLA were completed by 85 patients with HF. Measures were examined for internal consistency reliability and acceptability. The NVS and S-TOFHLA were correlated with the SILS to establish concurrent validity.

RESULTS

The NVS (α = 0.70) and S-TOFHLA (α = 0.88) were reliable. The SILS significantly correlated with the S-TOFHLA (r = -0.308). The S-TOFHLA (M = 6.16) and NVS (M = 6.10) were acceptable measures.

CONCLUSION

The S-TOFHLA and NVS were reliable and acceptable measures of health literacy in hospitalized HF population. The SILS correlated with the S-TOFHLA and may predict low health literacy when hospitalized. NVS total scores in this population aligned with the recent NAAL survey. Hospitalized adults with HF agreed to share the health literacy scores with their providers.

Health Literacy and 1-Year Mortality: Mechanisms of Association in Adults Hospitalized for Cardiovascular Disease

OBJECTIVE

To test theorized patient-level mediators in the causal pathway between health literacy (HL) and 1-year mortality in adults with cardiovascular disease (CVD).

PATIENTS AND METHODS

A total of 3000 adults treated at Vanderbilt University Hospital from October 11, 2011, through December 18, 2015, for acute coronary syndrome or acute decompensated heart failure (ADHF) participated in the Vanderbilt Inpatient Cohort Study. Participants completed a bedside-administered survey and consented to health record review and longitudinal follow-up. Multivariable mediation models examined the direct and indirect effects of HL (a latent variable with 4 indicators) with 1-year mortality after discharge (dichotomous). Hypothesized mediators included social support, health competence, health behavior, comorbidity index, type of CVD diagnosis, and previous-year hospitalizations.

RESULTS

Of the 2977 patients discharged from the hospital (60% male; mean age, 61 years; 83% non-Hispanic white, 37% admitted for ADHF), 17% to 23% had inadequate HL depending on the measure, and 10% (n=304) died within 1 year. The total effect of lower HL on 1-year mortality (adjusted odds ratio [AOR]=1.31; 95% CI, 1.01-1.69) was decomposed into an indirect effect (AOR=1.50; 95% CI, 1.35-1.67) via the mediators and a nonsignificant direct effect (AOR=0.87; 95% CI, 0.66-1.14). Each SD decrease in HL was associated with an absolute 3.2 percentage point increase in the probability of 1-year mortality via mediators admitted for ADHF, comorbidities, health behavior, health competence, and previous-year hospitalizations (listed by contribution to indirect effect).

CONCLUSION

Patient-level factors link low HL and mortality. Health competence and health behavior are modifiable mediators that could be targeted by interventions post hospitalization for CVD.

Health Literacy but Not Frailty Predict Self-Care Behaviors in Patients with Heart Failure

Heart failure (HF) is a chronic condition requiring continuous self-care. Health literacy is increasingly recognized as a key factor of self-care behaviors in patients with chronic diseases. Recently, frailty in chronic diseases has also been associated with self-care behaviors. However, relationships among health literacy, frailty, and self-care in the HF population are not well understood. Therefore, this cross-sectional study aimed to identify the impact of health literacy and frailty on self-care behaviors in patients with HF. Data were collected from 281 adults attending a cardiovascular outpatient clinic in Korea. Health literacy, frailty, and self-care behaviors were measured using Korean-validated instruments. The mean scores of health literacy and self-care behaviors were 8.89 (±3.44) and 31.49 (±5.38), respectively. The prevalence of frailty was around 26.3%. Health literacy was significantly associated with frailty and self-care behaviors. In a hierarchical linear regression analysis, health literacy was a significant determinant of self-care behaviors after adjusting for confounding variables, but frailty was not. Educational level was also a significant predictor of self-care behaviors. Our main findings showed that health literacy can facilitate improvements in HF self-care behaviors. Healthcare professionals should assess patients’ health literacy and educational backgrounds when designing self-management programs.

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Medicare Expenditures by Race/Ethnicity After Hospitalization for Heart Failure With Preserved Ejection Fraction

OBJECTIVES

The purpose of this study was to analyze cumulative Medicare expenditures at index admission and after discharge by race or ethnicity.

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a growing proportion of heart failure (HF) admissions. Research on health care expenditures for patients with HFpEF is limited.

METHODS

Records of patients discharged from the Get With The Guidelines-Heart Failure registry between 2006 and 2014 were linked to Medicare data. The primary outcome was unadjusted payments for acute care services. Comparisons between race/ethnic groups were made using generalized linear mixed models. Cost ratios were reported by race/ethnicity, and adjustments were made sequentially for patient characteristics, hospital factors, and regional socioeconomic status.

RESULTS

Median Medicare costs for index hospitalizations were $7,241 for the entire cohort, $7,049 for whites, $8,269 for blacks, $8,808 for Hispanics, $8,477 for Asians, and $8,963 for other races. Median costs at 30 days for readmitted patients were $9,803 and $17,456 for the entire cohort at 1-year. No significant differences were seen in index admission cost ratios by race/ethnicity. At 30 days among readmitted patients, costs were 9% higher (95% confidence interval [CI]: 1% to 17%; p = 0.020) for blacks in the fully adjusted model than whites. At 1 year, costs were 14% higher (95% CI: 9% to 18%; p < 0.001) for blacks, 7% higher (95% CI: 0% to 14%; p = 0.041) for Hispanics, and 24% higher (95% CI: 8% to 42%; p = 0.003) for patients of other races. No significant differences between white and Asian expenditures were noted.

CONCLUSIONS

Minority patients with HFpEF have greater acute care service costs. Further research of improving care delivery is needed to reduce acute care use for vulnerable populations.

The effect of nurse-led group discussions by race on depressive symptoms in patients with heart failure

BACKGROUND

African Americans with heart failure (HF) have the highest rates of depression among all ethnicities in the USA.

OBJECTIVES

To compare the effects by race on depressive symptoms and topics discussed in the first clinic appointment after HF hospitalization.

METHODS

This study is a secondary analysis of data from a randomized clinical trial testing a patient group discussion of HF self-management with 93 Caucasians and 77 African Americans.

RESULTS

Reduction in depressive symptoms was significantly greater among African American patients within the intervention group (F = 3.99, p = .047) than controls. There were significant differences by race in four topics (dietitian referral, appointment date, help preparing discussion questions, and advice on worsening HF symptoms) concerning patient-physician discussions.

CONCLUSION

The intervention showed greater effect in reducing depressive symptoms among African Americans than Caucasians. Preparing patients for discussions at physician appointments on diet, depressive symptoms, and HF symptoms is recommended.

Health Literacy in Older Latinos With Heart Failure: A Systematic Review

BACKGROUND

By 2050, one-third of US residents will be Latino, with an incidence of heart failure (HF) higher than other ethnicities. Culturally linked risk factors and socioeconomic challenges result in cardiometabolic risks, healthcare disparities, and worsening health outcomes. Individuals with low health literacy (HL) and HF are less likely to possess tools for optimal self-care, disease management, or preventative health strategies.

OBJECTIVE

In this systematic review, we analyzed the literature studying older Latinos with HF and limited HL.

METHOD

We searched the literature and used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in an iterative process. Inclusion criteria were research studies, Latinos, HF, and HL.

RESULTS

Eight quantitative studies were identified for final review. Inadequate HL was reported in 87.2% of elderly Latinos. Higher HL was associated with more HF knowledge. Clinics serving minorities reported lower HL levels and higher medical complexity.

CONCLUSIONS

Nurses and advanced practice nurses serve a pivotal role improving access and understanding of health information. Before conducting intervention research affecting clinical outcomes, it is essential to describe elderly Latinos with HF and their HL and self-care levels. Barriers identified confirm the need to alter research protocols for older adults and ensure the availability of assistive devices. The need to examine HL in older Latinos with HF is confirmed by the medical complexity of ethnic minority patients with limited HL, limited HL in the elderly, and the relationship of HL with HF knowledge. In culturally diverse populations, HL levels alone may not be reliable predictors of a person's ability to self-manage, recognize symptoms, and develop, implement, and revise a self-care action plan to manage their health.

Improving Health Outcomes for Low Health Literacy Heart Failure Patients

According to the National Assessment of Adult Literacy (2003), only 12% of U.S. adults have a proficient level of health literacy, with adults 65 years and older more likely to have a below basic or a basic health literacy level. An estimated 5.8 million individuals in the United States have heart failure (HF) and it is one of the most common reasons for those aged 65 and over to be hospitalized. Many patients with HF are at risk for poor health outcomes due to low health literacy. This article reviews the literature with regard to the effectiveness of methods used to address low health literacy among HF patients and describes a pilot study implemented by a home care agency in the northeast to address high HF readmission rates.

Health-Related Quality of Life in Heart Failure Patients With Varying Levels of Health Literacy Receiving Telemedicine and Standardized Education

The purpose of this study was to examine the effect of telemonitoring plus education by home healthcare nurses on health-related quality of life in patients with heart failure who had varying health literacy levels. In this pretest/posttest treatment only study, 35 patients with a diagnosis of heart failure received home healthcare nurse visits, including education and telemonitoring. Heart failure education was provided by nurses at each home healthcare visit for approximately 15 to 20 minutes. All participants completed the Short-Form Test of Functional Health Literacy in Adults (S-TOFHLA) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) during the first week of home healthcare services. The MLHFQ was administered again at the completion of the covered home healthcare services period (1-3 visits per week for 10 weeks). Most participants were older adults (mean age 70.91±12.47) and had adequate health literacy (51.4%). Almost half of the participants were NYHA Class III (47.1%). All participants received individual heart failure education, but this did not result in statistically significant improvements in health-related quality-of-life scores. With telemonitoring and home healthcare nurse visits, quality-of-life scores improved by the conclusion of home healthcare services (clinically significant), but the change was not statistically significant. Individuals with marginal and inadequate health literacy ability were able to correctly use the telemonitoring devices.

Design of a bilevel clinical trial targeting adherence in heart failure patients and their providers: The Congestive Heart Failure Adherence Redesign Trial (CHART)

BACKGROUND

Socioeconomically disadvantaged patients are at an increased risk for adverse heart failure (HF) outcomes based upon nonadherence to medications and diet. Physicians are also suboptimally adherent to prescribing evidence-based therapy for HF.

METHODS

Congestive Heart Failure Adherence Redesign Trial (CHART) (NCT01698242) is a multicenter, bilevel, cluster randomized behavioral efficacy trial designed to assess the impact of intervening simultaneously on physicians and their socioeconomically disadvantaged patients (annual income <$30,000) having HF with reduced ejection fraction. Treatment arm physicians received individualized feedback on their adherence to prescribing evidence-based therapy. Their patients received weekly home visits from community health workers aimed at promoting understanding of HF and integrating adherence into daily life. Control arm physicians received regular updates on advances in HF management, and patients received monthly HF educational tip sheets produced by the American Heart Association. The primary outcome was all-cause hospital days over 30 months.

RESULTS

A total of 72 physicians (treatment, 35; control, 37) and their 320 patients (treatment, 157; control, 163) were recruited within 2 years. Randomization of physicians with all of their patients being assigned to the same arm was feasible and did not compromise the comparability of patients by arm. Using 5 recruiting hospitals located within disadvantaged neighborhoods produced a cohort that was primarily African American and representative of low-income urban patients with HF with reduced ejection fraction.

CONCLUSION

CHART will determine the value of intervening on low adherence simultaneously in physicians and their socioeconomically disadvantaged patients in reducing all-cause hospitalization days.

Health literacy among caregivers of patients with heart failure: A multicentre cross-sectional survey

AIMS AND OBJECTIVES

To assess the levels of health literacy of Italian caregivers of patients with heart failure.

BACKGROUND

Health literacy is related to patients' health outcomes. Low health literacy has been found in older people with heart failure, and less is known on the health literacy of caregivers whose patients are suffering from heart failure.

DESIGN

Observational, multicentre, cross-sectional study.

METHODS

From July 2015-May 2016, caregivers were recruited in five hospitals from Central and Southern Italy. To assess health literacy, the Italian version of the Short Test of Functional Health Literacy tool was used.

RESULTS

A total of 173 caregivers participated in the research, the majority being females (60.1%), aged between 46-60 years (52.6%) and 96 (55.5%) were from Central Italy. 33.5% of caregivers were patients' children, and 16.2% were paid caregivers of foreign origins. The average level of health literacy was adequate; however, lower levels were found among patients' spouses and those of older age.

CONCLUSION

Our results, in contrast with previous studies, showed adequate health literacy levels of caregivers. However, caregivers older in age and with a low education level showed the lowest health literacy, emphasising the need for healthcare workers, to check caregivers' health literacy, before entrusting them with the care of patients.

RELEVANCE TO CLINICAL PRACTICE

As this research gives, for the first time, an overview on Italian caregivers' levels of health literacy, its results may be used to improve Italian healthcare professionals' knowledge of caregivers' health literacy, before entrusting them with the care of patients.

Health Literacy and Health Status in People With Chronic Heart Failure

PURPOSE/AIM

The aim of this study was to investigate whether health literacy, self-efficacy, and medication adherence can explain or predict the variance in health outcomes (measured as perceived physical or mental health status [HS]) in persons with chronic heart failure (HF).

DESIGN

A nonexperimental cross-sectional survey study used data gathered from 175 patients with chronic HF from urban cardiology practices in the northeast United States.

METHODS

The Paasche-Orlow and Wolf Causal Pathways conceptual model and Bandura's self-efficacy theory were used to select and test variables in the study. A demographic questionnaire, the Short Test of Functional Health Literacy, the Self-Efficacy for Appropriate Medication Use Scale, the Morisky Medication Adherence Scale, and the Short Form-12 version 2 assessing perceived physical and mental HS were completed. Multiple hierarchical regression analyses were used to analyze relationships among the variables.

RESULTS

Significant associations between health literacy and self-efficacy and between health literacy and perceived mental HS were found (P < .05). High self-efficacy was the strongest predictor of physical HS (P < .01). The strongest predictor of mental HS was medication adherence (P < .01).

CONCLUSIONS

Support of self-efficacy and medication adherence may improve HS. Including health literacy strategies in clinical practice may support improvements in HS in people with chronic HF.