A Typology of Heart Failure Self-Care Management in Non-Elders

The symptom perception processes of monitoring, awareness, and evaluation in patients with heart failure: a qualitative descriptive study

AIMS

Patients with heart failure (HF) experience various signs and symptoms and have difficulties in perceiving them. Integrating insights from patients who have engaged in the process of symptom perception is crucial for enhancing our understanding of the theoretical concept of symptom perception. This study aimed to describe how patients with HF perceive symptoms through the processes of monitoring, awareness, and evaluation and what influences the process.

METHODS AND RESULTS

Using a qualitative descriptive design, we conducted in-person semi-structured interviews with a purposeful sample of 40 adults experiencing an unplanned hospitalization for a HF symptom exacerbation. We elicited how patients monitor, become aware of, and evaluate symptoms prior to hospitalization. Data were analysed using directed qualitative content analysis. One overarching theme and three major themes emerged. Patients demonstrated Body listening, which involved active and individualized symptom monitoring tactics to observe bodily changes outside one's usual range. Trajectory of bodily change involved the patterns or characteristics of bodily changes that became apparent to patients. Three subthemes-sudden and alarming change, gradual change, and fluctuating change emerged. Patients evaluated symptoms through an Exclusionary process, sequentially attributing symptoms to a cause through a cognitive process of excluding possible causes until the most plausible cause remained. Facilitators and barriers to symptom monitoring, awareness, and evaluation were identified.

CONCLUSION

This study elaborates the comprehensive symptom perception process used by adults with HF. Tailored nursing interventions should be developed based on the factors identified in each phase of the process to improve symptom perception in HF.

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.

A Pre-Post, Mixed-Methods Study to Pilot Test a Gamified Heart Failure Self-Care Education Intervention

Objective: Self-care is essential to improving heart failure patient outcomes. However, the knowledge and behaviours necessary for self-care decision making, such as symptom perception and management, are complex and require patient education. The objective of this study was to test the feasibility, acceptability, and potential effectiveness of a web-based, gamified heart failure patient education solution, Heart Self-Care Patient Education (HeartSCaPE), that used narrative and virtual reward gamification techniques. Materials and Methods: This mixed-methods study used a pre-post-test design with an embedded explanatory qualitative phase. Patients completed the Self-Care of Heart Failure Index, that measured self-care behaviour change and the Dutch Heart Failure Knowledge Scale, used to measure heart failure knowledge. Usability measures of HeartSCaPE were tracked using Google Analytics and the System Usability Scale. Results: Nineteen patients completed the study, with a subset of six participating in semi-structured interviews. We found increases in HF knowledge despite high baseline knowledge scores. Post-intervention self-reported HF self-care behaviours (maintenance, management and confidence), as measured by the Self-Care of Heart Failure Index, were also improved. Knowledge and self-care scores were not correlated. Participants also scored HeartSCaPE as highly usable. In interviews, participants described valuing the opportunity to practice self-care decision-making. There were mixed opinions regarding the use of virtual rewards. Conclusion: We found that a gamified web-based solution that uses narrative and reward-based gamification techniques has the potential to improve HF patient knowledge and self-care. Further research is needed to confirm the study's clinical benefits and address technology literacy inequities.

Association Between Self-care and Resilience: A Cross-sectional Study in Heart Failure Patients

BACKGROUND

Self-care (SC) is a cornerstone in heart failure management and is related to patient outcomes. The continuous and complex demands of SC can be experienced as stressful and may require patients to apply resilient behaviors as they manage their conditions. Resilience may be a helpful factor in performing SC.

OBJECTIVE

The aim of this study was to determine the association between resilience and SC in patients with heart failure.

METHODS

A cross-sectional study was performed between January 2020 and January 2021. Participants were asked to complete a questionnaire addressing baseline characteristics, the 2-item Patient Health Questionnaire, the Resilience Evaluation Scale, and the Self-Care of Chronic Illness Inventory, which measures 3 concepts of SC: SC maintenance, SC monitoring, and SC management. Multiple regression analysis was performed to determine whether resilience was associated with SC.

RESULTS

Eighty-six patients were included, and 74 patients completed the questionnaire. In the univariate analysis, an association was found between resilience and SC maintenance, resulting in an increase in SC for patients with higher resilience (β = 0.24; 95% confidence interval, 0.03-0.96). In the multivariate analysis adjusted and corrected for confounders, no significant associations between resilience and all SC scales were found.

CONCLUSION

This study could not demonstrate significant associations between resilience and all SC scales. This study contributes to the body of knowledge on factors that can mediate or moderate SC. Further longitudinal research should be performed to study cause-effect relationships.

Trajectory of self-care in people with stable heart failure and insomnia after two self-care interventions

OBJECTIVE

To describe (1) self-care trajectories among adults with heart failure (HF) and insomnia over 1-year; (2) the extent to which trajectories varied between cognitive behavioral therapy for insomnia (CBT-I) or HF self-care intervention; and (3) the associations between self-care trajectories and clinical and demographic characteristics, sleep, symptoms and stress, and functional performance.

METHODS

We conducted secondary analysis of data from a randomized controlled trial of the effects of CBT-I compared with HF self-care education among adults with stable HF and insomnia. We used the Self-Care of Heart Failure Index v6.2. The analytic approaches included t-tests, group-based trajectory modeling, ANOVA, and chi-square.

RESULTS

We included 175 participants (M age=63.0 (12.9) years, White, N = 100]. We found four self-care trajectories: Low self-care (N = 47, 26.8%); Moderate self-care (N = 68, 38.9%): Adequate self-care (N = 42, 24.0%); and Optimal self-care (N = 18, 10.3%). There was no difference in self-care trajectories between interventions. The low self-care group had the most severe baseline fatigue, anxiety, and perceived stress, and lowest cognitive abilities.

CONCLUSION

Both interventions prevented declining self-care. Future research is needed to determine the most efficacious intervention to improve self-care trajectories.

PRACTICE IMPLICATIONS

Healthcare providers should provide ongoing self-care support for those with persistently low and moderate self-care.

The Situation-Specific Theory of Heart Failure Self-care: An Update on the Problem, Person, and Environmental Factors Influencing Heart Failure Self-care

Many studies of heart failure (HF) self-care have been conducted since the last update of the situation-specific theory of HF self-care.

OBJECTIVE

The aim of this study was to describe the manner in which characteristics of the problem, person, and environment interact to influence decisions about self-care made by adults with chronic HF.

METHODS

This study is a theoretical update. Literature on the influence of the problem, person, and environment on HF self-care is summarized.

RESULTS

Consistent with naturalistic decision making, the interaction of the problem, person, and environment creates a situation in which a self-care decision is needed. Problem factors influencing decisions about HF self-care include specific conditions such as cognitive impairment, diabetes mellitus, sleep disorders, depression, and symptoms. Comorbid conditions make HF self-care difficult for a variety of reasons. Person factors influencing HF self-care include age, knowledge, skill, health literacy, attitudes, perceived control, values, social norms, cultural beliefs, habits, motivation, activation, self-efficacy, and coping. Environmental factors include weather, crime, violence, access to the Internet, the built environment, social support, and public policy.

CONCLUSIONS

A robust body of knowledge has accumulated on the person-related factors influencing HF self-care. More research on the contribution of problem-related factors to HF self-care is needed because very few people have only HF and no other chronic conditions. The research on environment-related factors is particularly sparse. Seven new propositions are included in this update. We strongly encourage investigators to consider the interactions of problem, person, and environmental factors affecting self-care decisions in future studies.

Identification of four patterns for self-management behaviors in clients with schizophrenia: A cross-sectional study

This study aimed to describe different patterns of self-management behaviors among clients with schizophrenia in China. Two hundred twenty-eight clients with schizophrenia living in eight communities of Beijing were investigated using the Self-Management Instrument for Persons with Schizophrenia and a Demographic and Clinical Characteristics Questionnaire. Cluster analysis was performed to categorize the data. Four distinct self-management behavior patterns and variables of clients associated with non-adherent self-management were identified. The self-management behaviors and demographic characteristics were similar in each pattern but different among patterns. These findings could guide the development of more personalized and cost-effective self-management interventions for different patterns of clients in the future.

Occupational Therapy Practice Guidelines for Adults With Chronic Conditions

IMPORTANCE

Demand is increasing for occupational therapy practitioners to help the growing population of adults with chronic conditions manage their conditions.

OBJECTIVE

This Practice Guideline, which is informed by systematic reviews of the literature on the use of self-management interventions, is meant to guide occupational therapy practitioners' clinical decision making when working with community-dwelling adults with chronic conditions. The chronic conditions included heart disease, chronic lung conditions, diabetes, and kidney disease. The self-management interventions addressed ADLs and sleep and rest; IADLs; education, work, volunteering, leisure, and social participation; and the caregiver role.

METHOD

We reviewed, discussed, and integrated the clinical recommendations developed from four systematic reviews, supporting literature, and expert opinion to provide recommendations for practice.

RESULTS

A total of 102 articles were included in the systematic reviews, which served as the primary basis for the practice recommendations.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence supports clinical recommendations for the use of self-management interventions when working with clients with chronic conditions. We recommend the use of a multimodal approach that includes three components-education, goal setting, and problem solving-over an extended period to assist clients in establishing self-management habits and routines. On the basis of emerging evidence and expert opinion, we recommend that occupational therapy practitioners consider using a prevention approach, helping clients establish habits and routines, and emphasizing shared goal setting when addressing clients' self-management of chronic conditions. What This Article Adds: This Practice Guideline provides a summary of strong to moderate evidence that supports clinical recommendations for the use of self-management interventions with clients with chronic conditions. When guided by this evidence, occupational therapy practitioners are better able to help clients meet their occupational challenges.

Outpatient nursing support for self-monitoring in patients with chronic heart failure

Background

Early symptoms of worsening heart failure are difficult for patients to detect and manage, contributing to the high readmission rate for worsening heart failure. Thus, it is important to promote self-monitoring and to support patients in recognizing and interpreting their symptoms. This study aimed to explore the ways in which specialized nurses in the outpatient setting provide support for self-monitoring in patients with chronic heart failure in Japan.

Methods

This exploratory study adopted a qualitative study design. The participants were a convenience sample of five nurses certified in chronic heart failure nursing and one advanced practice nurse certified in chronic care nursing, all with experience in outpatient nursing in Japan. Data were collected from June 2017 to October 2017 through semi-structured one-on-one interviews and were analyzed using an established qualitative inductive method.

Results

The analysis identified seven themes describing the nursing support provided by the study participants. Among these were three themes describing different forms of direct support for self-monitoring: “Encourage patients to reflect on their own,” “Support touching the body and developing body awareness,” and “Support sharing the task.” Two themes described practice perspectives: “Support self-monitoring that is not overly sensitive” and “Support connection with the patient’s life.” Two final themes described contextual factors in the outpatient care setting: “Struggling with constraints and powerlessness” and “Building a support system in the outpatient setting.”

Conclusions

The findings provide a practice for nurses promoting self-monitoring in patients with chronic heart failure in the outpatient setting. The study findings inform and provide goals for the support of self-monitoring in patients with heart failure and also, suggest the need to establish a strong support system for outpatient care in Japan.

'There is always a way to living with illness'-Self-management strategies reported by Chinese hospitalized patients with cardiovascular disease: A descriptive qualitative study

OBJECTIVES

Patients living with cardiovascular diseases use different strategies to solve various problems. This study aimed to identify the category, type and specific self-management strategies reported by hospitalized patients with cardiovascular diseases.

METHODS

This is a qualitative descriptive study. Twenty-eight individuals with cardiovascular diseases from a Cardiology Department affiliated with a school in China were recruited by purposive sampling. Face-to-face semi-structured interviews were used. The interviews were audio-recorded, transcribed, translated and analysed by using content analysis.

RESULTS

Five self-management strategy categories (medical and alternative therapy uptake, risk assessment and avoidance, resource seeking and utilization, maintaining normality, and optional management), and seventeen self-management strategy types, encompassing one hundred and ten specific strategies were identified. The most commonly used self-management strategy types were lifestyle adjustment (eleven strategies), self-maintenance (nine strategies) and problem-solving (nine strategies). Additionally, the most described explicit self-management strategies were receiving family/colleague support, maintaining daily routines, monitoring symptoms and managing side effects, discussing with professionals, using medicines, and improving awareness.

CONCLUSION

This study identified diverse strategies reported by some Chinese cardiovascular patients. It may inform the design and development of personalized self-management interventions for health practitioners and policymakers, helping cardiovascular patients in Chinese communities worldwide receive culture-tailored services.

Symptom perception management education improves self-care in patients with heart failure

BACKGROUND

Patients with heart failure often have difficulty recognizing signs and symptoms of the disease, which delays seeking help, and therefore interferes with patient engagement and self-care management. Early detection of these symptoms could lead to care-seeking and avoid hospitalizations.

OBJECTIVE

The purpose of this study was to design a complex intervention through a systematic literature review and qualitative study.

METHODS

Our design followed the Medical Research Council's recommendations. To design a complex intervention, we combined a systematic literature review on education, symptom recognition, and self-care management in patients with heart failure, and semi-structured interviews with cardiology healthcare providers and patients with heart failure admitted to a cardiology ward.

RESULTS

The systematic literature review identified 582 studies published between 2005 and 2014, of which four were included in the final review. These suggested that patient education focused on symptom recognition, combined with reinforcements, led to better self-care behaviors. Additionally, content analysis of semi-structured interviews revealed three themes: health management, behavior management, and support received.

CONCLUSIONS

Combining the findings of the literature review and the themes that emerged from the semi-structured interviews, we proposed the development and implementation of a complex intervention on symptom perception and fluid management.

The Relationship Between Body Awareness and Self-care in Patients With Heart Failure: Moderating Effect of Age

BACKGROUND

Recognizing changing symptoms is challenging for patients with heart failure (HF), especially older patients. Body awareness involves an attentional focus on and awareness of internal bodily changes. Patients with poor body awareness are unlikely to recognize subtle bodily changes, which may result in improper self-care. Despite the potential benefits of body awareness, its contribution to HF management has not been examined.

AIMS

The aims of this study were to examine the relationship between body awareness and self-care in patients with HF and explore whether this relationship varies by age.

METHODS

Patients (N = 136) completed the Body Awareness Questionnaire and 2 scales of the Self-care of HF Index (maintenance and management). Linear regression models were constructed to explore the relationship between body awareness and self-care after controlling for covariates. The moderation effect of age on the relationship between body awareness and self-care was examined using the PROCESS macro.

RESULTS

Body awareness was associated with self-care maintenance (unstandardized coefficient = 0.19; 95% confidence interval, 0.05-0.34) but not management. When the interaction effect of body awareness and age was entered in the regression model, neither self-care maintenance nor management was related to this interaction term.

CONCLUSION

We found that body awareness is conducive to self-care maintenance but not self-care management in patients with HF, and the relationship between body awareness and self-care did not vary by age. Our findings suggest that relying on internal body sensations may be insufficient to facilitate self-care management. Thus, other strategies along with the strategies to enhance body awareness are necessary to improve the full process of self-care in HF patients.

Using mixed methods in cardiovascular nursing research: Answering the why, the how, and the what's next

Mixed methods is an innovative research approach that can be applied to understand complex cardiovascular phenomena. A mixed methods study involves collecting both quantitative and qualitative data and intentionally integrating the data to provide a better understanding of the phenomena than can be achieved by using a quantitative or qualitative approach alone. Conducting a mixed methods study requires planning and careful attention to methodological rigour in the data collection, analysis, and integration phases. This paper provides an overview of the mixed methods approach and describes its application to cardiovascular nursing science.

'What the herbal medicine can do for me in a week, the orthodox does in a year': Perceived efficacy of local alternative therapies influences medication adherence in patients with atherosclerotic cardiovascular disease

Background

There is strong evidence that anti‐platelet therapy, ACE inhibitors, beta‐blockers and statins are cost‐effective in reducing subsequent cardiovascular disease (CVD) events in patients with atherosclerotic cardiovascular disease (ACVD). In some settings, only a low proportion of people have access to these medications, and even lower adhere to them. The current study explored and presents data on the causes of poor adherence to orthodox medication and motivations for alternative therapies in patients with established atherosclerotic cardiovascular disease (ACVD).

Methods

The study was conducted among city‐dwelling adults with ACVD in Accra – Ghana's capital city. Eighteen interviews were conducted with patients with established ACVD. A follow‐up focus group discussion was conducted with some of them. The protocol was approved by two ethics review committees based in Ghana and in the United Kingdom. All participants were interviewed after informed consent. Analysis was done with the Nvivo qualitative data analysis software.

Results

We identified motivations for use of alternatives to orthodox therapies. These cover the five dimensions of adherence: social and economic, health‐care system, condition‐related, therapy‐related, and patient‐related dimensions. Perceived inability of an orthodox medication to provide immediate benefit is an important motivator for use of alternative forms of medication.

Conclusions

A multiplicity of factors precipitate non‐adherence to orthodox therapies. Perceived efficacy and easy access to local alternative therapies such as herbal and faith‐based therapies are important motivators.

Factors Associated with Heart Failure Knowledge and Adherence to Self-Care Behaviors in Hospitalized Patients with Acute Decompensated Heart Failure Based on Data from "the Weak Heart" Educational Program

PURPOSE

As insufficient adherence to recommendations is a major cause of poor health outcomes in patients with heart failure (HF), it is important to identify the factors that improve disease knowledge and self-care behaviors. We aimed to identify factors associated with HF knowledge and self-care behaviors in patients hospitalized due to acute decompensated heart failure (ADHF) in Poland.

PATIENTS AND METHODS

This was a secondary analysis of data from a multi-center, prospective, non-randomized educational program named "The Weak Heart", which was conducted in 14 cardiology centers in Poland. The level of HF knowledge was assessed using a questionnaire developed by the research team, and self-care behaviors were evaluated using the European Heart Failure Self-care Behaviour Scale (9-EHFScBS) questionnaire.

RESULTS

The study included 259 patients admitted to the hospital with ADHF. The mean HF knowledge and 9-EHFScBS questionnaire scores were 8.25± 4.34 and 25.2±9.5, respectively. The patients' level of education (P = 0.002), number of prior HF hospitalizations (P = 0.008), and previous disease education (P < 0.001) were independently associated with better HF knowledge. Age (P = 0.03) and disease education (P = 0.02) were independently associated with self-care behaviors.

CONCLUSION

The adherence to self-care recommendations among patients with ADHF is insufficient. Disease education positively influenced both HF knowledge and self-care abilities. To improve patients' adherence to HF recommendations, well-designed models of education based on HF management guidelines should be implemented.

Naturalistic Decision Making in Everyday Self-care Among Older Adults With Heart Failure

BACKGROUND

Every day, older adults living with heart failure make decisions regarding their health that may ultimately affect their disease trajectory. Experts describe these decisions as instances of naturalistic decision making influenced by the surrounding social and physical environment and involving shifting goals, high stakes, and the involvement of others.

OBJECTIVE

This study applied a naturalistic decision-making approach to better understand everyday decision making by older adults with heart failure.

METHODS

We present a cross-sectional qualitative field research study using a naturalistic decision-making conceptual model and critical incident technique to study health-related decision making. The study recruited 24 older adults with heart failure and 14 of their accompanying support persons from an ambulatory cardiology center. Critical incident interviews were performed and qualitatively analyzed to understand in depth how individuals made everyday health-related decisions.

RESULTS

White, male (66.7%), older adults' decision making accorded with a preliminary conceptual model of naturalistic decision making occurring in phases of monitoring, interpreting, and acting, both independently and in sequence, for various decisions. Analyses also uncovered that there are barriers and strategies affecting the performance of these phases, other actors can play important roles, and health decisions are made in the context of personal priorities, values, and emotions.

CONCLUSIONS

Study findings lead to an expanded conceptual model of naturalistic decision making by older adults with heart failure. In turn, the model bears implications for future research and the design of interventions grounded in the realities of everyday decision making.

Systematic review of frameworks used to conceptualise health pathways of individuals diagnosed with cardiovascular diseases

The treatment of cardiovascular disease (CVD) is managed inadequately globally. Theoretically informed frameworks have the potential to account for the multiple elements which constitute the CVD patient pathway, and capture their inter-relationships and processes of change. However, a review and critique of such frameworks is currently lacking. This systematic review aims to identify and critically assess frameworks of access to and utilisation of care which capture the pathways of patients diagnosed with one or more CVDs. The specific objectives are to (1) review how existing frameworks have been used and adapted to capture CVD patient pathways and (2) draw on elements of Strong Structuration Theory to critically appraise them, in terms of their ability to capture the dynamics of the patient journey and the factors that influence it. Five bibliographic databases were searched in January 2019. We included qualitative and quantitative studies containing frameworks used to capture the patient pathway of individuals with CVD, encompassing symptoms, diagnosis, treatment and long-term management. Data on patient behaviour and structural factors were interpreted according to elements of Strong Structuration Theory to assess frameworks on their ability to capture a holistic patient journey. The search yielded 15 articles. The majority were quantitative and all focused on management of CVDs, primarily hypertension. Commonly used frameworks included the common-sense self-regulation model, transtheoretical model and theory of planned behaviour. A critique drawing on elements of Strong Structuration Theory revealed these frameworks narrowly focused on patient attributes (patient beliefs/attitudes) and resulting patient action, but neglected external structures that interacted with these to produce particular outcomes, which results in an individualistic and linear view of the patient pathway. We suggest that a framework informed by Strong Structuration Theory is sufficiently flexible to examine the patient pathway, while avoiding a strict linear view facilitated by other frameworks.

Patient decision-making personas: An application of a patient-centered cognitive task analysis (P-CTA)

Personas can be used to understand patterns of variation in patients' performance of cognitive work, particularly self-care decision making. In this study, we used a patient-centered cognitive task analysis (P-CTA) to develop self-care decision-making personas. We collected data from 24 older adults with chronic heart failure and 14 support persons, using critical incident and fictitious scenario interviews. Qualitative analyses produced three personas but revealed that individuals exemplify different personas across situations. The Rule-Following persona seeks clear rules, exercises caution under uncertainty, and grounds actions in confidence in clinician experts. The Researching persona seeks information to gain better understanding, invents strategies, and conducts experiments independently or with clinicians. The Disengaging persona does not actively seek rules or information and does not attempt to reduce uncertainty or conduct experiments. We discuss the situational nature of personas, their use in design, and the benefits of P-CTA for studying patient decision making.

Executive dysfunction is associated with self-care confidence in patients with heart failure

AIM

To explore differences in self-care maintenance, management and confidence levels between American heart failure (HF) patients with and without executive dysfunction.

BACKGROUND

Evidence indicates some aspect of cognitive impairment is prevalent in up to 75% of the HF patient population. Moreover, cognitive impairment has been identified as a barrier to adequate self-care contributing to poor outcomes. There is limited understanding of the role executive function, a domain of cognitive performance, has on self-care behaviors for patients with HF.

METHOD

This secondary analysis examined the role of executive function, measured by the Clock Drawing Test (CDT), in relation to self-care measures. The Self Care of Heart Failure Index v6.2 (SCHFI v6.2) was used to measure self-care maintenance, management, and confidence.

RESULTS

Participants had a mean age of 75.1 ± 12.5 years, identified as male (59.4%), with New York Heart Association (NYHA) class III (57.3%). Executive function impairment was present in 28% of the sample. Comparison of self-care maintenance and management scores between the two groups were not significant. However, participants with executive dysfunction demonstrated an average self-care confidence score of 48.6 ± 23.3, while participants with no executive function impairment demonstrated a higher average self-care confidence score of 61.5 ± 18.4. Differences in self-care confidence scores between the groups were statistically significant (p = .014).

CONCLUSIONS

HF self-care confidence is considered a moderator of self-care behaviors. Understanding the influence executive function has on self-care confidence may lead to a better understanding of those needing greater support with self-care behaviors.

Heart Failure Care Dyadic Typology: Initial Conceptualization, Advances in Thinking, and Future Directions of a Clinically Relevant Classification System

BACKGROUND

Heart failure (HF) dyadic self-care science is advancing rapidly, as evidenced by recent theoretical work, literature reviews, and multiple empiric studies. Typologies, once considered archaic, are now viewed as person-oriented classification systems that allow a whole-system view of information patterns. This whole-system view is particularly needed to understand complex tasks like dyadic HF self-care.

PURPOSE

The purpose of this article is to review the initial conceptualization of an HF care dyadic typology and the present advances in our thinking and suggest future directions for this clinically relevant classification system.

CONCLUSIONS

Development and testing of the typology across 5 studies resulted in a well-characterized, pragmatic and parsimonious, person-oriented classification system for understanding how patients and informal caregivers conduct patients' HF self-care at home. The 4 types are characterized as 2 individually oriented types-type I, patient oriented; type II, caregiver oriented; and 2 relationally oriented types-type III, collaboratively oriented; and type IV, incongruently oriented. We have devised a single-item measure of typology group that can be assessed in the clinical setting. Once this information is ascertained, the clinician can personalize the plan of care to the realities of the dyad.

IMPLICATIONS

Dyads that disagree on who is responsible for self-care may forego or delay action, resulting in self-care failures with subsequent HF advancement, hospitalization, and mortality. As the HF dyadic self-care science has advanced, we have come to appreciate the complexity that arises when 2 individuals work together on 1 complex task-HF self-care.

Knowledge, Adherence to Lifestyle Recommendations, and Quality of Life Among Koreans With Heart Failure

OBJECTIVE

To assess heart failure (HF) knowledge, adherence to lifestyle recommendations, and quality of life (QOL) among Koreans with HF and identify factors influencing QOL.

METHODS

A cross-sectional and correlational design was used and a total of 142 Koreans with HF were recruited between April 2012 and September 2013. Data were analyzed using multiple logistic regression with SPSS version 21.0.

RESULTS

The mean age of participants was 64.1 ± 7.4 years. A higher proportion of participants were male, married, unemployed, had a high education level, and class I New York Heart Association (NYHA) functional status. A higher proportion of participants had ≥2 comorbidities and the most prevalent comorbidity was diabetes. The mean score of HF knowledge was 6.9 (possible range 0-15) and the most frequent incorrect items were "proper actions to reduce thirst" and "causes of leg swelling" in both better and worse QOL groups. Among the recommended lifestyle, pneumococcal vaccination had the least adherence in both groups. Multiple logistic regression showed that patients in NYHA class I, with a higher left ventricular ejection fraction, who had knowledge of "amount of fluid intake a day" and consumed more than moderate alcohol tended to have better QOL. Conclusion: More active interventions targeting HF knowledge in proper actions to reduce thirst, causes of leg swelling, and the amount of fluid intake per day are required. Patients with HF in more serious condition need special attention regarding the risk of worse QOL. The role of alcohol consumption in QOL among HF patients in Korea needs further exploration.

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.

An evolutionary concept analysis of "patients' values"

BACKGROUND

Patients' values are everywhere and nowhere in nursing: frequently invoked and associated with effective nursing care but seldom explicitly defined or subject to dedicated analysis. Clarification of the concept of patients' values is pivotal because respecting and supporting patients' values are widely recognized as crucial for ethical nursing care. Despite this and the pervasive employment of the term patients' values in theories, approaches, and clinical guidelines, the concept remains ambiguous.

PURPOSE

We sought to understand the key elements of the concept by investigating its use in theoretical and empirical literature.

METHOD

This study used Rodgers' evolutionary concept analysis approach.

FINDINGS

We found that values are core individual beliefs that function in hierarchical systems; however, in the context of disease, the priority assigned to values by the individual may change. This is important, given that values play a foundational role in health-related decisions, such as in the context of chronic diseases.

DISCUSSION

Values are influenced by both individual intrinsic needs and the social context, but importantly, are involved in guiding decision-making. The attributes of the values may vary according to the context of the disease, the type of disease, and the decision at hand.

Self-management of heart failure in dementia and cognitive impairment: a systematic review

BACKGROUND

The cornerstone of effective management in heart failure (HF) is the ability to self-care. Aims include i) To determine factors influencing self-care in HF patients with cognitive impairment (CI) and ii) to determine the influence of cognitive domains on self-care in patients with HF and CI.

METHODS

MEDLINE, CINAHL, EMBASE, EBSCOHost, PsychINFO, ProQuest Research Library, Health Technology Assessment Database, The Cochrane Library, Web of Science and Scopus databases were systematically searched. Original research describing the relationship between cognition and HF self-care in community-dwelling older persons with dementia/CI in English, published in a peer-reviewed journal from 1^stJanuary(2000)-22^ndMarch(2016) was identified. Study and population characteristics, data sources, self-care processes, methods of cognitive assessment, cognitive domains affected, study outcomes, impact of impairment, and other risk factors of self-care impairment were abstracted by two reviewers.

RESULTS

Of 10,688 studies identified, 14 met the inclusion criteria. Patients with HF and CI ranged from 14 to 73%. Where reported, self-care maintenance adequacy ranged from 50 to 61%; self-care management adequacy ranged from 14 to 36% and self-care confidence adequacy ranged from 0 to 44% on the Self-care of Heart Failure Index (SCHFI). All but one study predicted poor self-care ability according to poor outcome on cognitive testing. Additionally, specific cognitive domain deficits impaired self-care. Subjects with lower cognitive scores were less likely to seek assistance while subjects with depression had poor self-care abilities.

CONCLUSIONS

Clinicians must consider the type and severity of impairments in cognitive domains to tailor management. Awareness of depression, self-confidence and support access may modulate self-care ability.

Symptom Management and Hospital Readmission in Heart Failure Patients: A Qualitative Study From Portugal

This article reports a study aimed at identifying the factors that result in hospital readmissions for patients with heart failure. The high rates of readmission are often due to a lack of knowledge about symptoms and signs of disease progression, and these Portuguese nurses believed that readmissions could be decreased through disease management programs in which patients assumed a more active role in self-care. A study was designed to identify broad categories of problems that lead Portuguese patients with heart failure to be readmitted to hospital. Semistructured interviews were conducted, recorded, and submitted for content analysis, revealing 3 main categories for targeting: health management, behavioral management, and psychological support. This study revealed that patients with heart failure seem to struggle with management of multiple treatment regimens during the long course of their chronic illness. Based on these interviews, authors conclude that a disease management program be tailored expressly for the Portuguese culture and their lifestyle.

Impairment of cognitive functions in congestive cardiac failure patients

BACKGROUND

Congestive cardiac failure (CCF) patients show several neuropsychological impairments and reduced quality of life and impairment of functioning.

OBJECTIVE

The objective of this study was to recognize the deficits in cognition in CCF patients and comparing this cognitive function in the same number of healthy participants.

MATERIALS AND METHODS

A case-control study design was adopted. The study was conducted in the cardiology department of a tertiary care hospital. Convenience sampling was done. Twenty-one participants with CCF (New York Cardiac Association - Class III severity) and 21 healthy participants participated in the study. Each participant in the control group was screened by the General Health Questionnaire-12-item version. We evaluated both groups for the various domains of their cognitive function using a comprehensive battery of neuropsychological tests. Student's t-test was used to analyze the difference between the means for the study variables.

RESULTS

We observed that attention, executive function, working memory, psychomotor speed, and visuospatial ability were impaired in the patients with CCF compared to the controls. However, they did not differ significantly in language function.

CONCLUSIONS

Cognitive functioning is significantly impaired in CCF patients.

Use of software applications to improve medication adherence and achieve more integrated disease management in heart failure

The treatment and management of heart failure is associated with high mortality rates and treatment costs. Poor medication adherence is a major barrier to improving care and traditional interventions addressing non-adherence have not consistently demonstrated improvement in health care outcomes like readmission. The reasons for non-adherence are complicated and illustrate the broader challenges patients face when managing a complex disease like heart failure. In this review, a digitally enabled heart failure management platform consisting of medical digital tools and software solutions that are designed to be patient-facing and continuously accessed is explored as a way to integrate the multiple components of heart failure care and deliver personalized patient management tools.

Patterns of Self-care in Adults With Heart Failure and Their Associations With Sociodemographic and Clinical Characteristics, Quality of Life, and Hospitalizations: A Cluster Analysis

BACKGROUND

Self-care is important in heart failure (HF) treatment, but patients may have difficulties and be inconsistent in its performance. Inconsistencies in self-care behaviors may mirror patterns of self-care in HF patients that are worth identifying to provide interventions tailored to patients.

OBJECTIVES

The aims of this study are to identify clusters of HF patients in relation to self-care behaviors and to examine and compare the profile of each HF patient cluster considering the patient's sociodemographics, clinical variables, quality of life, and hospitalizations.

METHODS

This was a secondary analysis of data from a cross-sectional study in which we enrolled 1192 HF patients across Italy. A cluster analysis was used to identify clusters of patients based on the European Heart Failure Self-care Behaviour Scale factor scores. Analysis of variance and χ test were used to examine the characteristics of each cluster.

RESULTS

Patients were 72.4 years old on average, and 58% were men. Four clusters of patients were identified: (1) high consistent adherence with high consulting behaviors, characterized by younger patients, with higher formal education and higher income, less clinically compromised, with the best physical and mental quality of life (QOL) and lowest hospitalization rates; (2) low consistent adherence with low consulting behaviors, characterized mainly by male patients, with lower formal education and lowest income, more clinically compromised, and worse mental QOL; (3) inconsistent adherence with low consulting behaviors, characterized by patients who were less likely to have a caregiver, with the longest illness duration, the highest number of prescribed medications, and the best mental QOL; (4) and inconsistent adherence with high consulting behaviors, characterized by patients who were mostly female, with lower formal education, worst cognitive impairment, worst physical and mental QOL, and higher hospitalization rates.

CONCLUSION

The 4 clusters identified in this study and their associated characteristics could be used to tailor interventions aimed at improving self-care behaviors in HF patients.

Relationship between self-care and comprehensive understanding of heart failure and its signs and symptoms

Background:

Although incomplete understanding of heart failure and its signs and symptoms appears to be a barrier to successful self-care, there are few studies examining the relationship between self-care and levels of comprehensive understanding of heart failure and its signs and symptoms.

Aim:

To determine whether incomplete understanding of heart failure and its signs and symptoms is associated with self-care in heart failure patients who were recently discharged from the hospital due to heart failure exacerbation.

Methods:

Patients completed the nine-item European Heart Failure Self-care Behavior scale and questionnaire to assess knowledge of heart failure and its signs and symptoms. Three groups were formed by their different levels of understanding of heart failure and its signs and symptoms. Multivariable linear regression was used to determine whether these three levels of understanding groups predicted self-care after controlling for demographic and clinical variables.

Results:

Of 571 patients 22.1%, 40.1% and 37.8% had poor, moderate, and complete understanding, respectively. Compared with patients in the poor understanding group, patients in complete and moderate understanding groups were more likely to have better adherence to self-care activities (standardized β = −0.14, 95% confidence interval −3.41, −0.47; standardized β = −0.19, 95% confidence interval −4.26, −1.23, respectively).

Conclusions:

Fewer than half of the patients had a comprehensive understanding of heart failure and its signs and symptoms, which was associated with poor self-care. Our study suggests that patient education should include contents to promote comprehensive understanding of heart failure and its symptoms, as well as the importance of self-care behaviors.

Self-Care for the Prevention and Management of Cardiovascular Disease and Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association

Self-care is defined as a naturalistic decision-making process addressing both the prevention and management of chronic illness, with core elements of self-care maintenance, self-care monitoring, and self-care management. In this scientific statement, we describe the importance of self-care in the American Heart Association mission and vision of building healthier lives, free of cardiovascular diseases and stroke. The evidence supporting specific self-care behaviors such as diet and exercise, barriers to self-care, and the effectiveness of self-care in improving outcomes is reviewed, as is the evidence supporting various individual, family-based, and community-based approaches to improving self-care. Although there are many nuances to the relationships between self-care and outcomes, there is strong evidence that self-care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self-care in evidence-based guidelines.

Heart Failure: Self-care to Success: Development and evaluation of a program toolkit

The Heart Failure: Self-care to Success toolkit was developed to assist NPs in empowering patients with heart failure (HF) to improve individual self-care behaviors. This article details the evolution of this toolkit for NPs, its effectiveness with patients with HF, and recommendations for future research and dissemination strategies.

Perceived social support and self-care in patients hospitalized with heart failure

BACKGROUND

Rehospitalization of heart failure patients is often considered the result of inadequate self-care yet only one study documents superior outcomes with better self-care.

AIMS

If inadequate self-care is related to hospitalizations, then hospitalized heart failure patients should have lower self-care skills than non-hospitalized patients. The purpose of this study was to evaluate perceived social support and self-care characteristics of patients hospitalized with an exacerbation of heart failure. The self-care of heart failure index (SCHFI) and medical outcomes study of social support (MOS-SS) were the key instruments used in the research.

METHODS AND RESULTS

This descriptive study used t tests and multiple regression to analyze the data. Results were compared with non-hospitalized heart failure patients in another study. Perceived social support ( t=-4.007, df=211, P<0.001) and self-care maintenance ( t=-3.343, df=220, P<0.002) scores were lower in the hospitalized participants than the comparison group. Self-care confidence was the only variable significantly related to perceived social support ( β=0.210, t=2.210, P<0.30).

CONCLUSIONS

This study supports the premise that heart failure rehospitalizations are related to inadequate self-care.

The effect on patient outcomes of a nursing care and follow-up program for patients with heart failure: A randomized controlled trial

BACKGROUND

Heart failure is associated with exacerbated symptoms such as dyspnea and edema and results in frequent hospitalization and a poor quality of life. With the adoption of a comprehensive nursing care and follow-up program, patients with heart failure may exhibit improvements in their self-care capabilities and their hospitalizations may be reduced.

OBJECTIVE

The purpose of this study was to examine the effect of a nursing care and follow-up program for patients with heart failure on self-care, quality of life, and rehospitalization.

DESIGN AND SETTING

This research was conducted as a single-center, single-blind, randomized controlled study at the heart failure outpatient clinic of a university hospital in Turkey.

PARTICIPANTS

A total of 90 patients with heart failure were randomly assigned into either the specialized nursing care group (n=45) or the control group (n=45).

METHODS

The nursing care and follow-up program applied in the intervention group was based on the Theory of Heart Failure Self-care. Data were collected at the beginning of the trial, and at three and six months after the study commenced. Self-care of the patients was assessed by the Self-Care of Heart Failure Index. Quality of life was assessed with the "Left Ventricular Dysfunction Scale". Rehospitalization was evaluated based on information provided by the patients or by hospital records.

RESULTS

A statistically significant difference was found between the intervention and control group with respect to the self-care and quality of life scores at both three and six months. While the intervention group experienced fewer rehospitalizations at three months, no significant differences were found at six months.

CONCLUSION

The results obtained in this study show that the nursing care and follow-up program implemented for patients with heart failure improved self-care and quality of life. Although there were no significant differences between the groups at six months, fewer rehospitalizations in the intervention group was considered to be an important result.

The Situation-Specific Theory of Heart Failure Self-Care: Revised and Updated

BACKGROUND

Since the situation-specific theory of heart failure (HF) self-care was published in 2008, we have learned much about how and why patients with HF take care of themselves. This knowledge was used to revise and update the theory.

OBJECTIVE

The purpose of this article was to describe the revised, updated situation-specific theory of HF self-care.

RESULT

Three major revisions were made to the existing theory: (1) a new theoretical concept reflecting the process of symptom perception was added; (2) each self-care process now involves both autonomous and consultative elements; and (3) a closer link between the self-care processes and the naturalistic decision-making process is described. In the revised theory, HF self-care is defined as a naturalistic decision-making process with person, problem, and environmental factors that influence the everyday decisions made by patients and the self-care actions taken. The first self-care process, maintenance, captures those behaviors typically referred to as treatment adherence. The second self-care process, symptom perception, involves body listening, monitoring signs, as well as recognition, interpretation, and labeling of symptoms. The third self-care process, management, is the response to symptoms when they occur. A total of 5 assumptions and 8 testable propositions are specified in this revised theory.

CONCLUSION

Prior research illustrates that all 3 self-care processes (ie, maintenance, symptom perception, and management) are integral to self-care. Further research is greatly needed to identify how best to help patients become experts in HF self-care.

Dynamics of cerebral blood flow in patients with mild non-ischaemic heart failure

AIMS

Heart failure (HF) is associated with tissue hypoperfusion and congestion leading to organ dysfunction. Although cerebral blood flow (CBF) is preserved over a wide range of perfusion pressures in healthy subjects, it is impaired in end-stage HF. We aimed to compare CBF, autoregulation, and cognitive function in patients with mild non-ischaemic HF with healthy controls.

METHODS AND RESULTS

Fifteen patients with mild idiopathic dilated cardiomyopathy and 15 matched healthy controls were studied. Co-existing cerebrovascular disease was excluded. All subjects, except five patients with an implantable cardioverter defibrillator, underwent magnetic resonance imaging for measurements of both CBF by arterial spin labelling and quantitative volume flow entering the brain. Cardiocerebral vascular function was assessed with Doppler techniques testing cerebral dynamic autoregulation and vasomotor reactivity. Cognitive analysis was performed by neuropsychological testing. Global and regional CBF did not differ between HF patients (44.3 mL/100 g.min) and controls (42.1 mL/100 g.min). Basilar but not carotid artery inflow was reduced in patients (1.95 mL/s vs. 2.51 mL/s, P = 0.009). Testing autoregulation revealed fewer dampened blood flow fluctuations in HF patients vs. controls (0.96% vs. 0.67%, P < 0.001). Vasomotor reactivity in HF patients showed a reduced CBF velocity (48.4% vs. 61.0%, P = 0.05) and regional cerebral oxygen saturation (18.3% vs. 23.8%, P = 0.02). Cognitive function overall was not affected.

CONCLUSION

Although global CBF was unaffected in patients with mild HF, significant changes in basilar inflow volume, cerebral autoregulation and vasomotor reactivity were observed. We describe a model of dynamic cerebral mechanisms required to compensate for the impaired haemodynamics in early-stage HF.

Psychometric Testing of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI)

Although coronary heart disease (CHD) requires a significant amount of self-care, there are no instruments available to measure self-care in this population. The purpose of this study was to test the psychometric properties of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI). Using the Self-Care of Chronic Illness theory, we developed a 22-item measure of maintenance, management, and confidence appropriate for persons with stable CHD and tested it in a convenience sample of 392 adults (62% male, mean age 61.4 ± 9.6 years). Factorial validity was tested with confirmatory factor analysis. Convergent validity was tested with the Medical Outcomes Study MOS-SAS Specific Adherence Scale and the Decision Making Competency Inventory (DMCI). Cronbach alpha and factor determinacy scores (FDS) were calculated to assess reliability. Two multidimensional self-care scales were confirmed: self-care maintenance included "consultative behaviors" (e.g., taking medicines as prescribed) and "autonomous behaviors" (e.g., exercising 30 minute/day; FDS = .87). The multidimensional self-care management scale included "early recognition and response" (e.g., recognizing symptoms) and "delayed response" (e.g., taking an aspirin; FDS = .76). A unidimensional confidence factor captured confidence in each self-care process (α = .84). All the self-care dimensions were associated with treatment adherence as measured by the MOS-SAS. Only self-care maintenance and confidence were associated with decision-making (DCMI). These findings support the conceptual basis of self-care in patients with CHD as a process of maintenance that includes both consultative and autonomous behaviors, and management with symptom awareness and response. The SC-CHDI confidence scale is promising as a measure of self-efficacy, an important factor influencing self-care. © 2016 Wiley Periodicals, Inc.

Self-efficacy mediates the relationship of depressive symptoms and social support with adherence in patients with heart failure

Poor self-care is common among adults with heart failure and leads to poor health outcomes. Low self-efficacy, depression, and low social support are associated with poor self-care, but knowledge about these relationships in heart failure is limited. Secondary data analysis of cross-sectional data from 346 adults with heart failure measuring self-efficacy, depressive symptoms, social support, and self-care adherence was conducted. Tests of mediation using multiple linear regressions indicate that self-efficacy fully mediates the relationships between depression and adherence, and social support and adherence. Bolstering self-efficacy may have a greater impact on self-care adherence than targeting either depression or social support alone.

Establishing a pragmatic framework to optimise health outcomes in heart failure and multimorbidity (ARISE-HF): A multidisciplinary position statement

Background

Multimorbidity in heart failure (HF), defined as HF of any aetiology and multiple concurrent conditions that require active management, represents an emerging problem within the ageing HF patient population worldwide.

Methods

To inform this position paper, we performed: 1) an initial review of the literature identifying the ten most common conditions, other than hypertension and ischaemic heart disease, complicating the management of HF (anaemia, arrhythmias, cognitive dysfunction, depression, diabetes, musculoskeletal disorders, renal dysfunction, respiratory disease, sleep disorders and thyroid disease) and then 2) a review of the published literature describing the association between HF with each of the ten conditions. From these data we describe a clinical framework, comprising five key steps, to potentially improve historically poor health outcomes in this patient population.

Results

We identified five key steps (ARISE-HF) that could potentially improve clinical outcomes if applied in a systematic manner: 1) Acknowledge multimorbidity as a clinical syndrome that is associated with poor health outcomes, 2) Routinely profile (using a standardised protocol — adapted to the local health care system) all patients hospitalised with HF to determine the extent of concurrent multimorbidity, 3) Identify individualised priorities and person-centred goals based on the extent and nature of multimorbidity, 4) Support individualised, home-based, multidisciplinary, case management to supplement standard HF management, and 5) Evaluate health outcomes well beyond acute hospitalisation and encompass all-cause events and a person-centred perspective in affected individuals.

Conclusions

We propose ARISE-HF as a framework for improving typically poor health outcomes in those affected by multimorbidity in HF.

An eHealth Diary and Symptom-Tracking Tool Combined With Person-Centered Care for Improving Self-Efficacy After a Diagnosis of Acute Coronary Syndrome: A Substudy of a Randomized Controlled Trial

Background

Patients with cardiovascular diseases managed by a person-centered care (PCC) approach have been observed to have better treatment outcomes and satisfaction than with traditional care. eHealth may facilitate the often slow transition to more person-centered health care by increasing patients’ beliefs in their own capacities (self-efficacy) to manage their care trajectory. eHealth is being increasingly used, but most studies continue to focus on health care professionals’ logic of care. Knowledge is lacking regarding the effects of an eHealth tool on self-efficacy when combined with PCC for patients with chronic heart diseases.

Objective

The objective of our study was to investigate the effect of an eHealth diary and symptom-tracking tool in combination with PCC for patients with acute coronary syndrome (ACS).

Methods

This was a substudy of a randomized controlled trial investigating the effects of PCC in patients hospitalized with ACS. In total, 199 patients with ACS aged <75 years were randomly assigned to a PCC intervention (n=94) or standard treatment (control group, n=105) and were followed up for 6 months. Patients in the intervention arm could choose to use a Web-based or mobile-based eHealth tool, or both, for at least 2 months after hospital discharge. The primary end point was a composite score of changes in general self-efficacy, return to work or prior activity level, and rehospitalization or death 6 months after discharge.

Results

Of the 94 patients in the intervention arm, 37 (39%) used the eHealth tool at least once after the index hospitalization. Most of these (24/37, 65%) used the mobile app and not the Web-based app as the primary source of daily self-rating input. Patients used the eHealth tool a mean of 38 times during the first 8 weeks (range 1–118, SD 33) and 64 times over a 6-month period (range 1–597, SD 104). Patients who used the eHealth tool in combination with the PCC intervention had a 4-fold improvement in the primary end point compared with the control group (odds ratio 4.0, 95% CI 1.5–10.5; P=.005). This improvement was driven by a significant increase in general self-efficacy compared with the control group (P=.011). Patients in the PCC group who did not use the eHealth tool (n=57) showed a nonsignificant composite score improvement compared with those in the control group (n=105) (odds ratio 2.0, 95% CI 0.8–5.2; P=.14).

Conclusions

We found a significant effect on improved general self-efficacy and the composite score for patients using an eHealth diary and symptom-tracking tool in combination with PCC compared with traditional care.

Trial Registration

Swedish registry, Researchweb.org, ID NR 65 791.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSION

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

What matters to patients with heart failure? The influence of non-health-related goals on patient adherence to self-care management

OBJECTIVE

To describe the life goals of heart failure (HF) patients and to determine whether adherence is influenced by the extent to which these priorities are perceived as compatible with HF self-care regimens.

METHOD

Forty HF outpatients identified their top-five life goals and indicated the compatibility of HF self-care regimens (diet, exercise, weighing) with these priorities. HF knowledge, self-efficacy and reported adherence were also assessed.

RESULTS

Patients valued autonomy and social relationships as much as physical health. However, the rated importance of these domains did not predict adherence. Adherence positively correlated with the extent to which the regimen, specifically exercise, was considered compatible with life goals (r=.34, p<.05). Exercise adherence also correlated with illness severity and self-efficacy (rs=-.42 and .36, p<.05, respectively). The perceived compatibility of physical activity with personal goals predicted 11% of the variance in exercise adherence above and beyond that accounted for by illness severity and self-efficacy (FΔ (1, 36)=7.11, p<.05).

CONCLUSIONS

Patients' goals outside of the illness management context influence self-care practices.

PRACTICE IMPLICATIONS

Exploring patients' broad life goals may increase opportunities to resolve ambivalence and enhance motivation for self-care adherence.

Self-care confidence may be the key: A cross-sectional study on the association between cognition and self-care behaviors in adults with heart failure

BACKGROUND

Self-care, a key element of heart failure care, is challenging for patients with impaired cognition. Mechanisms through which cognitive impairment affects self-care are not currently well defined but evidence from other patient populations suggests that self-efficacy, or task-specific confidence, mediates the relationship between cognitive functioning and patient behaviors such as self-care.

OBJECTIVE

The aim of this study was to test the mediating role of self-care confidence in the relationship between cognition and self-care behaviors.

DESIGN

A secondary analysis of data from a cross-sectional study.

SETTING

Outpatient heart failure clinics in 28 Italian provinces.

PARTICIPANTS

628 Italian heart failure patients.

METHODS

We used the Self-Care of Heart Failure Index v.6.2 to measure self-care maintenance, self-care management, and self-care confidence. Cognition was assessed with the Mini Mental State Examination. Structural equation modeling was used to analyze the data.

RESULTS

Participants were 73 years old on average (SD=11), mostly (58%) male and mostly (77%) in New York Heart Association functional classes II and III. The mediation model showed excellent fit (comparative fit index=1.0; root mean square error of approximation=0.02): Self-care confidence totally mediated the relationship between cognition and self-care maintenance and management.

CONCLUSION

Cognition affects self-care behaviors indirectly, through self-care confidence. Interventions aimed at improving self-care confidence may improve self-care, even in heart failure patients with impaired cognition.

Predictors of medication nonadherence differ among black and white patients with heart failure

Heart failure (HF) is a global public health problem, and outcomes remain poor, especially among ethnic minority populations. Medication adherence can improve heart failure outcomes but is notoriously low. The purpose of this secondary analysis of data from a prospective cohort comparison study of adults with heart failure was to explore differences in predictors of medication nonadherence by racial group (Black vs. White) in 212 adults with heart failure. Adaptive modeling analytic methods were used to model HF patient medication nonadherence separately for Black (31.7%) and White (68.3%) participants in order to investigate differences between these two racial groups. Of the 63 Black participants, 33.3% had low medication adherence, compared to 27.5% of the 149 White participants. Among Blacks, 16 risk factors were related to adherence in bivariate analyses; four of these (more comorbidities, lower serum sodium, higher systolic blood pressure, and use of fewer activities compensating for forgetfulness) jointly predicted nonadherence. In the multiple risk factor model, the number of risk factors in Black patients ranged from 0 to 4, and 76.2% had at least one risk factor. The estimated odds ratio for medication nonadherence was increased 9.34 times with each additional risk factor. Among White participants, five risk factors were related to adherence in bivariate analyses; one of these (older age) explained the individual effects of the other four. Because Blacks with HF have different and more risk factors than Whites for low medication adherence, interventions are needed that address unique risk factors among Black patients with HF.

Erythropoietin in the general population: reference ranges and clinical, biochemical and genetic correlates

Background

Although erythropoietin has been used for decades in the treatment of anemia, data regarding endogenous levels in the general population are scarce. Therefore, we determined erythropoietin reference ranges and its clinical, biochemical and genetic associations in the general population.

Methods

We used data from 6,777 subjects enrolled in the Prevention of REnal and Vascular ENd-stage Disease (PREVEND) study. Fasting venous blood samples were obtained in the morning from all participants from 2001–2003. Serum erythropoietin concentrations were measured using a fully automated chemiluminescent enzyme-labeled immunometric assay. A genome-wide association study was performed to identify genetic determinants.

Results

Mean age (± SD) was 53 ± 12 years and 50% were female. Median (IQR) erythropoietin concentrations were 7.6 (5.8–9.9) IU/L in men and 7.9 (6.0–10.6) IU/L in women. A strong positive correlation was found between erythropoietin and waist circumference, glucose and systolic blood pressure (all P < 0.05). In subjects with normal renal function there was a strong exponential relation between hemoglobin and erythropoietin, whereas in renal impairment (eGFR < 60 mL/min/1.73m^²) this relation was linear (men) or absent (women) (P < 0.001 for interaction). Single-nucleotide polymorphisms at the HBS1L-MYB locus were shown to be related to erythropoietin levels (P < 9x10^-21), more significantly than other erythrocyte parameters.

Conclusion

We provide age-specific reference ranges for endogenous serum erythropoietin. Erythropoietin levels are positively associated with the components of the metabolic syndrome, except cholesterol. We show that even mild renal failure blunts erythropoietin production and propose the HBS1L-MYB locus as a regulator of erythropoietin.