A trial of family partnership and education interventions in heart failure

Effects of dyadic care interventions for heart failure on patients' and caregivers' outcomes: A systematic review, meta-analysis and meta-regression

BACKGROUND

The contemporary model for managing heart failure has been extended to a patient-family caregiver dyadic context. However, the key characteristics of the model that can optimise health outcomes for both patients and caregivers remain to be investigated.

OBJECTIVES

This study aimed to identify the effects of dyadic care interventions on the behavioural, health, and health-service utilisation outcomes of patients with heart failure and their family caregivers and to explore how the intervention design characteristics influence these outcomes.

DESIGN

This study involved systematic review, meta-analysis, and meta-regression techniques.

METHODS

We performed a systematic review and meta-analysis, using 12 databases to identify randomised controlled trials or quasi-experimental studies published in English or Chinese between database inception and 31 December 2022. The considered interventions included those targeting patients with heart failure and their family caregivers to enhance disease management. Data synthesis was performed on various patient- and caregiver-related outcomes. The identified interventions were categorised according to their design characteristics for subgroup analysis. Meta-regression was performed to explore the relationship between care delivery methods and their effectiveness.

RESULTS

We identified 48 studies representing 9171 patient-caregiver dyads. Meta-analyses suggested the positive effects of dyadic care interventions on patients' health outcomes [Hedges' g (95 % confidence interval {CI}): heart failure knowledge = 1.0 (0.26, 1.75), p = 0.008; self-care confidence = 0.45 (0.08, 0.83), p = 0.02; self-care maintenance = 1.12 (0.55, 1.70), p < 0.001; self-care management = 1.01 (0.54, 1.49), p < 0.001; anxiety = -0.18 (-0.34, -0.02), p = 0.03; health-related quality of life = 0.30 (0.08, 0.51), p < 0.001; hospital admission (risk ratio {95 % CI}: hospital admission = 0.79 (0.65, 0.97), p = 0.007; and mortality = 0.58 (0.36, 0.93), p = 0.02)]. Dyadic care interventions also improved the caregivers' outcomes [Hedges' g (95 % CI): social support = 0.67 (0.01, 1.32), p = 0.05; perceived burden = -1.43 (-2.27, -0.59), p < 0.001]. Although the design of the identified care interventions was heterogeneous, the core care components included enabling and motivational strategies to improve self-care, measures to promote collaborative coping within the care dyads, and nurse-caregiver collaborative practice. Incorporating the first two core components appeared to enhance the behavioural and health outcomes of the patients, and the addition of the last component reduced readmission. Interventions that engaged both patients and caregivers in care provision, offered access to nurses, and optimised continuity of care led to better patient outcomes.

CONCLUSIONS

These findings demonstrate that dyadic care interventions can effectively improve disease management in a family context, resulting in better health outcomes for both patients and caregivers. Additionally, this study provides important insights into the more-effective design characteristics of these interventions.

REGISTRATION NUMBER

The review protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42022322492).

Dietary sodium and fluid intake in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC

Sodium and fluid restriction has traditionally been advocated in patients with heart failure (HF) due to their sodium and water avid state. However, most evidence regarding the altered sodium handling, fluid homeostasis and congestion-related signs and symptoms in patients with HF originates from untreated patient cohorts and physiological investigations. Recent data challenge the beneficial role of dietary sodium and fluid restriction in HF. Consequently, the European Society of Cardiology HF guidelines have gradually downgraded these recommendations over time, now advising for the limitation of salt intake to no more than 5 g/day in patients with HF, while contemplating fluid restriction of 1.5-2 L/day only in selected patients. Therefore, the objective of this clinical consensus statement is to provide advice on fluid and sodium intake in patients with acute and chronic HF, based on contemporary evidence and expert opinion.

Mediators of the Association Between Cognitive Function and Self-care Behaviors in Patients Hospitalized With an Exacerbation of Heart Failure

BACKGROUND

Patients with heart failure (HF) must engage in self-care, yet their self-care is often poor. Cognitive function commonly is impaired in HF and is associated with poor self-care. Heart failure knowledge and self-care confidence also are needed to preform self-care. Few investigators have examined mediators of the association of cognitive function with self-care.

OBJECTIVES

The aim of this study was to determine whether HF knowledge and self-care confidence mediated the association of cognitive function with self-care maintenance and management among patients with HF.

METHODS

This was a cross-sectional observational study of 164 patients with HF. Cognitive function was assessed using the Montreal Cognitive Assessment. Self-care maintenance and self-care management behaviors and self-care confidence were measured using the Self-care of Heart Failure Index. Heart failure knowledge was measured using the Dutch Heart Failure Knowledge Scale. We conducted 2 parallel mediation analyses using the PROCESS macro in SPSS, one for self-care maintenance and one for self-care management.

RESULTS

Cognitive function was indirectly associated with self-care maintenance through HF knowledge (indirect effect, 0.54; 95% confidence interval, 0.10-1.02) and self-care confidence (indirect effect, 0.26; 95% confidence interval, 0.04-0.54). Those with better cognitive function had more HF knowledge and self-care confidence. Better cognitive function was not directly associated with self-care management but indirectly associated with better self-care management through higher self-care confidence (indirect effect, 0.50; 95% confidence interval, 0.04-1.05).

CONCLUSIONS

Both HF knowledge and self-care confidence mediated the association of cognitive function with self-care maintenance, and only self-care confidence mediated the association between cognitive function and self-care management. Interventions targeting HF knowledge and self-care confidence may improve self-care even for those with lower cognitive function and need to be developed and tested.

Nurse-coordinated home-based cardiac rehabilitation for patients with heart failure: A scoping review

Objectives

This study aimed to review and summarize the studies of nurse-coordinated home-based cardiac rehabilitation for patients with heart failure.

Methods

The review was performed using Arksey and O'Malley's scoping review framework. A systematic search was conducted across eight databases, including PubMed, Embase, Web of Science, EBSCO, China Biomedical Literature Service System (SinoMed), China National Knowledge Infrastructure (CNKI), Wanfang Database, and Chinese Science and Technology Journals (CSTJ) Database, and Chinese Clinical Trial Registry, from inception to 30 April 2023. Articles relevant to the nurse-coordinated home-based cardiac rehabilitation for patients with heart failure were included.

Results

Eighteen studies were included in this review. These studies showed that nurses primarily focused on patient assessment, home-based cardiac rehabilitation planning and guidance, and follow-up. The studies also reported positive outcomes in patient safety, feasibility, and efficacy of the programs coordinated by nurses.

Conclusions

Home-based cardiac rehabilitation coordinated by nurses is beneficial to patients with heart failure. Future research will explore the potential of nurses in home-based cardiac rehabilitation for patients with heart failure, determine optimal evaluation criteria, and formulate safe, effective, and economical rehabilitation programs suitable for the patients.

Person with Heart Failure and Care Partner Dyads: Current Knowledge, Challenges, and Future Directions: State-of-the-Art Review

Over the past decade, there has been substantial growth in heart failure (HF) research that focuses on persons with HF and their care partners (family members or other close friends that provide unpaid support) as an interdependent team, or care dyad. In this state-of-the-art review, we use a dyadic lens to identify and summarize current research on HF care dyads, from qualitative studies, to nonexperimental quantitative studies, to randomized controlled trials. Although much work has been done, this literature is younger and less well-developed than care dyad literatures from other conditions (eg, cancer, Alzheimer's disease). We discuss the substantial challenges and limitations in this body of work, with an eye toward addressing common issues that impact rigor. We also look toward future directions, and discuss the promise dyadic research holds for improving patient, care partner, and relationship health.

Social network interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease

BACKGROUND

Globally, cardiovascular diseases (CVD, that is, coronary heart (CHD) and circulatory diseases combined) contribute to 31% of all deaths, more than any other cause. In line with guidance in the UK and globally, cardiac rehabilitation programmes are widely offered to people with heart disease, and include psychosocial, educational, health behaviour change, and risk management components. Social support and social network interventions have potential to improve outcomes of these programmes, but whether and how these interventions work is poorly understood.  OBJECTIVES: To assess the effectiveness of social network and social support interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease. The comparator was usual care with no element of social support (i.e. secondary prevention alone or with cardiac rehabilitation).  SEARCH METHODS: We undertook a systematic search of the following databases on 9 August 2022: CENTRAL, MEDLINE, Embase, and the Web of Science. We also searched ClinicalTrials.gov and the WHO ICTRP. We reviewed the reference lists of relevant systematic reviews and included primary studies, and we contacted experts to identify additional studies.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of social network or social support interventions for people with heart disease. We included studies regardless of their duration of follow-up, and included those reported as full text, published as abstract only, and unpublished data.

DATA COLLECTION AND ANALYSIS

Using Covidence, two review authors independently screened all identified titles. We retrieved full-text study reports and publications marked 'included', and two review authors independently screened these, and conducted data extraction. Two authors independently assessed risk of bias, and assessed the certainty of the evidence using GRADE. Primary outcomes were all-cause mortality, cardiovascular-related mortality, all-cause hospital admission, cardiovascular-related hospital admission, and health-related quality of life (HRQoL) measured at > 12 months follow-up.  MAIN RESULTS: We included 54 RCTs (126 publications) reporting data for a total of 11,445 people with heart disease. The median follow-up was seven months and median sample size was 96 participants. Of included study participants, 6414 (56%) were male, and the mean age ranged from 48.6 to 76.3 years. Studies included heart failure (41%), mixed cardiac disease (31%), post-myocardial infarction (13%), post-revascularisation (7%), CHD (7%), and cardiac X syndrome (1%) patients. The median intervention duration was 12 weeks. We identified notable diversity in social network and social support interventions, across what was delivered, how, and by whom.  We assessed risk of bias (RoB) in primary outcomes at > 12 months follow-up as either 'low' (2/15 studies), 'some concerns' (11/15), or 'high' (2/15). 'Some concerns' or 'high' RoB resulted from insufficient detail on blinding of outcome assessors, data missingness, and absence of pre-agreed statistical analysis plans. In particular, HRQoL outcomes were at high RoB. Using the GRADE method, we assessed the certainty of evidence as low or very low across outcomes. Social network or social support interventions had no clear effect on all-cause mortality (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.49 to 1.13, I2 = 40%) or cardiovascular-related mortality (RR 0.85, 95% CI 0.66 to 1.10, I2 = 0%) at > 12 months follow-up. The evidence suggests that social network or social support interventions for heart disease may result in little to no difference in all-cause hospital admission (RR 1.03, 95% CI 0.86 to 1.22, I2 = 0%), or cardiovascular-related hospital admission (RR 0.92, 95% CI 0.77 to 1.10, I2 = 16%), with a low level of certainty. The evidence was very uncertain regarding the impact of social network interventions on HRQoL at > 12 months follow-up (SF-36 physical component score: mean difference (MD) 31.53, 95% CI -28.65 to 91.71, I2 = 100%, 2 trials/comparisons, 166 participants; mental component score MD 30.62, 95% CI -33.88 to 95.13, I2 = 100%, 2 trials/comparisons, 166 participants).  Regarding secondary outcomes, there may be a decrease in both systolic and diastolic blood pressure with social network or social support interventions. There was no evidence of impact found on psychological well-being, smoking, cholesterol, myocardial infarction, revascularisation, return to work/education, social isolation or connectedness, patient satisfaction, or adverse events.  Results of meta-regression did not suggest that the intervention effect was related to risk of bias, intervention type, duration, setting, and delivery mode, population type, study location, participant age, or percentage of male participants.  AUTHORS' CONCLUSIONS: We found no strong evidence for the effectiveness of such interventions, although modest effects were identified in relation to blood pressure. While the data presented in this review are indicative of potential for positive effects, the review also highlights the lack of sufficient evidence to conclusively support such interventions for people with heart disease. Further high-quality, well-reported RCTs are required to fully explore the potential of social support interventions in this context. Future reporting of social network and social support interventions for people with heart disease needs to be significantly clearer, and more effectively theorised, in order to ascertain causal pathways and effect on outcomes.

Nurse-led heart failure educational interventions for patient and informal caregiver dyads: An integrative review

BACKGROUND

Heart failure is a major health problem with significant economic burden in the United States. Educating heart failure dyads (heart failure patient and informal caregiver) is a relatively new domain and is being proposed by providers, policy makers, and third-party payors. Nurse-led dyad education can improve quality of life and reduce hospital admissions in the heart failure population.

OBJECTIVES

This integrative literature review focused on evaluating design, delivery content, and outcomes of nurse-led dyadic educational interventions.

METHODS

PubMed, CINAHL, Cochrane, and Google Scholar databases (1999 -2022) were searched for quantitative and qualitative studies that included these search terms: heart failure, dyads, nonmedical caregivers, caregivers, randomized controlled trials, nurse-led education, education.

RESULTS

The search yielded 92 articles. The results included seven randomized controlled trials and one pilot study conducted from 2005 to 2017. Sample sizes ranged from 20 to 155 dyads. Dyads who received education interventions had positive outcomes. Face-to-face coaching provided stronger outcomes. Interventions varied in length from baseline to three months, with post-intervention follow-ups from one to 12 months.

CONCLUSIONS

A paucity of studies of nurse-led heart failure dyadic educational interventions have been reported in the literature. To advance the science and decrease heart failure readmissions, greater efforts to study and incorporate education and support for heart failure dyads is needed, along with assessment of both patient and caregiver outcomes.

Heart Failure Knowledge, Symptom Perception, and Symptom Management in Patients With Heart Failure

BACKGROUND

Prevention of heart failure (HF) exacerbations requires that patients carefully self-manage their condition. Symptom perception is a key component in self-care for patients with HF that involves monitoring for HF symptoms and recognizing symptom changes. Heart failure knowledge is a prerequisite for better symptom perception and symptom management. However, the relationships among HF knowledge, symptom perception, and symptom management remain unclear.

OBJECTIVE

The aim of this study was to explore the inter-relationships among HF knowledge, symptom monitoring, symptom recognition, and symptom response in patients with HF.

METHOD

We included 185 patients with HF in this study. Heart failure knowledge was measured using the Dutch HF Knowledge Scale. Symptom monitoring, symptom recognition, and symptom response were measured using the Self-care of HF Index. Structural equation modeling was used for data analyses.

RESULTS

Heart failure knowledge was associated with symptom monitoring (β = .357, P < .001). Symptom monitoring was directly associated with both symptom recognition (β = .371, P < .001) and symptom response (β = .499, P < .001). Symptom recognition was directly associated with symptom response (β = .274, P < .001). Heart failure knowledge was not directly associated with symptom recognition, nor with symptom response. Heart failure knowledge was indirectly associated with symptom recognition and symptom response through symptom monitoring.

CONCLUSION

Symptom monitoring is associated with both symptom recognition and symptom response and is a mediator between HF knowledge and symptom recognition and between HF knowledge and symptom response. This finding suggests that it is important for clinicians not just to increase patients' HF knowledge but also to enhance their skills of symptom monitoring and symptom recognition and promote symptom monitoring among patients to improve symptom response in self-care.

Improvement in Heart Failure Self-Care and Patient Readmissions with Caregiver Education: A Randomized Controlled Trial

Caregivers support heart failure (HF) self-care with little HF education. The purpose of this study was to evaluate the effectiveness of a caregiver-only educational intervention aimed at improving caregiver self-efficacy, perceived control, and HF knowledge, as well as patient self-care and 30-day cardiac readmission. In total, 37 patients and their caregivers were randomly assigned to a control condition or a caregiver-only educational intervention with telephone follow-up. Outcomes included patient 30-day cardiac readmission, patient self-care, caregiver self-efficacy, caregiver perceived control, and caregiver HF knowledge. Linear mixed model, Kaplan–Meier, and Cox regression analyses were used to determine the effects of the intervention on outcomes. Self-care maintenance ( p = 0.002), self-care management ( p = 0.005), 30-day cardiac readmission ( p = 0.003), and caregiver perceived control ( p < 0.001) were significantly better in the intervention group. The results suggest that interventions targeting caregiver HF education could be effective in improving HF patients’ 30-day cardiac readmissions, patient self-care, and caregiver perceived control.

Systematic Review of Dyadic Interventions for Ambulatory Care Sensitive Conditions: Current Evidence and Key Gaps

OBJECTIVES

Identify non-pharmacological interventions to support patient/caregiver dyads with ACSCs; review the effects of dyadic interventions on health services outcomes; and review the effectiveness of dyadic interventions on patient and caregiver biopsychosocial outcomes.

METHODS

A systematic review of randomized controlled trials (RCTs).

RESULTS

Twenty-six manuscripts representing 20 unique RCTs (Mean N = 154 patients, 140 caregivers) were eligible. Eleven RCTs examined caregiving in patients with HF, seven with T2DM, one with COPD, and one with mixed ACSCs. Dyadic interventions for ACSCs were diverse in terms of length and content, with most including an educational component. Only 4/26 included studies had a low risk of bias. Interventions were most successful at improving quality of life, clinical health outcomes, health behaviors, and health services outcomes, with fewer improvements in patient mental health outcomes, psychosocial outcomes, relationship outcomes, and caregiver outcomes in general. The largest effect sizes were reported from trials focused on T2DM.

CONCLUSIONS

High-quality research with consistent measuring instruments is needed to understand which interventions are associated with improved patient and caregiver outcomes.

CLINICAL IMPLICATIONS

There may be clinically relevant benefits to including caregivers in interventions for patients with ACSCs, and clinicians should consider this when devising treatment plans.

Care Partner Support Following a Diabetes Self-Management Education and Support Intervention

PURPOSE

The purpose of the study was to understand care partner (CP) perceptions of an interdisciplinary diabetes self-management education and support (DSMES) intervention and explore how the interdisciplinary DSMES intervention influences diabetes-specific day-to-day interactions from the CP's perspective.

METHODS

A multiple-methods research design comprised of an online survey including demographics and supportive behaviors and a semistructured interview was conducted. The survey was completed by 16 CPs. Of the 16 CPs, 11 participated in semistructured interviews. Survey data were analyzed using descriptive statistics. Thematic analysis of semistructured interviews was conducted.

RESULTS

CPs provided support in 3 primary areas: (1) meal planning and preparation (87.5%), (2) participating in physical activity (56.3%), and (3) assisting with technology (43.8%). The main themes described by CPs include (1) the importance of diabetes education for caregivers, including the information they retained from the program, the acquisition of tools to support the person with diabetes, and the desire for more and ongoing education; (2) diabetes education enhances the CP's ability to provide social support and the challenges associated with support; and (3) partners described collaborative diabetes management such as finding middle ground and making changes together.

CONCLUSION

CPs play a significant role in patient diabetes self-management by providing social support and partnership. DSMES programs should seek to include CPs to enhance patient support.

Self-Care Behaviors Mediate the Impacts of Social Support and Disease Knowledge on Health-Related Quality of Life in Patients With Heart Failure

This study was aimed to test the mediation effect of self-care on the associations of social support and heart failure (HF) knowledge with health-related quality of life (HRQOL). We analyzed baseline data from patients with HF ( n = 122) enrolled in a randomized controlled trial. Mediation analysis was conducted using Hayes’ PROCESS macro for SPSS with Model 4, based on the bias-corrected bootstrap method. Higher levels of social support and HF knowledge were associated with better self-care. Better self-care was associated with better HRQOL. While social support and HF knowledge had no significant direct effects on HRQOL, they indirectly affected HRQOL through self-care. Our findings suggest that social support and HF knowledge affect HRQOL indirectly through self-care. To improve the HRQOL in patients with HF, it is necessary to motivate them to perform regular self-care by enhancing their HF knowledge and providing social support.

Clinical trial identifier: KCT0002400 ( https://cris.nih.go.kr )

Reducing salt intake: a systematic review and meta-analysis of behavior change interventions in adults

CONTEXT

Prolonged high salt (sodium) intake can increase the risk of hypertension and cardiovascular disease. Behavioral interventions may help reduce sodium intake at the population level.

OBJECTIVE

The effectiveness of behavior change interventions to reduce sodium intake in adults was investigated in this systematic review and meta-analysis.

DATA SOURCE

The PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and EMBASE databases were searched.

DATA EXTRACTION

Narrative synthesis and random-effects meta-analyses were used to determine intervention efficacy. A total of 61 trials (46 controlled trials and 15 quasi-experimental studies) were included.

RESULTS

Behavior change interventions resulted in significant improvements in salt consumption behavior (eg, decrease in purchase of salty foods; increase in use of salt substitutes), leading to reductions in sodium intake as measured by urinary sodium in 32 trials (N = 7840 participants; mean difference, -486.19 mg/d [95%CI, -669.44 to -302.95]; P < 0.001; I2 = 92%) and dietary sodium in 19 trials (N = 3750 participants; mean difference -399.86 mg/d [95%CI, -581.51 to -218.20]; P < 0.001; I2 = 96%), equivalent to a reduction of >1 g of salt intake daily. Effects were not significantly different based on baseline sodium intakes, blood pressure status, disease status, the use of behavior change theories, or the main method of intervention delivery (ie, online vs face-to-face).

CONCLUSION

Behavior change interventions are effective at improving salt consumption practices and appear to reduce salt intake by >1 g/d.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020185639.

Caregiver Strain and Heart Failure Patient Clinical Event Risk: An Extension of Previous Work

BACKGROUND

In a study of Italian heart failure patient-caregiver dyads, greater caregiver strain significantly predicted lower patient clinical event risk.

OBJECTIVE

The purpose of this secondary analysis was to examine this relationship in a sample from the United States.

METHODS

Data came from 92 dyads who participated in a self-care intervention. Logistic regression was used to test the relationship between baseline strain (Bakas Caregiving Outcomes Scale, divided into tertiles) and patient likelihood of events (heart failure hospitalization/emergency visit or all-cause mortality) over 8 months.

RESULTS

Nearly half of patients (n = 40, 43.5%) had an event. High (vs low) caregiver strain was associated with a 92.7% event-risk reduction, but with substantial variability around the effect (odds ratio, 0.07; 95% confidence interval, 0.01-0.63; P = .02).

CONCLUSIONS

Although findings were similar to the Italian study, the high degree of variability and contrasting findings to other studies signal a level of complexity that warrants further investigation.

Insight Into Differences in Dietary Sodium Adherence Between Men and Women With Heart Failure

BACKGROUND

Men with heart failure are reported to be less adherent to low-sodium diets than women are. One potential reason may be that men consume more food and, consequently, more sodium than women do.

OBJECTIVES

The aims of this study were to compare dietary sodium intake, urine sodium excretion, and sodium density of diet consumed between men and women with heart failure and to determine whether sex moderated the relationship of kilocalories (kcals) consumed with dietary and urine sodium.

METHODS

A total of 223 patients with heart failure (mean age, 62 ± 12 years; 70% men, 46% New York Heart Association class III-IV) completed detailed 4-day food diaries and provided 24-hour urine sodium samples. To account for sodium density of food, dietary sodium and urine sodium were referenced to sodium per 1000 kcal.

RESULTS

On an absolute basis, men consumed 23% more kcals and 28% more sodium than women did; 24-hour sodium excretion was 16% higher in men than in women. There were no differences between men and women when dietary sodium and urinary sodium were referenced to 1000 kcal, indicating they consumed foods with similar sodium density. However, both moderation analyses showed that the dietary sodium intake of men and women with lower kcal intake was similar, whereas men with higher kcal intake consumed more sodium-dense foods than women did.

CONCLUSION

The results suggest that the men with higher sodium intake than women had 2 reasons for nonadherence. They consumed more food and foods with higher sodium density than women did.

Medication adherence in cardiovascular medicine

Cardiovascular disease is the leading cause of death globally. While pharmacological advancements have improved the morbidity and mortality associated with cardiovascular disease, non-adherence to prescribed treatment remains a significant barrier to improved patient outcomes. A variety of strategies to improve medication adherence have been tested in clinical trials, and include the following categories: improving patient education, implementing medication reminders, testing cognitive behavioral interventions, reducing medication costs, utilizing healthcare team members, and streamlining medication dosing regimens. In this review, we describe specific trials within each of these categories and highlight the impact of each on medication adherence. We also examine ongoing trials and future lines of inquiry for improving medication adherence in patients with cardiovascular diseases.

Caregiver autonomy support: A systematic review of interventions for adults with chronic illness and their caregivers with narrative synthesis

Chronic illnesses cause significant mortality in adults. Caregivers (spouses, adult children, friends) support adults with chronic illness in multiple ways, for instance through support of their autonomous decisions about how and why to engage in self-care.

AIM

To examine interventions designed to improve the health and well-being of adults with chronic illness by enhancing the autonomy supportive behaviours of caregivers.

DESIGN

Systematic review of randomized controlled trials with narrative synthesis.

DATA SOURCES

All available dates of publication through August 2020 conducted in PubMed, Medline, Ageline, PsychInfo, and CINAHL.

METHODS

Randomized controlled interventions of adults with chronic illness and their caregivers with content to enhance caregiver autonomy support were included. Interventions involving healthcare personnel, adults without self-care capacity, or not published in English were excluded. Quality was appraised using Joanna Briggs Institute recommendations. Common themes in autonomy support and associated outcomes (e.g., self-care, social support) were synthesized.

RESULTS

Search identified 1,426 studies with 16 included in review (N = 2,486 dyads). Methodological quality was moderate. Successful interventions were skills-based, targeted various communication styles, contained in-person elements, and involved nurses. Half of the interventions assessed autonomy support outcomes; 63% (5 of 8) of these improved autonomy support. Results were generally positive for social support, mixed for self-care, and null for caregiver burden. Heterogeneity and complexity of studies limited attribution of effects.

CONCLUSION

Behavioural interventions designed to enhance dyadic caregiver interpersonal communication to be autonomy supportive may positively influence caregiver skills and chronic illness outcomes. Future studies of autonomy support are needed to identify core intervention components.

IMPACT

This is the first systematic review examining interventions promoting caregiver to care-receiver autonomy support. Modifying interpersonal communication to be autonomy supportive has potential to improve chronic illness outcomes. Findings can inform how clinicians and investigators enlist caregiver autonomy support to encourage behaviour change.

The relational dynamics of caregivers of patients with a left ventricular assist device for destination-therapy: A qualitative investigation

BACKGROUND

Caregivers are critical to the recovery and management of patients with destination-therapy left ventricular assist devices (DT-LVADs).

OBJECTIVE

To explore the needs and impacts of caregiving for patients with DT-LVAD relative to the various relationships caregivers navigate from the shared perspectives of patients, caregivers, and healthcare providers.

METHODS

Qualitative descriptive secondary analysis. Patients with a DT-LVAD (n = 3), caregivers (n = 2), and healthcare providers (n = 13) from all DT-LVAD programs in Ontario, Canada were invited to participate in semi-structured interviews. We used thematic analysis to identify, analyze, organize, describe, and report caregiver-related themes.

RESULTS

Eighteen participants were interviewed. The needs and impact of caregiving for patients with DT-LVADs were characterized by connection with others (relational), and drastic and ongoing changes from normalcy within established and new relationships (dynamics).

CONCLUSIONS

DT-LVAD caregivers' unique needs may be a result of multi-leveled and compounding relational dynamics within and across established and new relationships. These could be considered to inform the content of targeted support strategies.

The Effect of Education with a Family-Centered and Client-Centered Approach on the Quality of Life in Patients with Stoma

Introduction: Colorectal cancer is known as the third leading cause of death from cancer in the world and the second cause of death in developing countries. Family care can positively affect the patient's general health system. The present study was conducted to determine and compare the effect of family-centered and client-centered training approaches on the life quality of individuals with digestive ostomy.

Methods: This is a semi-experimental study conducted on 60 individuals. The individuals participating in the present study were chosen from either those with digestive ostomy or their attendants. The participants fulfilled the requirements (criteria) for entering the present study. For conducting the training procedure, both groups received family-centered or client-centered training. Two months later, the quality of life of the individuals with digestive ostomy was measured once more. The data were then analyzed in SPSS version 21 by using chi-squared test, paired t-test, and independent t-test.

Results: According to the findings of the present study, there is no significant difference between the family-centered and the client-centered groups in terms of demographic features. By investigating the mean changes of both groups, There was a significant difference between quality of life score and spiritual-psychological aspect of scores before and after the intervention in the family-centered group.

Conclusion: The findings of the present study showed that family-centered education can increase the quality of life for people with gastrointestinal ostomy. This study concluded that family-centered education can be considered an effective intervention in people with gastrointestinal ostomy.

Health-Related Quality of Life and Use of Hospital Services by Patients with Heart Failure and Their Family Caregivers: A Multicenter Case-Control Study

BACKGROUND

Heart failure (HF) causes high rates of hospital admissions. It is known that disease progression impacts the health-related quality of life (HRQoL) of both patients and caregivers, yet to date, this finding is based on cross-sectional studies with limited samples.

OBJECTIVES

The study aim is to analyze the relationship between HF patients' use of hospital services (a proxy for disease progression) and the HRQoL of their family caregivers.

METHODS

This work is a multicenter nested case-control study on a population of patients admitted to hospitals in southern Spain due to heart failure. The sample comprised 530 patient-caregiver dyads. Hospital admission data were retrospectively collected for the 5 years prior to inclusion in the study. Bivariate analyses and multivariate logistic regression were used to determine associations between patient deterioration and caregivers' quality of life.

RESULTS

Patients' use of hospital services was associated with worsened quality of life for family caregivers, with an overall OR of 1.48 (95% CI: 1.23-1.79). A positive correlation was found between patients' perceptions of their physical health and the perceived mental health of caregivers (r = 0.127, p = 0.004) and between the perceived mental health of both (r = 0.291; p <0.0001).

CONCLUSIONS

Greater use of hospital services by patients with HF is an independent predictor of deterioration of family caregivers' HRQoL. The physical and mental components of patients' and their family caregivers' HRQoL interact and influence each other. Additional factors, such as the nature and intensity of care provided, also determine the worsening of a family caregiver's HRQoL.

CLINICAL RELEVANCE

These results can be used to identify family caregivers of people with heart failure at risk of suffering a deterioration in their health-related quality of life. Increased use of hospital services is an independent predictor of the deterioration of the family caregivers' health-related quality of life. Since clinical nurses are the main provider who gives support and education to family caregivers, they should be alert to this situation and individualize interventions to prevent this deterioration.

Dietary Sodium Restriction for Heart Failure: A Systematic Review of Intervention Outcomes and Behavioral Determinants

The 1500 mg/d dietary sodium restriction commonly recommended for patients with heart failure has recently been questioned. Poor adherence to sodium-restricted diets makes assessing the efficacy of sodium restriction challenging. Therefore, successful behavioral interventions are needed. We reviewed sodium restriction trials and descriptive studies of sodium restriction to: 1) determine if sodium restriction was achieved in interventions among heart failure patients; and 2) characterize predictors of successful dietary sodium restriction. Among 638 identified studies, 10 intervention trials, and 25 descriptive studies met inclusion criteria. We used content analysis to extract information about sodium restriction and behavioral determinants of sodium restriction. Dietary sodium was reduced in 7 trials; none achieved 1500 mg/d (range 1938-4564 mg/d). The interventions implemented in the interventional trials emphasized knowledge, skills, and self-regulation strategies, but few addressed the determinants correlated with successful sodium restriction in the descriptive studies (eg, social/cultural norms, social support, taste preferences, food access, self-efficacy). Findings suggest that incorporating determinants predictive of successful dietary sodium restriction may improve the success of interventional trials. Without effective interventions to deploy in trials, the safety and efficacy of sodium restriction remains unknown.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

A Tailored Dietary Sodium Intervention Using Technology and Psychosocial Support: A Pilot Study

BACKGROUND

In patients with heart failure (HF), high dietary sodium intake is common and associated with HF symptoms, poor health-related quality of life (HRQOL), and high hospitalization rates.

PURPOSE

The aims of this study were to examine the feasibility of a tailored dietary intervention with a practical tool (MyFitnessPal) and to obtain preliminary data about the effects on sodium intake, factors affecting sodium intake (knowledge, skills, experiences, confidence, perceived benefits and barriers, and depressive symptoms), HF symptoms, and HRQOL.

METHODS

A 6-session intervention was delivered to 11 participants. Paired t tests were used to compare the baseline outcomes with those at 3 months.

RESULTS

Participants completed 98% of intervention sessions, and 91% used MyFitnessPal. Sodium intake was reduced, and factors affecting sodium intake, symptoms, and HRQOL were improved (all P < .05).

CONCLUSION

The intervention was feasible and warrants further research to test the effects of the intervention on the outcomes using larger, heterogeneous samples.

Family-Centered Care During Constraint-Induced Therapy After Chronic Stroke: A Feasibility Study

PURPOSE

This feasibility study evaluated a theory-based intervention (CARE-CITE) designed to engage carepartners (CPs) in supporting stroke survivor upper extremity rehabilitation.

DESIGN

The study was a one-group design with pre- and posttest and 1 month follow-up (N = 7 dyads).

METHODS

Feasibility was determined by participant retention, CP and stroke survivor intervention adherence, and CP acceptability of the intervention (exit interview). Measures of CP depressive symptoms, fatigue, and family conflict around stroke recovery and stroke survivor upper extremity function are reported. Data were analyzed using descriptive statistics.

FINDINGS

All participants completed the study and adhered to the intervention, and CPs found CARE-CITE helpful. Descriptively, better scores were observed for CP's mental health, family conflict, stroke survivor confidence, and upper extremity tasks performed.

CONCLUSION

These results provide initial evidence that CARE-CITE is feasible after chronic stroke and that CPs and stroke survivors may benefit from family-centered care.

CLINICAL RELEVANCE

Improving CP skills in supporting rehabilitation activities may improve stroke survivor upper extremity function.

Low- Versus Moderate-Sodium Diet in Patients With Recent Hospitalization for Heart Failure: The PROHIBIT (Prevent Adverse Outcomes in Heart Failure by Limiting Sodium) Pilot Study

BACKGROUND

We conducted a pilot study to assess feasibility, on-study retention, trends in natriuretic peptide levels, quality of life, and safety of a 12-week feeding trial with 1500- versus 3000-mg daily sodium meals in high-risk patients with heart failure.

METHODS

Of 196 patients with recent (≤2 weeks) hospitalization for heart failure, ejection fraction ≤40%, on optimal medical therapy, functionally independent, and able to communicate, 83 (47%) consented to participate. Of these, 27 (age, 62±11 years; 22 men; 20 white; ejection fraction, 26±8%) had 24-hour urine sodium ≥3000 mg and agreed to randomly receive either 1500-mg (N=12) or 3000-mg (N=15) sodium meals.

RESULTS

On-study retention at 12 weeks was 77% (82% versus 73%; P=0.53); 6 patients (2 in 1500-mg, 4 in 3000-mg arm) withdrew before study completion. Food satisfaction questionnaires indicated that both diets were well tolerated. Quality of life improved in the 1500-mg arm at 12 weeks but did not change in the 3000-mg arm. Average compliance with meals was 52% (based on urinary sodium) and was not significantly different between arms (42% versus 60%; P=0.25). Study meals reduced 24-hour urinary sodium by 137±21 mmol (1500-mg arm) and 82±16 mmol (3000-mg arm), both P<0.001; between-arms difference was 55 mmol (95% CI, 3-107; P=0.037). NT-proBNP (N-terminal pro-B-type natriuretic peptide) was not affected. Hospitalizations and low blood pressure events did not differ significantly between arms. Serum creatinine decreased more (by 0.17 mg/dL [95% CI, 0.06-0.28]; P=0.003) in the 1500-mg arm. Creatinine increases >0.5 mg/dL over baseline only occurred in 1 patient in the 3000-mg arm.

CONCLUSIONS

Even with prepared meals, investigating optimal dietary sodium in heart failure comes with challenges, including need for extensive screening, reluctance to participate, and compliance issues. Because both diets reduced urinary sodium without adverse safety or quality of life signals, a larger trial, with modifications to improve participation and compliance, would be ethical and feasible.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02467296.

Attitudes, beliefs and barriers for adherence to the hyposodic diet in patients with heart failure

ABSTRACT Objectives: To identify attitudes, beliefs and barriers to adherence to the hyposodic diet in patients with heart failure and associated factors. Methods: Cross-sectional study with 41 individuals. The Dietary Sodium Restriction Questionnaire was used. Fisher's test was applied for analysis. Results: Attitudes were based on family and professional relationships; in the beliefs, it was highlighted to believe in the diet to improve health. As barriers, insufficient efforts were found to change the diet and taste of low salt foods. It was associated with adherence among the components factors such as: income, perception of cardiac improvement with the diet, family history of renal and heart failure and family adherence to the diet. Conclusions: The identified attitudes and beliefs refer, respectively, to social relationships and trust in the diet to improve health status. The barriers were: insufficient effort to modify the diet and food palatability. Economic, family and clinical factors were associated with hyposodic adherence.

Inviting Autonomy Back to the Table: The Importance of Autonomy for Healthy Relationship Functioning

Autonomy, or self-determination, is a key ingredient in promoting relationship flourishing. Although autonomy has long been an important concept in the family therapy field (labeled differentiation; Family therapy in clinical practice, 1978), definitional confusions and the ascendency of attachment theory and attachment-based clinical approaches to treating couples have relegated autonomy to a minor role at best and a caricature of rugged individualism and antirelational separateness at worst. Given recent research showing the importance of autonomy for the development of secure attachment in children and the key role autonomy plays in healthy intimate partner functioning, the concept of autonomy needs to take a more central role in our research and clinical practice with couples.

Cut-Point for Satisfactory Adherence of the Dietary Sodium Restriction Questionnaire for Patients with Heart Failure

BACKGROUND

The low or non-adherence to reduction of sodium intake has been identified as one of the main precipitating factors of heart failure (HF). The Dietary Sodium Restriction Questionnaire (DSRQ) identifies factors that can interfere with adherence to this recommendation. However, there is still no cut-point to define adherence for this questionnaire.

OBJECTIVES

To identify the cut-point for satisfactory adherence to the Brazilian version of the DSRQ, (the Questionário de Restrição de Sódio na Dieta, QRSD).

METHODS

Multicenter study. Patients with HF in outpatient treatment (compensated) and those treated in emergency departments due to acute HF (decompensated) were included. For the cut-point definition, the DSRQ scores were compared between groups. A ROC curve was constructed for each subscale to determine the best point of sensitivity and specificity regarding adherence. A 5% significance level was adopted.

RESULTS

A total of 206 compensated patients and 225 decompensated were included. Compensated patients exhibited scores that showed higher adhesion in all subscales (all p <0.05). Scores ≥ 40 points of a total of 45 for the subscale of Attitude and Subjective Norm; scores ≤ eight of a total of 20 for Perceived Behavioral Control; and ≤ three of a total of 15 for Dependent Behavior Control were indicative of satisfactory adherence.

CONCLUSIONS

Based on the evaluation of patients in these two scenarios, it was possible to determine the cut-point for satisfactory adherence to the reduction of sodium in the diet of patients with HF. Countries with similar culture could use this cut-point, as other researchers could also use the results as a reference for further studies.

Evaluating the Use of Mobile Health Technology in Older Adults With Heart Failure: Mixed-Methods Study

BACKGROUND

Heart failure (HF) is associated with high rates of hospitalizations, morbidity, mortality, and costs. Remote patient monitoring (mobile health, mHealth) shows promise in improving self-care and HF management, thus increasing quality of care while reducing hospitalizations and costs; however, limited information exists regarding perceptions of older adults with HF about mHealth use.

OBJECTIVE

This study aimed to compare perspectives of older adults with HF who were randomized to either (1) mHealth equipment connected to a 24-hour call center, (2) digital home equipment, or (3) standard care, with regard to ease and satisfaction with equipment, provider communication and engagement, and ability to self-monitor and manage their disease.

METHODS

We performed a pilot study using a mixed-methods descriptive design with pre- and postsurveys, following participants for 12 weeks. We augmented these data with semistructured qualitative interviews to learn more about feasibility, satisfaction, communication, and self-management.

RESULTS

We enrolled 28 patients with HF aged 55 years and above, with 57% (16/28) male, 79% (22/28) non-Hispanic white, and with multiple comorbid conditions. At baseline, 50% (14/28) rated their health fair or poor and 36% (10/28) and 25% (7/28) were very often/always frustrated and discouraged by their health. At baseline, 46% (13/28) did not monitor their weight, 29% (8/28) did not monitor their blood pressure, and 68% (19/28) did not monitor for symptoms. Post intervention, 100% of the equipment groups home monitored daily. For technology anxiety, 36% (10/28) indicated technology made them nervous, and 32% (9/28) reported fear of technology, without significant changes post intervention. Technology usability post intervention scored high (91/100), reflecting ease of use. A majority indicated that a health care provider should be managing their health, and 71% reported that one should trust and not question the provider. Moreover, 57% (16/28) believed it was better to seek professional help than caring for oneself. Post intervention, mHealth users relied more on themselves, which was not mirrored in the home equipment or standard care groups. Participants were satisfied with communication and engagement with providers, yet many described access problems. Distressing symptoms were unpredictable and prevailed over the 12 weeks with 79 provider visits and 7 visits to emergency departments. The nurse call center received 872 readings, and we completed 289 telephone calls with participants. Narrative data revealed the following main themes: (1) traditional communication and engagement with providers prevailed, delaying access to care; (2) home monitoring with technology was described as useful, and mHealth users felt secure knowing that someone was observing them; (3) equipment groups felt more confident in self-monitoring and managing; and finally, (4) uncertainty and frustration with persistent health problems.

CONCLUSIONS

mHealth equipment is feasible with potential to improve patient-centered outcomes and increase self-management in older adults with HF.

Essential considerations in developing attention control groups in behavioral research

Attention control groups strengthen randomized controlled trials of behavioral interventions, but researchers need to give careful consideration to the attention control activities. A comparative effectiveness research framework provides an ideal opportunity for an attention control group as a supplement to standard care, so participants potentially receive benefit regardless of group assignment. The anticipated benefit of the control condition must be independent of the study outcome. Resources needed for attention control activities need to be carefully considered and ethical considerations carefully weighed. In this paper we address nine considerations for the design and implementation of attention control groups: (1) ensure attention control activities are not associated with the outcome; (2) avoid contamination of the intervention or control group; (3) design comparable control and intervention activities; (4) ensure researcher training to adequately administer both treatment arms; (5) design control activities to be interesting and acceptable to participants; (6) evaluate attention control activities; (7) consider additional resources needed to implement attention control activities; (8) quantifying the effects of attention control and intervention groups; and (9) ethical considerations with attention control groups. Examples from the literature and ongoing research are presented. Careful planning for the attention control group is as important as for the intervention group. Researchers can use the considerations presented here to assist in planning for the best attention control group for their study.

Projected Costs of Informal Caregiving for Cardiovascular Disease: 2015 to 2035: A Policy Statement From the American Heart Association

Introduction:

In a recent report, the American Heart Association estimated that medical costs and productivity losses of cardiovascular disease (CVD) are expected to grow from $555 billion in 2015 to $1.1 trillion in 2035. Although the burden is significant, the estimate does not include the costs of family, informal, or unpaid caregiving provided to patients with CVD. In this analysis, we estimated projections of costs of informal caregiving attributable to CVD for 2015 to 2035.

Methods:

We used data from the 2014 Health and Retirement Survey to estimate hours of informal caregiving for individuals with CVD by age/sex/race using a zero-inflated binomial model and controlling for sociodemographic factors and health conditions. Costs of informal caregiving were estimated separately for hypertension, coronary heart disease, heart failure, stroke, and other heart disease. We analyzed data from a nationally representative sample of 16 731 noninstitutionalized adults ≥54 years of age. The value of caregiving hours was monetized by the use of home health aide workers’ wages. The per-person costs were multiplied by census population counts to estimate nation-level costs and to be consistent with other American Heart Association analyses of burden of CVD, and the costs were projected from 2015 through 2035, assuming that within each age/sex/racial group, CVD prevalence and caregiving hours remain constant.

Results:

The costs of informal caregiving for patients with CVD were estimated to be $61 billion in 2015 and are projected to increase to $128 billion in 2035. Costs of informal caregiving of patients with stroke constitute more than half of the total costs of CVD informal caregiving ($31 billion in 2015 and $66 billion in 2035). By age, costs are the highest among those 65 to 79 years of age in 2015 but are expected to be surpassed by costs among those ≥80 years of age by 2035. Costs of informal caregiving for patients with CVD represent an additional 11% of medical and productivity costs attributable to CVD.

Conclusions:

The burden of informal caregiving for patients with CVD is significant; accounting for these costs increases total CVD costs to $616 billion in 2015 and $1.2 trillion in 2035. These estimates have important research and policy implications, and they may be used to guide policy development to reduce the burden of CVD on patients and their caregivers.

Self-reported Adherence to a Low-Sodium Diet and Health Outcomes in Patients With Heart Failure

BACKGROUND

Most clinicians rely on patients' self-report of following a low-sodium diet to determine adherence of patients with heart failure (HF). Whether self-reported adherence to a low-sodium diet is associated with cardiac event-free survival is unclear.

PURPOSES

To determine (1) whether self-reported is concordant with adherence to a low-sodium diet measured by food diaries and 24-hour urinary sodium excretion and (2) whether self-reported adherence to a low-sodium diet predicts cardiac event-free survival.

METHODS

Adherence to a low-sodium diet was measured using 3 measures in 119 HF patients: (1) self-reported adherence, 1 item from the Self-care of Heart Failure Index scale; (2) a 3-day food diary; (3) 24-hour urinary sodium excretion. Patients were followed up for a median of 297 days to determine cardiac hospitalization or emergency department visit. One-way analysis of variance and Cox regression were used to address our purposes.

RESULTS

Self-reported adherence was concordant with adherence to a low-sodium diet measured by food diaries and 24-hour urinary sodium excretion. Thirty-one patients who reported they always follow a low-sodium diet had an average sodium intake less than 3 g/d (F = 5.07, P = .002) and 3.3 g of a mean 24-hour urinary sodium excretion (F = 3.393, P = .020). Patients who reported they never or rarely follow a low-sodium diet had 4.7 times greater risk of having cardiac events than did those who always followed a low-sodium diet (P = .017).

CONCLUSION

Self-reported adherence to a low-sodium diet predicted cardiac event-free survival demonstrating clinicians can use this as an indicator of adherence.

Caregiver Well-being and Patient Outcomes in Heart Failure: A Meta-analysis

BACKGROUND

Despite evidence from the broader caregiving literature about the interdependent nature of the caregiving dyad, few studies in heart failure (HF) have examined associations between caregiver and patient characteristics.

OBJECTIVE

The aim of this study is to quantitatively synthesize the relationships between caregiver well-being and patient outcomes.

METHODS

The MEDLINE, PsycINFO, and CINAHL databases were searched for studies of adult HF patients and informal caregivers that tested the relationship between caregiver well-being (perceived strain and psychological distress) and patient outcomes of interest. Summary effects across studies were estimated using random effects meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 15 articles meeting inclusion criteria were included in the meta-analysis. Taking into account differences across studies, higher caregiver strain was associated significantly with greater patient symptoms (Fisher z = 0.22, P < .001) and higher caregiver strain was associated significantly with lower patient quality of life (Fisher z = -0.36, P < .001). Relationships between caregiver psychological distress and both patient symptoms and quality of life were not significant. Although individual studies largely found significant relationships between worse caregiver well-being and higher patient clinical event-risk, these studies were not amenable to meta-analysis because of substantial variation in event-risk measures.

CONCLUSIONS

Clinical management and research approaches that acknowledge the interdependent nature of the caregiving dyad hold great potential to benefit both patients and caregivers.

Nursing research in heart failure care: a position statement of the american association of heart failure nurses (AAHFN)

BACKGROUND

Heart Failure (HF) is a public health problem globally affecting approximately 6 million in the United States.

OBJECTIVES

A tailored position statement was developed by the American Association of Heart Failure Nurses (AAHFN) and their Research Consortium to assist researchers, funding institutions and policymakers with improving HF clinical advancements and outcomes.

METHODS

A comprehensive review was conducted using multiple search terms in various combinations to describe gaps in HF nursing science. Based on gaps described in the literature, the AAHFN made recommendations for future areas of research in HF.

RESULTS

Nursing has made positive contributions through disease management interventions, however, quality, rigorous research is needed to improve the lives of patients and families while advancing nursing science.

CONCLUSIONS

Advancing HF science is critical to managing and improving patient outcomes while promoting the nursing profession. Based on this review, the AAHFN is putting forth a call to action for research designs that promote validity, sustainability, and funding of future nursing research.

Efficacy of a social support and problem-solving intervention on heart failure self-care: A pilot study

OBJECTIVE

The purpose of this study was to examine the preliminary effects of a coping partnership intervention comprised of social support and problem-solving on HF self-care maintenance, management, and confidence.

METHODS

A 3-group randomized controlled pilot study was conducted. The intervention group received 1 home visit, weekly (month 1), and biweekly (months 2 and 3) telephone calls. The attention group received telephone calls starting at week 2, following a similar pattern. The control group received usual care only. The Self-care of Heart Failure Index, was administered at baseline, 5, 9, and 13 weeks. Linear mixed modeling examined intervention effect on study outcomes.

RESULTS

A total of 66 participants completed the study. The participants were mean age 61 years; 54.2% male; 56% Non-Caucasian; and 43.9% New York Heart Association HF Class II. Significant treatment-by-time interaction effects were noted for self-care maintenance (F=4.813; p=0.010) and self-care confidence (F=4.469; p=0.014). There was no significant treatment-by-time interaction effect on self-care management.

CONCLUSIONS

Coping partnership interventions that strengthen support and social problem- solving may improve self-care maintenance and confidence in individuals with HF.

PRACTICE IMPLICATIONS

Clinicians should consider including these components in HF patient education and clinical follow-up.

An Intervention to Improve Physical Function and Caregiver Perceptions in Family Caregivers of Persons With Heart Failure

Objective: This randomized controlled trial was conducted to determine whether a 12-week home-based aerobic and resistance exercise program would improve physical function and caregiving perceptions among family caregivers (FCGs) of persons with heart failure. Method: Overall, 127 FCGs were randomized to one of three groups: usual care attention control (UCAC), psychoeducation only (PE), and psychoeducation plus exercise (PE + EX). Physical function measures (6-min walk test, handgrip, and upper and lower strength) and caregiving perceptions (Bakas Caregiving Outcomes Scale) were obtained at baseline and at 6 months. Results: FCGs in the PE + EX showed significant improvement in 6-min walk distance (p = .012), handgrip, and lower extremity strength compared with the PE and UCAC groups. The combined group had the greatest improvement in caregiver perceptions (p < .001). Conclusion: FCGs in the PE + EX group improved the most in physical function and caregiver perception outcomes. Directions for future research are provided.

Agreement between Heart Failure Patients and Their Primary Caregivers on Symptom Assessment

BACKGROUND

To decrease the readmission rate of heart failure (HF) patients, patients and their caregivers (CGs) should participate in symptoms assessment. This study aimed to assess the agreement between HF patients and their CGs on symptoms assessment.

METHODS

Using a correlational design, 100 HF patients with their CGs (100 dyads) were recruited from Department of Cardiology, Iranshahr, during August-December 2014. Data were collected using modified Heart Failure Symptom Survey (HFSS).Pearson and intra-class correlation coefficients (ICC) were used to analyze the degree of agreement within HF dyads, using SPSS16. The level of significance was set at 0.05.

RESULTS

The most frequent and severe symptom assessed equally by partners was shortness of breath (SOB). Dyads had a good agreement on assessment of extremity swelling (r=0.87, P≤0.01, ICC=0.861 CI: 0.798-0.901), SOB at rest (r=0.83, P≤0.01, ICC=0.775, CI: 0.680-0.845), SOB with activity (r=0.81, P≤0.01, ICC=0.795 CI: 0.711-0.858), and feeling depressed (r=0.77, P≤0.01, ICC=0.769, CI: 0.675-0.838). 28.6% of HF dyad had a good, 50% had a moderate, and 21.4 % had a poor agreement in assessment of HF symptoms.

CONCLUSION

Most of the HF dyad members did not agree with each other on the assessment of symptoms. Knowledge, skills and ability of each dyad in HF symptoms assessment should be included in the patients' discharge planning and nurses must modify their misunderstanding or inability.

A systematic review of heart failure dyadic self-care interventions focusing on intervention components, contexts, and outcomes

BACKGROUND

Having support from an informal carer is important for heart failure patients. Carers have the potential to improve patient self-care. At the same time, it should be acknowledged that caregiving could affect the carer negatively and cause emotional reactions of burden and stress. Dyadic (patient and informal carer) heart failure self-care interventions seek to improve patient self-care such as adherence to medical treatment, exercise training, symptom monitoring and symptom management when needed. Currently, no systematic assessment of dyadic interventions has been conducted with a focus on describing components, examining physical and delivery contexts, or determining the effect on patient and/or carer outcomes.

OBJECTIVE

To examine the components, context, and outcomes of dyadic self-care interventions.

DESIGN

A systematic review registered in PROSPERO, following PRISMA guidelines with a narrative analysis and realist synthesis.

DATA SOURCES

PubMed, EMBASE, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials were searched using MeSH, EMTREE terms, keywords, and keyword phrases for the following concepts: dyadic, carers, heart failure and intervention. Eligible studies were original research, written in English, on dyadic self-care interventions in adult samples.

REVIEW METHODS

We used a two-tiered analytic approach including both completed studies with power to determine outcomes and ongoing studies including abstracts, small pilot studies and protocols to forecast future directions.

RESULTS

Eighteen papers - 12 unique, completed intervention studies (two quasi- and ten experimental trials) from 2000 to 2016 were reviewed. Intervention components fell into three groups - education, support, and guidance. Interventions were implemented in 5 countries, across multiple settings of care, and involved 3 delivery modes - face to face, telephone or technology based. Dyadic intervention effects on cognitive, behavioral, affective and health services utilization outcomes were found within studies. However, findings across studies were inconclusive as some studies reported positive and some non-sustaining outcomes on the same variables. All the included papers had methodological limitations including insufficient sample size, mixed intervention effects and counter-intuitive outcomes.

CONCLUSIONS

We found that the evidence from dyadic interventions to promote heart failure self-care, while growing, is still very limited. Future research needs to involve advanced sample size justification, innovative solutions to increase and sustain behavior change, and use of mixed methods for capturing a more holistic picture of effects in clinical practice.

Shared heart failure knowledge and self-care outcomes in patient-caregiver dyads

BACKGROUND

Patient's knowledge about heart failure (HF) contributes to successful HF self-care, but less is known about shared patient-caregiver knowledge.

OBJECTIVES

The purpose of this analysis was to: 1) identify configurations of shared HF knowledge in patient-caregiver dyads; 2) characterize dyads within each configuration by comparing sociodemographic factors, HF characteristics, and psychosocial factors; and 3) quantify the relationship between configurations and patient self-care adherence to managing dietary sodium and HF medications.

METHODS

This was a secondary analysis of cross-sectional data (N = 114 dyads, 53% spousal). Patient and caregiver HF knowledge was measured with the Atlanta Heart Failure Knowledge Test. Patient dietary sodium intake was measured by 3-day food record and 24 h urine sodium. Medication adherence was measured by Medication Events Monitoring System caps. Patient HF-related quality of life was measured by the Minnesota Heart Failure Questionnaire; caregiver health-related quality of life was measured by the Short Form-12 Physical Component Summary. Patient and caregiver depression were measured with the Beck Depression Inventory-II. Patient and caregiver perceptions of caregiver-provided autonomy support to succeed in heart failure self-care were measured by the Family Care Climate Questionnaire. Multilevel and latent class modeling were used to identify dyadic knowledge configurations. T-tests and chi-square tests were used to characterize differences in sociodemographic, clinical, and psychosocial characteristics by configuration. Logistic/linear regression were used to quantify relationships between configurations and patient dietary sodium and medication adherence.

RESULTS

Two dyadic knowledge configurations were identified: "Knowledgeable Together" (higher dyad knowledge, less incongruence; N = 85, 75%) and "Knowledge Gap" (lower dyad knowledge, greater incongruence; N = 29, 25%). Dyads were more likely to be in the "Knowledgeable Together" group if they were White and more highly educated, if the patient had a higher ejection fraction, fewer depressive symptoms, and better autonomy support, and if the caregiver had better quality of life. In unadjusted comparisons, patients in the "Knowledge Gap" group were less likely to adhere to HF medication and diet. In adjusted models, significance was retained for dietary sodium only.

CONCLUSIONS

Dyads with higher shared HF knowledge are likely more successful with select self-care adherence behaviors.

Dialogues between nurses, patients with heart failure and their partners during a dyadic psychoeducational intervention: a qualitative study

OBJECTIVES

To describe nurses' documentation of the content in a psychoeducational intervention inspired by Stuifbergen's model addressing cognitive, supportive and behavioural needs of patient-partner dyads affected by heart failure.

DESIGN

A descriptive qualitative design was used analysing nurses' documentation in a dialogue guide based on a health promotion model.

SETTINGS

The dialogue guide was used during three nurse-led sessions at two heart failure clinics in Sweden with patients affected with heart failure and their partners during the years 2005-2008.

PARTICIPANTS

The dialogue guides from 71 patient-partner dyads were analysed using direct deductive content analyses. Patients' mean age was 69 years and 31% were female, partners' mean age was 67 years and 69% were female.

RESULTS

The findings supported the conceptual health promotion model and identified barriers, recourses and self-efficacy described by the dyads within each category.

CONCLUSION

The dyads described that during the sessions, they had gained enhanced knowledge and greater confidence to handle their life situation and expressed that they needed psychoeducational support during the whole illness trajectory. The results may guide and help to improve content and quality when caring for patients affected with heart failure and their partners and also when designing new interventions.

TRIAL REGISTRATION NUMBER

NCT02398799; Post-results.

Caregiver determinants of patient clinical event risk in heart failure

BACKGROUND

Preventing hospitalization and improving event-free survival are primary goals of heart failure (HF) treatment according to current European Society of Cardiology guidelines; however, substantial uncertainty remains in our ability to predict risk and improve outcomes. Although caregivers often assist patients to manage their HF, little is known about their influence on clinical outcomes.

AIMS

To quantify the influence of patient and caregiver characteristics on patient clinical event risk in HF.

METHODS

This was a secondary analysis of data using a sample of Italian adults with HF and their informal caregivers ( n = 183 patient-caregiver dyads). HF patients were followed over 12 months for the following clinical events: hospitalization for HF, emergency room visit for HF or all-cause mortality. Influence of baseline caregiver- and patient-level factors (patient and caregiver age; dyad relationship type; patient New York Heart Association (NYHA) Class, cognition, and comorbidities; and caregiver strain, mental health status, and contributions to HF self-care) on patient risk of death or hospitalization/emergency room use was quantified using Cox proportional hazards regression.

RESULTS

Over the course of follow up, 32.8% of patients died, 19.7% were hospitalized for HF and 10.4% visited the emergency room. Higher caregiver strain, better caregiver mental health status and greater caregiver contributions to HF self-care maintenance were associated with significantly better event-free survival. Worse patient functional class and greater caregiver contributions to patient self-care management were associated with significantly worse patient event-free survival.

CONCLUSION

Considering caregiving factors together with patient factors significantly increases our understanding of patient clinical event risk in HF.

The Third Time's a Charm: Psychometric Testing and Update of the Atlanta Heart Failure Knowledge Test

BACKGROUND AND OBJECTIVE

Since first being published in 2009, the Atlanta Heart Failure Knowledge Test (AHFKT) has proven a reliable and valid instrument and has been used in multiple studies. Given advances in heart failure (HF) self-care, we proposed to reevaluate the psychometric properties of the AHFKTv2 across these recent studies and update the instrument.

METHODS

Demographic, clinical, and baseline AHFKTv2 data from 4 intervention studies in persons with HF were combined for this analysis (N = 284). The 30 questions of the AHFKT are focused on 5 HF self-care knowledge domains: pathophysiology, nutrition, behavior, medications, and symptoms. Characteristics of the sample were analyzed using descriptive statistics; validity testing with t tests and Mann-Whitney 2-group tests and Pearson r and Spearman ρ correlations; and reliability calculations and factor analysis were performed based on tetrachoric correlations.

RESULTS

Participants were 22 to 84 years of age, 66% were African American, 63% were male, and 94% had New York Heart Association class II to III HF. Mean AHFKT score was 80.6% (±11%). Hypotheses that higher levels of knowledge would be associated with higher education level (t = -2.7, P < .01) and less sodium consumption (ρ = -0.22, P = .03) were validated. Factor analysis revealed 1 general knowledge factor with good reliability, Cronbach's α was .87. Item response analysis identified individual questions requiring review and revision.

CONCLUSION

Comprehensive psychometric evaluation of the AHFKTv2 confirmed its internal consistency reliability and validity and provided direction for production of the AHFKTv3 available for use in research and clinical practice.

Relationship of Health Literacy of Heart Failure Patients and Their Family Members on Heart Failure Knowledge and Self-Care

We explored the relationships among patients' and family members' (FMs) health literacy, heart failure (HF) knowledge, and self-care behaviors using baseline data from HF patients and their FMs ( N = 113 pairs) in a trial of a self-care intervention. Measures included Rapid Estimate of Adult Literacy in Medicine, Atlanta HF Knowledge Test, a heart failure Medication Adherence Scale, and sodium intake (24-hr urine and 3-day food record). Patients with low health literacy (LHL) were more likely to have lower HF knowledge ( p < .001) and trended to poorer medication adherence ( p = .077) and higher sodium intake ( p = .072). When FMs had LHL, FMs were more likely to have lower HF knowledge ( p = .001) and patients trended toward higher sodium intake ( p = .067). When both patients and FMs had LHL, lowest HF knowledge and poorest medication adherence were observed ( p < .027). The health literacy of both patient and FM needs to be considered when designing interventions to foster self-care.

Towards Optimal Heart Failure Care: Couples-Oriented Strategies to Improve Patient Adherence and Health Outcomes

Psychosocial factors play an important role in the development and progression of cardiovascular diseases (CVD), such as chronic heart failure (CHF). In particular, psycho-cognitive disturbance is common in CHF, which presents additional challenges to secondary prevention and management strategies. This review provides a summary of the contemporary psycho-cardiology literature, including coverage of common mood and cognitive symptoms, and explores some of the pathophysiologic evidence linking psycho-cognition to CHF, with particular emphasis on sympathetic nervous system activation and neuroendocrine functioning. Social support is identified as a strategy by which to reduce depressive symptoms, manage cognitive impairment and to, potentially, improve health outcomes through improved patient self care and adherence. Recent research outcomes suggest that the integration of family caregivers into CHF psycho-educational disease management programs, as providers and recipients of support, may achieve best outcomes. In this regard, couples-oriented strategies that promote communication, emotional attachment and support may enhance health-promoting behaviours in patients and their partners.

Does the Theory of Planned Behavior Predict Dietary Sodium Intake in Patients With Heart Failure?

Sodium intake in heart failure (HF) is a crucial but poorly understood phenomenon. Theoretical models promote understanding and provide a context for rational appraisal of complex situations. The purpose of this study was to determine which factors were associated with sodium intake in HF patients using theory of planned behavior (TPB). In this study, patients’ ( N = 244) attitudes, subjective norms, and perceived behavioral control (tenets of the TPB) were assessed using the Dietary Sodium Restriction Questionnaire. Sodium intake was estimated objectively by 24-hr urinary sodium excretion (UNa). The average UNa was 3,811 mg. Subjective norms, gender, and New York Heart Association functional class were associated with sodium intake ( p < .001). Thus, it is important for health care providers to clearly express their approval of following low-sodium diet to their HF patients, and include significant others in interventions to help patients develop/maintain a positive subjective norm to decrease sodium intake and reduce HF exacerbations.

Long-term effects of a dyadic psycho-educational intervention on caregiver burden and morbidity in partners of patients with heart failure: a randomized controlled trial

BACKGROUND

Partners of patients with heart failure provide both practical and emotional support. Many partners assume caregiving responsibilities without being aware of the burden related with this role.

OBJECTIVE

Our work has established that a psycho-educational intervention has benefits at 3, but not at 12 months for patients with heart failure. Further we had not described the long-term effects in caregivers. This study aimed to determine the 24-months effects of a dyadic psycho-educational intervention on caregiver burden and morbidity in partners of patients with heart failure and study factors associated with a change in caregiver burden.

DESIGN

A randomized controlled study design, with a follow-up assessment after 24 months.

SETTING AND PARTICIPANTS

Partners to patients with heart failure were recruited from two hospitals in the southeast of Sweden.

INTERVENTION

A three session nurse-led psycho-educational program was tested and included psychosocial support to maintain the partners' physical and mental functions, and perceived control. Several instrument were used to measure caregiver burden, perceived control, physical and mental health, depression and morbidity.

RESULTS

One hundred fifty-five partners were included. There were no significant differences in any index of caregiver burden or morbidity among the partners in the intervention and control groups after 24 months. Overall, the mean total caregiver burden was found to be significantly increased compared to baseline (36 ± 12 vs 38 ± 14, p < 0.05). A younger partner, less comorbidity, higher levels of perceived control, better physical health and less symptoms of depression in patients, and better mental health in the partners were factors associated with absence of increased caregiver burden over time.

DISCUSSION AND CONCLUSION

Our intervention did not significantly decrease caregiver burden or morbidity. Over time, several aspects of burden increased in both groups. To improve outcomes, individualized and targeted interventions might be beneficial. REGISTERED ON CLINICALTRIALS.

GOV IDENTIFIER

NCT02398799.