Factors associated with the development of expertise in heart failure self-care

A Longitudinal Study of the Association of Awareness of Disease Incurability with Patient-Reported Outcomes in Heart Failure

OBJECTIVES

To examine awareness of disease incurability among patients with heart failure over 24 mo and its associations with patient characteristics and patient-reported outcomes (distress, emotional, and spiritual well-being).

METHODS

This study analyzed 24-mo data from a prospective cohort study of 251 patients with heart failure (New York Heart Association class III/IV) recruited from inpatient wards in Singapore General Hospital and National Heart Centre Singapore. Patients were asked to report if their doctor told them they were receiving treatment to cure their condition. "No" responses were categorized as being aware of disease incurability, while "Yes" and "Uncertain" were categorized as being unaware and being uncertain about disease incurability, respectively. We used mixed-effects multinomial logistic regression to investigate the associations between awareness of disease incurability and patient characteristics and mixed-effects linear regressions to investigate associations with patient outcomes.

RESULTS

The percentage of patients who were aware of disease incurability increased from 51.6% at baseline to 76.4% at 24-mo follow-up (P < 0.001). Compared with being unaware of disease incurability, being aware was associated with older age (relative risk ratio [RRR] = 1.04; P = 0.005), adequate self-care confidence (RRR = 5.06; P < 0.001), participation in treatment decision making (RRR = 2.13; P = 0.006), higher education (RRR = 2.00; P = 0.033), financial difficulty (RRR = 1.18; P = 0.020), symptom burden (RRR = 1.08; P = 0.001), and ethnicity (P < 0.05). Compared with being unaware of disease incurability, being aware was associated with higher emotional well-being (β = 0.76; P = 0.024), while being uncertain about disease incurability was associated with poorer spiritual well-being (β = -3.16; P = 0.006).

CONCLUSIONS

Our findings support the importance of being aware of disease incurability, addressing uncertainty around disease incurability among patients with heart failure, and helping patients make informed medical decisions. The findings are important to Asian and other cultures where the prognosis disclosure to terminally ill patients is generally low with an intention to "protect" patients.

HIGHLIGHTS

Our 24-mo study with heart failure patients showed an increase from 52% to 76% in patients being aware of disease incurability.Compared with being unaware of disease incurability, being aware was associated with higher emotional well-being, while uncertainty about disease incurability was associated with poorer spiritual well-being.

Sleep Deficiency: A Symptoms Perspective: Exemplars from Chronic Heart Failure, Inflammatory Bowel Disease, and Breast Cancer

Sleep deficiency is associated with disabling daytime symptoms, including excessive daytime sleepiness (EDS) and fatigue. The purpose of this article is to discuss the contributions of sleep deficiency and sleep disorders to fatigue and EDS among people with chronic conditions. We use exemplars from the literature on chronic heart failure, inflammatory bowel disease, and breast cancer to (1) describe the prevalence of fatigue and EDS and their consequences; (2) examine the evidence for the contributions of sleep deficiency and sleep disorders to these symptoms; and (3) recommend implications for future research and practice.

Self-management education for hypertension, diabetes, and dyslipidemia as major risk factors for cardiovascular disease: Insights from stakeholders' experiences and expectations

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of premature death, with hypertension, diabetes, and dyslipidemia as major risk factors. Effective self-management (SM) is crucial for controlling these conditions and improving quality of life. This study examines stakeholders' experiences and expectations of SM education to enhance program development.

METHODS

This study employed a qualitative grounded theory approach to explore the perspectives of three stakeholder groups: 19 patients with hypertension, type 2 diabetes, and dyslipidemia, 11 primary healthcare providers, and five provincial health policymakers and managers. Data were collected via semi-structured patient interviews and focus group discussions(FGDs) with health professionals. Coding and analysis were conducted separately using Corbin and Strauss principles with ATLAS. ti version 9.0 software.

RESULTS

Most patients were women (68%) aged 50-60 years (37%), with education levels from illiterate to master's degree; 32% had completed primary school. Most were housewives (52%), and 12 had multiple chronic diseases. Healthcare providers included six community health workers and five primary care physicians, with average experience of 12 and 19 years, respectively. Health policymakers and managers averaged 25 years of experience. Patient interviews and FGDs resulted in 12 and 13 subthemes, respectively, with five subthemes common to both sources. These subthemes were grouped into broader main themes, including "effective content design," "effective presentation and delivery," "characteristics and conditions of involved parties," and "educational needs," collectively reflect the central concept of "effective self-management education".

CONCLUSION

Although the core concept and its main themes were evident and consistent across stakeholder groups, significant variations in subthemes from each stakeholder emerged. This underscores the importance of considering diverse viewpoints and highlights that, while overarching concepts may seem uniform, exploring the details of stakeholder perspectives is crucial for understanding their nuanced opinions. Effective education should integrate these insights, focusing on tailored communication, interactivity, and active monitoring.

What are key characteristics of adults with advanced heart failure discharged from ICU?

BACKGROUND

As the number of people with heart failure and treatment complexity increases, many hospitals are implementing Advanced Heart Failure Intensive Care Units (AHFICU). However, little evidence concerning the clinical characteristics of people admitted to AHFICUs exists. Understanding the clinical characteristics of people admitted to the AHFICU will assist nurses with implementing tailored interventions to ensure high-quality care delivery.

AIM

The purpose of this study was to describe the clinical characteristics of people who are admitted to and discharged from an AHFICU.

STUDY DESIGN

Baseline data from a longitudinal descriptive study were collected on adults (N = 43) admitted to an AHFICU. Heart failure severity, self-management ability, cognition, sleep quality, and other clinical characteristics were assessed.

RESULTS

Most study participants were New York Heart Association functional class IV (n = 24) or class III (n = 14), indicating poor functional capacity. Over half had mild cognitive impairment and poor sleep quality was prevalent (92.7%). Participants had adequate levels of heart failure knowledge, but low levels of heart failure self-management decision-making and ability.

CONCLUSIONS

Interventions to address the unique clinical characteristics of AHFICU patients include sleep hygiene, integration of cognitive, sleep, and self-management assessments into the electronic medical record. Addressing the unique clinical needs of people with heart failure will lead to patient-centered, evidence-based, and safe care.

RELEVANCE TO CLINICAL PRACTICE

Understanding characteristics of this population addresses this evidence gap and targeted clinical interventions to address unique discharge needs of this population are proposed. Sleep quality education should be done throughout hospitalization on sleep strategies and self-management coaching to facilitate adoption of new sleep routines. Healthcare providers should ensure each patient has care support upon discharge and take cognitive status into consideration during teaching. Addressing self-management readiness should include providing scenarios as part of discharge preparation. Providers must include addressing comorbidities and how they may affect heart failure self-management, such as teaching about sleep apnea device use and encouraging compliance.

Social Support and Adherence to Self-Care Behavior Among Patients With Coronary Heart Disease and Heart Failure: A Systematic Review

Cardiovascular diseases stand out as the foremost cause of mortality on a global scale and encompass conditions that require long term self-care. Coronary heart disease and heart failure are two cardiovascular conditions that require significant lifestyle modifications. Adherence to self-care is a multifaceted phenomenon, and is influenced by various factors that include social, economic, disease-related and healthcare system-related factors. A key factor in adherence to self-care in chronic illnesses is social support. To explore this relationship between social support and adherence to self-care, a systematic review was carried out across Scopus, EBSCO host and ProQuest from October 2022 to February 2023 using predefined search criteria. Studies from inception to February 2023 were considered for the review, ultimately incorporating a total of 11 studies. Six studies had an adult population with coronary heart disease while the remaining five had adults with heart failure. All the studies reported a significant positive correlation between social support and adherence to self-care. Our findings revealed that social support plays a significant role in promoting self-care, emphasizing the need for a holistic understanding of self-care to develop effective interventions. Along with self-report measures, objective measures should be used to assess adherence accurately. There is a need for scales that assess all aspects of self-care, as well as the development of new interventions and teaching strategies to facilitate the individual's self-care journey. In addition, family members and trusted resources should be involved in encouraging self-care, and interventions should target both patients and their family members.

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.

A Prospective Cohort Study of Medical Decision-Making Roles and Their Associations with Patient Characteristics and Patient-Reported Outcomes among Patients with Heart Failure

OBJECTIVE

Among patients with heart failure (HF), we examined 1) the evolution of patient involvement in decision making over 2 y, 2) the association of patient characteristics with decision-making roles, and 3) the association of decision-making roles with distress, spiritual well-being, and quality of physician communication.

METHODS

We administered the survey every 4 mo over 24 mo to patients with New York Heart Association class 3/4 symptoms recruited from inpatient clinics. The decision-making roles were categorized as no patient involvement, physician/family-led, joint (with family and/or physicians), patient-led, or patient-alone decision making. The associations between patient characteristics and decision-making roles were assessed using a mixed-effects ordered logistic regression, whereas those between patient outcomes and decision-making roles were investigated using mixed-effects linear regressions.

RESULTS

Of the 557 patients invited, 251 participated in the study. The most common roles in decision making at baseline assessment were "no involvement" (27.53%) and "patient-alone decision making" (25.10%). The proportions of different decision-making roles did not change over 2 y (P = 0.37). Older age (odds ratio [OR] = 0.97; P = 0.003) and being married (OR = 0.63; P = 0.035) were associated with lower involvement in decision making. Chinese ethnicity (OR = 1.91; P = 0.003), higher education (OR = 1.87; P = 0.003), awareness of terminal condition (OR = 2.00; P < 0.001), and adequate self-care confidence (OR = 1.74; P < 0.001) were associated with greater involvement. Compared with no patient involvement, joint (β = -0.58; P = 0.026) and patient-led (β = -0.59; P = 0.014) decision making were associated with lower distress, while family/physician-led (β = 4.37; P = 0.001), joint (β = 3.86; P < 0.001), patient-led (β = 3.46; P < 0.001), and patient-alone (β = 3.99; P < 0.001) decision making were associated with better spiritual well-being.

CONCLUSION

A substantial proportion of patients was not involved in decision making. Patients should be encouraged to participate in decision making since it is associated with lower distress and better spiritual well-being.

HIGHLIGHTS

The level of involvement in medical decision making did not change over time among patients with heart failure. A substantial proportion of patients were not involved in decision making throughout the 24-mo study period.Patients' involvement in decision making varied by age, ethnicity, education level, marital status, awareness of the terminal condition, and confidence in self-care.Compared with no patient involvement in decision making, joint and patient-led decision making were associated with lower distress, and any level of patient involvement in decision making was associated with better spiritual well-being.

The effectiveness of cognitive-behavioral therapy for heart failure patients: a narrative review

Heart failure (HF) remains a major cause of morbidity, mortality and healthcare costs, despite available treatments. Psychological issues such as depression, anxiety and poor self-care are prevalent in HF patients. Such issues adversely affect patients' daily lives and increase hospitalization and mortality rates; therefore, effective approaches to address these are needed. Cognitive-behavioral therapy (CBT) has been proposed as potentially useful for psychological comorbidities in HF patients, but its efficacy is not well-established. This narrative review aimed to summarize the evidence on the effectiveness of CBT for HF patients. A search was conducted using PubMed and Google Scholar for randomized controlled trials (RCTs) on CBT for HF patients. Ten studies (nine RCTs and one case study) were included in the review. CBT was found to be an effective intervention for managing depression, anxiety, low quality of life, and impaired social and physical functioning in HF patients. The results suggest that CBT can improve psychological well-being and enhance the benefits of rehabilitation programs. Face-to-face CBT appears to be superior to conventional therapy and can be implemented in cardiac rehabilitation settings. Further research is needed to evaluate the efficacy of internet-based CBT for cardiac patients and identify factors that promote treatment adherence.

Determination of the relationship between self-care agency and sleepiness in chronic hemodialysis patients

OBJECTIVE

This study was conducted to determine the relationship between self-care agency and sleepiness in chronic hemodialysis patients.

METHODS

The study was conducted with 75 patients with chronic renal failure in the hemodialysis unit of a training and research hospital in our country. In the descriptive study, the data were collected through a face-to-face questionnaire. The IBM SPSS Statistics 22.0 program was used to evaluate the data.

RESULTS

It was determined that there was no significant relationship between self-care agency and sleepiness total scores in chronic hemodialysis patients (p>0.05) and a significant relationship between sleepiness and drug use compliance and mental status in female patients and between diet compliance and sleepiness in patients younger than 52 years of age (p<0.05).

CONCLUSION

As a result, it was observed that there was no relationship between self-care agency and sleepiness in chronic hemodialysis patients. We think that working with a larger sample group can lead to clearer results.

Associations between continuity of care, perceived control and self-care and their impact on health-related quality of life and hospital readmission-A structural equation model

AIM

The aim of this study is to examine whether a conceptual model including the associations between continuity of care, perceived control and self-care could explain variations in health-related quality of life and hospital readmissions in people with chronic cardiac conditions after hospital discharge.

DESIGN

Correlational design based on cross-sectional data from a multicentre survey study.

METHODS

People hospitalized due to angina, atrial fibrillation, heart failure or myocardial infarction were included at four hospitals using consecutive sampling procedures during 2017-2019. Eligible people received questionnaires by regular mail 4-6 weeks after discharge. A tentative conceptual model describing the relationship between continuity of care, self-care, perceived control, health-related quality of life and readmission was developed and evaluated using structural equation modelling.

RESULTS

In total, 542 people (mean age 75 years, 37% females) were included in the analyses. According to the structural equation model, continuity of care predicted self-care, which in turn predicted health-related quality of life and hospital readmission. The association between continuity of care and self-care was partly mediated by perceived control. The model had an excellent model fit: RMSEA = 0.06, 90% CI, 0.05-0.06; CFI = 0.90; TLI = 0.90.

CONCLUSION

Interventions aiming to improve health-related quality of life and reduce hospital readmission rates should focus on enhancing continuity of care, perceived control and self-care.

IMPACT

This study reduces the knowledge gap on how central factors after hospitalization, such as continuity of care, self-care and perceived control, are associated with improved health-related quality of life and hospital readmission in people with cardiac conditions. The results suggest that these factors together predicted the quality of life and readmissions in this sample. This knowledge is relevant to researchers when designing interventions or predicting health-related quality of life and hospital readmission. For clinicians, it emphasizes that enhancing continuity of care, perceived control and self-care positively impacts clinical outcomes.

PATIENT OR PUBLIC CONTRIBUTION

People and healthcare personnel evaluated content validity and were included in selecting items for the short version.

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.

Factors associated with poor self-management documented in home health care narrative notes for patients with heart failure

BACKGROUND

Patients with heart failure (HF) who actively engage in their own self-management have better outcomes. Extracting data through natural language processing (NLP) holds great promise for identifying patients with or at risk of poor self-management.

OBJECTIVE

To identify home health care (HHC) patients with HF who have poor self-management using NLP of narrative notes, and to examine patient factors associated with poor self-management.

METHODS

An NLP algorithm was applied to extract poor self-management documentation using 353,718 HHC narrative notes of 9,710 patients with HF. Sociodemographic and structured clinical data were incorporated into multivariate logistic regression models to identify factors associated with poor self-management.

RESULTS

There were 758 (7.8%) patients in this sample identified as having notes with language describing poor HF self-management. Younger age (OR 0.982, 95% CI 0.976-0.987, p < .001), longer length of stay in HHC (OR 1.036, 95% CI 1.029- 1.043, p < .001), diagnosis of diabetes (OR 1.47, 95% CI 1.3-1.67, p < .001) and depression (OR 1.36, 95% CI 1.09-1.68, p < .01), impaired decision-making (OR 1.64, 95% CI 1.37-1.95, p < .001), smoking (OR 1.7, 95% CI 1.4-2.04, p < .001), and shortness of breath with exertion (OR 1.25, 95% CI 1.1-1.42, p < .01) were associated with poor self-management.

CONCLUSIONS

Patients with HF who have poor self-management can be identified from the narrative notes in HHC using novel NLP methods. Meaningful information about the self-management of patients with HF can support HHC clinicians in developing individualized care plans to improve self-management and clinical outcomes.

Sleep Deficiency: A Symptoms Perspective: Exemplars from Chronic Heart Failure, Inflammatory Bowel Disease, and Breast Cancer

Sleep deficiency is associated with disabling daytime symptoms, including excessive daytime sleepiness (EDS) and fatigue. The purpose of this article is to discuss the contributions of sleep deficiency and sleep disorders to fatigue and EDS among people with chronic conditions. We use exemplars from the literature on chronic heart failure, inflammatory bowel disease, and breast cancer to (1) describe the prevalence of fatigue and EDS and their consequences; (2) examine the evidence for the contributions of sleep deficiency and sleep disorders to these symptoms; and (3) recommend implications for future research and practice.

The Association Between Self-reported Sleep Quality and Self-care in Adults With Heart Failure

BACKGROUND

Sleep disturbance is one of the most common symptoms among patients with heart failure (HF), and it may affect the ability of patients to perform self-care. There is a lack of evidence on the association between sleep quality and its components and self-care in adults with HF.

OBJECTIVE

The aim of this study was to evaluate the association between sleep quality and its components and self-care in adults with HF.

METHODS

This study is a secondary analysis of baseline data from the MOTIVATE-HF study, a randomized controlled trial on patients with HF and their caregivers. Only patients' data were analyzed in this study (n = 498). Sleep quality and self-care were evaluated with the Pittsburgh Sleep Quality Index and the Self-Care of Heart Failure Index v6.2, respectively.

RESULTS

A habitual sleep efficiency of 75% to 84% was associated with lower self-care maintenance compared with a habitual sleep efficiency of 85% or greater ( P = .031), as was taking sleep medications once or twice a week compared with less than once a week ( P = .001). A frequency of daytime dysfunction less than once a week was associated with lower self-care management compared with a frequency of daytime dysfunction of 3 or more times a week ( P = .025). Taking sleep medications less than once a week was associated with lower self-care confidence compared with taking sleep medications 3 or more times a week ( P = .018).

CONCLUSION

Poor sleep quality is frequently reported by patients with HF. Sleep efficiency, sleep medications, and daytime dysfunction may influence self-care more than the other sleep quality components.

The effectiveness of a nurse-led home-based heart failure self-management programme (the HOM-HEMP) for patients with chronic heart failure: A three-arm stratified randomized controlled trial

BACKGROUND

Although important, heart failure self-care remains a challenge for many patients. This study aimed to evaluate the effect of a nurse-led, home-based self-management psychosocial education intervention (HOM-HEMP). The primary outcome was patient's HF self-care in terms of maintenance, management and confidence. The secondary outcomes were cardiac self-efficacy, psychological wellbeing in terms of perceived social support, health related quality of life and levels of anxiety and depression. The clinical outcomes included New York Heart Association (NYHA) functional class and numbers of unplanned health service visits due to cardiac-related reasons.

DESIGN

A three-arm stratified randomized controlled trial was conducted (Clinical trial registration number: NCT03108235).

METHODS

A total of 213 participants admitted for heart failure were recruited from the inpatient wards of a tertiary public hospital in Singapore. They were randomly allocated to the control group, the experimental group A or the experimental group B. All participants received the usual care provided by the hospital. Participants in experimental groups A and B received the HOM-HEMP intervention, and those in experimental group B received an additional supplemental smartphone application. Data were collected at baseline, 6 weeks, 3 months and 6 months from baseline.

RESULTS

Compared to the control groups, participants in either of the experimental group had significantly higher levels of heart failure self-care maintenance (F = 4.222, p = 0.001), self-care confidence (F = 5.796, p < 0.001) and self-care management (p < 0.05) at 6-week, 3-month and 6-month follow-ups. In addition, both experimental groups had significantly higher levels of cardiac self-efficacy, better health related quality of life and lower depression levels than the control group after the study intervention. A higher proportion of participants in both experimental groups had a better New York Heart Association functional class at 6-week and 3-month follow-ups. Participants in the experimental group B also had significantly fewer cardiac-related unplanned hospital admissions and emergency room visits than the control group at 6-month follow-up. Results on perceived social support were not significant. The study outcomes in experimental group A and B were not significantly different at any of the post intervention follow-up.

CONCLUSION

The findings suggested that HOM-HEMP is an effective intervention for patients with heart failure in Singapore.

Characteristics of dyadic care types among patients living with multiple chronic conditions and their informal caregivers

AIMS

To examine the distribution of dyadic care types in multiple chronic conditions, compare self-care and caregiver contributions to patients' self-care in each care type and identify the patient and caregiver characteristics associated with each care type.

DESIGN

Secondary analysis of a multicentre, cross-sectional study.

METHODS

Patient-caregiver dyads were enrolled from outpatient clinics and community settings. The Dyadic Symptom Management Type Scale was used to categorize dyads by type. Self-care, self-efficacy, comorbidities and cognitive impairment were measured in patients, whereas caregiver contributions to patient self-care, self-efficacy, caregiver burden and hours of caregiving were measured in caregivers. Sociodemographic characteristics perceived social support and mutuality were measured in both patients and caregivers. Univariate and multivariate analyses were performed.

RESULTS

A sample of 541 patient-caregiver dyads was examined. The most frequent dyadic care type was the collaborative-oriented (63%). In the patient-oriented type, patients scored higher on self-care compared with caregivers; in the caregiver-oriented and collaborative types, caregivers scored higher than patients supporting the typology. The patient-oriented type was associated with younger, healthier male patients with better cognitive status, who scored higher for mutuality and whose caregivers scored lower for burden. The caregiver-oriented type was associated with older, less educated patients, with caregivers experiencing higher burden and unemployment. The collaborative type was associated with sicker patients, with the caregiver more probably to be female and employed, with higher perceived social support, mutuality and burden. The incongruent dyadic care type was associated with lower caregiver mutuality.

IMPACT

In the context of multiple chronic conditions, clinicians should consider targeting any educational interventions aimed at improving patient self-care and caregiver contributions to self-care by dyadic care types.

Sleep disturbance in heart failure: A concept analysis

AIM

This concept analysis aims to analyze the concept of sleep disturbance (SD) in the context of heart failure (HF) to guide the development of a clearly defined definition.

BACKGROUND

The term "sleep disturbance" has been used in the literature to describe sleep problems and sleep disorders among individuals with HF. Environmental, physical, psychological, behavioral, and developmental factors complicate the phenomenon of SD in HF.

DESIGN

Walker and Avant's method was used for this concept analysis.

DATA SOURCE

Published literature from 2000 to 2020 was identified from electronic health profession-related databases. The current definition and usages of SD were abstracted from empirical work and electronic databases.

REVIEW METHODS

A focused review of abstracts and full text relating to SD in HF was performed. Studies featuring original data and peer-reviewed articles written in English were included to investigate the multifactorial contextual meaning of the concept.

RESULTS

SD in HF can be described as a condition in which individuals experience difficulty initiating and maintaining sleep, and difficulty continuing or resuming sleep due to frequent nocturnal arousals due to HF symptoms, sleep-disordered breathing, insomnia, and psychological burdens.

CONCLUSIONS

To evaluate SD in HF, clinicians must examine the underlying causes to provide the contextual meaning of the concept. A clearly defined and distinguishable concept of SD in HF provides a possibility for accurate measurements of sleep quality, exploring interventions, and evaluating outcomes.

The effects of marital status on outcome of heart failure population: a systematic review and meta-analysis

BACKGROUND

Traditional risk factors for worse outcome in heart failure (HF) are well-established. However, there are still many unknown risk factors for worse outcome in this population. Several studies have shown that unmarried status is associated with an increased risk of rehospitalization and mortality in HF patients. However, there is no systematic review or meta-analysis to confirm this association. We performed a systematic review and meta-analysis to explore the effect of marital status on outcome regarding mortality and rehospitalization in HF population.

METHODS

We searched the databases of MEDLINE and EMBASE from inception to July 2019. Included studies were published cohort studies or randomised controlled trials reporting rates of mortality and/or rehospitalization in HF patients, married and unmarried. Data from each study were combined using the random-effects model.

RESULTS

Ten studies were included in our meta-analysis. We found that unmarried status is associated with increased risk of mortality (pooled OR = 1.52, 95%CI = 1.30-1.78, p < .001), increased risk of rehospitalization (pooled OR = 1.80, 95%CI = 1.18-2.74, p = .007), and increased risk of combined endpoint of mortality and rehospitalization (pooled OR = 1.72, 95%CI = 1.36-2.17, p < .001).

CONCLUSIONS

Our meta-analysis demonstrated that being unmarried, divorced, and widowed is associated with a worse outcome in HF population regarding mortality and rehospitalization rate.

Patients' and caregivers' perspectives in determining discharge readiness from home health

There are no national, empirically derived clinical decision support tools to assist the interprofessional home health team in determining readiness for discharge from skilled home health. Eliciting patient and family caregiver perspectives around readiness for home health discharge is integral to developing tools that address their needs in this decision-making process. The purpose of this study was to describe the factors home health patients and their family caregivers perceive as critical when determining readiness for discharge from services. A qualitative descriptive study was conducted among skilled home health recipients and their family caregivers who were either recently discharged or recertified for additional care from two different Medicare-certified skilled home health agencies. Nine themes emerged: self-care ability, functional status, status of condition(s) and symptoms, presence of a caregiver, support for the caregiver, connection to community resources/support, safety needs of the home environment addressed, adherence to the prescribed regimen, and care coordination.

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.

Exercise and Cognitive Training Intervention Improves Self-Care, Quality of Life and Functional Capacity in Persons With Heart Failure

This study evaluated a 12-week, home-based combined aerobic exercise (walking) and computerized cognitive training (EX/CCT) program on heart failure (HF) self-care behaviors (Self-care of HF Index [SCHFI]), disease specific quality of life (Kansas City Cardiomyopathy Questionnaire [KCCQ]), and functional capacity (6-minute walk distance) compared to exercise only (EX) or a usual care attention control (AC) stretching and flexibility program. Participants (N = 69) were older, predominately female (54%) and African American (55%). There was significant improvement in self-care management, F(2, 13) = 5.7, p < .016; KCCQ physical limitation subscale, F(2, 52) = 3.4, p < .039; and functional capacity (336 ± 18 vs 388 ± 20 m, p < .05) among the EX/CCT participants. The underlying mechanisms that EX and CCT targets and the optimal dose that leads to improved outcomes are needed to design effective interventions for this rapidly growing population.

An Integrative Review of the Symptom Perception Process in Heart Failure

BACKGROUND

Accurate symptom perception is a fundamentally essential component of self-care for patients with heart failure (HF) so they can make appropriate decisions about their symptoms.

OBJECTIVE

The purpose of this integrative review was to describe the pathways of the symptom perception process and its contributing factors in patients with HF.

METHODS

A comprehensive literature search was conducted using PubMed, EMBASE, and PsycINFO databases to identify studies describing the symptom perception process (symptom detection, comprehension, and response) in adult patients with HF.

RESULTS

Two pathways of the symptom perception process were identified from 42 articles: ideal and undesirable pathways. Patients in the ideal symptom perception pathway had a comprehensive understanding of HF and a firm belief in the importance of self-care, were vigilant, and possessed good decision-making skills. They also were able to successfully use their experiences for future care. However, patients in the undesirable symptom perception pathway had a limited understanding of HF with poor symptom monitoring skills and inaccurate judgments about symptoms. Diverse factors contributing to the symptom perception process were identified (eg, levels of understandings of HF and social support).

CONCLUSION

Our review indicated that symptom perception was likely to diversify the pathway of HF management. A variety of contributing factors to the symptom perception process were found to be intertwined. The findings of our review can inform the development of best patient education practice, although further research needs to be conducted to understand why and how patients can follow the most appropriate path from their past experiences.

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.

Association between sleep quality and self-care in adults with heart failure: A systematic review

BACKGROUND

Sleep disturbance is one of the most common symptoms among heart failure patients. Sleep disturbance reduces quality of life and leads to higher rates of mortality. It may affect the ability of patients to perform adequate self-care. Although some research has evaluated the association between sleep quality and heart failure self-care, a synthesis of the most recent available evidence is lacking.

AIMS

This systematic review aimed to assess the association between sleep quality and self-care in adults with heart failure.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was used. Medline, CINAHL, PsycINFO and SCOPUS were searched. Observational, case-control and cohort studies were considered. The quality of the studies was evaluated with the Joanna Briggs Institute's Critical Appraisal Tools.

RESULTS

Six articles were included. Association between sleep quality and self-care was reported by three studies. One of these did not find an association between sleep disturbance and heart failure self-care, while the other two studies did. An association between sleep quality and medication adherence was reported by three studies. All three of these studies found associations between these two variables. Studies have measured similar but different constructs. Two studies assessed sleep quality, while four other studies measured excessive daytime sleepiness. Half of the studies examined self-care, while the other half measured medication adherence.

CONCLUSIONS

Although the evidence should be strengthened, sleep quality seems to affect self-care in heart failure patients. The mechanism underlying the effect of sleep quality on heart failure self-care remains unclear. Future longitudinal interaction analyses could be useful to clarify this mechanism.

Depression and self-care in older adults with multiple chronic conditions: A multivariate analysis

AIMS

To investigate the relationship between depression and self-care behaviours in older individuals with multimorbidity.

DESIGN

Cross-sectional study. Data were collected between April 2017 - June 2019.

METHODS

Patients were enrolled from community and outpatient settings and included if they were ≥65 years, affected by heart failure, diabetes mellitus or chronic obstructive pulmonary disease and at least another chronic condition. They were excluded if they had dementia and/or cancer. Patient Health Questionnaire-9 was used to measure depression and Self-Care of Chronic Illness Inventory was used to measure self-care maintenance, monitoring, and management. The relationship between depression and self-care was evaluated by performing two sets of univariate analyses, followed by multivariate and step-down analyses. The second set was performed to control for the number of chronic conditions, age, and cognitive function.

RESULTS

The sample (N = 366) was mostly female (54.2%), with a mean age of 76.4 years. Most participants (65.6%) had mild to very severe depressive symptoms. Preliminary analysis indicated a significant negative association between depression and self-care maintenance and monitoring and a significant negative association between depression and multivariate self-care. Step-down analysis showed that self-care maintenance was the only dimension negatively associated with depression, even after controlling for the number of chronic conditions, age, and cognitive function.

CONCLUSION

In multimorbid populations, depression is more likely to be associated with self-care maintenance than the other self-care dimensions. Therefore, self-care maintenance behaviours (e.g., physical activity and medication adherence) should be prioritized in assessment and focused on when developing interventions targeting depressed older adults with multimorbidity.

IMPACT

The results of this study may help guide clinical practice. In patients with depressive symptoms, self-care maintenance behaviours should be assessed first, as a potential first indicator of poor self-care.

A Mobile Phone-Based Telemonitoring Program for Heart Failure Patients After an Incidence of Acute Decompensation (Medly-AID): Protocol for a Randomized Controlled Trial

BACKGROUND

Patients with heart failure (HF) are at the highest risk for hospital readmissions during the first few weeks after discharge when patients are transitioning from hospital to home. Telemonitoring (TM) for HF management has been found to reduce mortality risk and hospital readmissions if implemented appropriately; however, the impact of TM targeted for patients recently discharged from hospital, for whom TM might have the biggest benefit, is still unknown. Medly, a mobile phone-based TM system that is currently being used as a standard of care for HF at a large Canadian hospital, may be an effective tool for the management of HF in patients recently discharged from hospital.

OBJECTIVE

The objective of the Medly-After an Incidence of acute Decompensation (Medly-AID) trial is to determine the effect of Medly on the self-care and quality of life of patients with HF who have been recently discharged from hospital after an HF-related decompensation.

METHODS

A multisite multimethod randomized controlled trial (RCT) will be conducted at 2 academic hospitals and at least one community hospital to evaluate the impact of Medly-enabled HF management on the outcomes of patients with HF who had been hospitalized for HF-related decompensation and discharged during the 2 weeks before recruitment. The trial will include 144 participants with HF (74 in each control and intervention groups). Control patients will receive standard of care, whereas patients in the intervention group will receive standard of care and Medly. Specifically, patients in the intervention group will record daily weight, blood pressure, and heart rate and answer symptom-related questions via the Medly app. Medly will generate automated patient self-care messages such as to adjust diuretic medications, based on the rules-based algorithm personalized to the individual patient, and send real-time alerts to their health care providers as necessary. All patients will be followed for 3 months. Primary outcome measures are self-care and quality of life as measured through the validated questionnaires Self-Care of Heart Failure Index, EQ-5D-5L, and the Kansas City Cardiomyopathy Questionnaire-12. Secondary outcome measures for this study include cost of health care services used and health outcomes.

RESULTS

Patient recruitment began in November 2018 at the Sunnybrook Health Sciences Centre, with a total of 35 participants recruited by July 30, 2019 (17 in the intervention group and 18 in the control group). The final analysis is expected to occur in the fall of 2020.

CONCLUSIONS

This RCT will be the first to assess the effectiveness of the Medly TM system for use following discharge from hospital after a HF-related decompensation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03358303; https://clinicaltrials.gov/ct2/show/NCT03358303.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15753.

Functional support and burden among out-of-home supporters of heart failure patients with and without depression

OBJECTIVE

Over 20% of patients with heart failure (HF) experience clinical depression, which is associated with higher rates of mortality, morbidity, and hospitalization. Support from family members or friends (whom we refer to as care partners [CPs]) can lower the risk of these outcomes. We examined whether HF patients with depression received assistance from CPs living outside of their homes. Further, we examined whether patient depression was associated with support-related strain among out-of-home CPs.

METHOD

We analyzed baseline survey data from 348 HF patients with reduced ejection fraction and their CPs. Patients with scores on the Center for Epidemiological Studies Depression Scale-10 (Kohout, Berkman, Evans, & Cornoni-Huntley, 1993) of ≥10 were classified as having clinically significant depressive symptoms (i.e., depression). Outcomes included CP-reported hr per week helping with health care and talking with patients via telephone and scores on the Modified Caregiver Strain Index. Negative binomial regression models examined differences in the amount of in-person and telephone support for patients with and without depression, controlling for patients' comorbidities, living alone, CP geographic distance, and CP emotional closeness to the patient.

RESULTS

CPs provided more in-person support to HF patients with depression (M = 3.64 hr) compared with those without depression (M = 2.60 hr per week, incident rate ratio [IRR] = 1.40, p = .019). CPs provided more telephone support to patients with depression (M = 3.02 hr) compared with those without depression (M = 2.09 hr per week, IRR = 1.42, p < .001). Patient depression had no effect on caregiver burden (IRR = 1.00, p = .843).

CONCLUSION

Patients with clinically significant depressive symptoms receive more in-person assistance and telephonic support from CPs. Despite that additional contact, caregiver burden was not greater among the supporters of depressed patients. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The development and pilot study of a nurse-led HOMe-based HEart failure self-Management Programme (the HOM-HEMP) for patients with chronic heart failure, following Medical Research Council guidelines

BACKGROUND

Chronic heart failure (CHF) is one of the most common causes of hospital admissions and readmissions. Managing CHF requires a comprehensive treatment plan that consists of medication treatment and behavioural change. However, patients often feel unprepared for their self-management role in the community, especially during the period of transition after discharge from hospital. Therefore, an effective intervention to promote CHF self-management is needed.

AIMS

This paper describes the development and pilot testing of a multicomponent nursing intervention (i.e. the HOM-HEMP) for a randomised controlled trial to assess its effectiveness in improving self-care behaviour among CHF patients in Singapore. A description of the study intervention is also delineated in detail.

METHODS

The HOM-HEMP was developed based on the UK Medical Research Council framework for developing and evaluating complex interventions. After the development of the study intervention, a single group pre- and post-repeated measure pilot test was conducted to evaluate the study intervention package for its acceptability and the feasibility of the data collection procedure. Ten participants were recruited through consecutive sampling. All of the participants received the full intervention package with the supplementary mobile application. The data were collected at baseline and immediately after the study intervention (i.e. 6 weeks from baseline). The outcome measures included the Self-Care Heart Failure Index, Cardiac Self-Efficacy Scale, Minnesota Living with Heart Failure Questionnaire, Hospital Anxiety and Depression Scale and Short Form of the Social Support Questionnaire.

RESULTS

The results from the pilot testing showed that the programme was feasible and potentially effective in improving patient's self-care management, psychological outcomes and health-related quality of life.

CONCLUSION

A self-management psychosocial education approach is the preferred choice for many patients with chronic diseases. The effectiveness of the HOM-HEMP will next be tested in a full scale randomised control trial.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Mobile Application for Patients With Heart Failure: Theory- and Evidence-Based Design and Testing

Self-care is vital for the successful management of heart failure. Mobile health can enable patients with heart failure to perform effective self-care. This article describes the theory-guided development and beta testing of a mobile application intervention to support self-care and increase symptom awareness in community-dwelling patients with heart failure. Ten participants entered physiologic data, answered qualitative questions about symptoms, and reviewed heart failure education within the HF App daily. Two validated instruments, the Self-care of Heart Failure Index and Heart Failure Somatic Awareness Scale, were administered both before and after the intervention, and results were compared using t tests. Results indicated that there were clinically significant changes from preintervention to postintervention in self-care scores in each subscale, with a statistically significant difference in the confidence subscale scores (P = .037). However, there were no statistically significant differences between preintervention and postintervention symptom awareness scores. These results indicate that incorporating mobile applications that comprise symptom monitoring, reminders, education, and the ability to track trends in physiologic data is most useful to assist individuals with heart failure to perform effective self-care.

Patient Activation in Acute Decompensated Heart Failure

BACKGROUND

Recent data suggest that patient activation, or having the knowledge, skills, and confidence to engage and manage one's own health, favorably impacts patient behaviors and health outcomes. However, the role of activation in patients with heart failure is unknown.

OBJECTIVES

The aims of this study are to measure the level of activation of patients hospitalized with acute decompensated heart failure (ADHF) and to determine whether activation is associated with in-hospital and early postdischarge outcomes.

METHODS

We prospectively recruited Southeastern Minnesota residents hospitalized at Mayo Clinic hospitals with ADHF from January 2014 to July 2015. Activation was measured using the Patient Activation Measure questionnaire.

RESULTS

Among the 302 patients enrolled, the mean age was 77.3 years, 57.3% were men, and 46.8% had preserved ejection fraction. The median (25th-75th percentile) length of stay was 4 (3-7) days. In total, 7 (2.3%) patients died before discharge. Most survivors were discharged to home (73.6%) or skilled nursing facilities (23.7%). The number of patients in each activation level from highest to lowest was 9 (3.0%), 121 (40.1%), 122 (40.4%), and 50 (16.6%). Patients with lower activation were older, were less educated, had lower patient satisfaction, and had worse health literacy. They were more often discharged to skilled nursing facilities and had higher 30-day mortality, although 30-day readmission did not differ by activation.

CONCLUSIONS

Patients hospitalized with ADHF with lower activation are less satisfied, have worse health literacy, more often require skilled care, and are at increased risk for early postdischarge mortality. Activation can be easily measured and may help clinicians identify high-risk patients.

A mixed methods study of symptom perception in patients with chronic heart failure

BACKGROUND

Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF.

METHODS

We enrolled 36 HF out-patients into a longitudinal sequential explanatory mixed methods study. We used objectively measured thoracic fluid accumulation and daily reports of signs and symptoms to evaluate accuracy of detected changes in fluid retention. Patterns of symptom interpretation and response were explored in telephone interviews conducted every 2 weeks for 3-months.

RESULTS

In this sample, 44% had a mismatch between objective and subjective fluid retention; younger persons were more likely to have mismatch. In interviews, two patterns were identified: those able to interpret and respond appropriately to symptoms were higher in decision-making skill and the quality of social support received.

CONCLUSION

Many HF patients were poor at interpreting and managing their symptoms. These results suggest a subgroup of patients to target for intervention.

Living Arrangements Modify the Relationship Between Depressive Symptoms and Self-care in Patients With Heart Failure

BACKGROUND

Depressive symptoms hinder heart failure patients' engagement in self-care. As social support helps improve self-care and decrease depressive symptoms, it is possible that social support buffers the negative impact of depressive symptoms on self-care.

OBJECTIVE

The purpose of this study is to examine the effect of living arrangements as an indicator of social support on the relationship between depressive symptoms and self-care in heart failure patients.

METHODS

Stable heart failure patients (N = 206) completed the Patient Health Questionnaire-9 to measure depressive symptoms. Self-care (maintenance, management, and confidence) was measured with the Self-Care of Heart Failure Index. Path analyses were used to examine associations among depressive symptoms and the self-care constructs by living arrangements.

RESULTS

Depressive symptoms had a direct effect on self-care maintenance and management (standardized β = -0.362 and -0.351, respectively), but not on self-care confidence in patients living alone. Depressive symptoms had no direct or indirect effect on any of the 3 self-care constructs in patients living with someone.

CONCLUSIONS

Depressive symptoms had negative effects on self-care in patients living alone, but were not related to self-care in patients living with someone. Our results suggest that negative effects of depressive symptoms on self-care are buffered by social support.

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.

Cognitive deficits and self-care behaviors in elderly adults with heart failure

Introduction

Elderly adults with heart failure (HF) may have problems with self-care behaviors because of cognitive deficits. Self-care deficits have been found to be significantly associated with negative health care outcomes among HF patients. The aim of this paper was to assess cognitive deficits and the level of self-care ability in elderly patients with HF, and to determine if a relationship exists between cognitive deficits and self-care.

Materials and methods

The study included 270 elderly patients (mean age: 72.5 years) with HF. We used the Mini Mental State Examination Scale (MMSE) to evaluate cognitive functioning, and the European Heart Failure Self-care Behavior Scale, revised into a nine-item scale (EHFScBS-9), to evaluate self-care behaviors. Associations between the variables were examined using multiple regression analysis.

Results

Lower scores in both MMSE and EHFScBS-9 questionnaires were correlated with older age, living alone, lower education, longer duration of illness, higher number of rehospitalizations, as well as lower left ventricular ejection fraction and higher New York Heart Association (NYHA) class. The multiple regression analysis was used for evaluation of the impact of the following predictors: MMSE score, age, duration of illness, ejection fraction, number of hospitalizations, sex, residence, education, relationship status, and NYHA class on EHFScBS-9 score.

Conclusions

Elderly patients with HF may have worse self-care behaviors because of their cognitive deficits. Age was the strongest predictor of worse MMSE scores. Multidisciplinary health teams should pay attention to the special needs of elderly patients who live with their illness for many years and have no social support because of living alone.

Activity Theory Analysis of Heart Failure Self-Care

The management of chronic health conditions such as heart failure is a complex process emerging from the activity of a network of individuals and artifacts. This article presents an Activity Theory-based secondary analysis of data from a geriatric heart failure management study. Twenty-one patients' interviews and clinic visit observations were analyzed to uncover eight configurations of roles and activities involving patients, clinicians, and others in the sociotechnical network. For each configuration or activity pattern, we identify points of tension and propose guidelines for developing interventions for future computer-supported healthcare systems.

Physical function and exercise training in older patients with heart failure

Heart failure (HF) is a common end point for numerous cardiovascular conditions, including coronary artery disease, valvular disease, and hypertension. HF predominantly affects older individuals (aged ≥70 years), particularly those living in developed countries. The pathophysiological sequelae of HF progression have a substantial negative effect on physical function. Diminished physical function in older patients with HF, which is the result of combined disease-related and age-related effects, has important implications on health. A large body of research spanning several decades has demonstrated the safety and efficacy of regular physical activity in improving outcomes among the HF population, regardless of age, sex, or ethnicity. However, patients with HF, especially those who are older, are less likely to engage in regular exercise training compared with the general population. To improve initiation of regular exercise training and subsequent long-term compliance, there is a need to rethink the dialogue between clinicians and patients. This Review discusses the need to improve physical function and exercise habits in patients with HF, focusing on the older population.

Correlates of Health Literacy and Its Impact on Illness Beliefs for Emergency Department Patients With Acute Heart Failure

OBJECTIVES

To study the relationship between health literacy (HL) and socioeconomic, demographic factors and disease-specific illness beliefs among patients who present to the emergency department with heart failure (HF).

BACKGROUND

Maintenance of well-being for patients with HF is partially dependent on appropriate self-care behaviors, which, in turn, are influenced by underlying illness beliefs. HL is a potential modifier of the interaction between behaviors and beliefs. There have been limited investigations studying this relationship among individuals with acute HF.

METHODS

A cross-sectional study of patients with hemodynamically stable acute HF was conducted. Demographic, education, and social support data were obtained from all patients along with self-reported responses to the 36-item STOFHLA survey, a 14 item HF-specific illness belief questionnaire, and a 5-item self-care adherence survey. General association was assessed using the χ or Fisher exact test, and comparisons were made using the Kruskal-Wallis test.

RESULTS

A total of 100 patients (51 females and 49 males) were included, 94% of whom were African-American (mean age [SD]: 57.5 [13.2] years). Inadequate, marginal, and adequate health literacy were present in 35%, 17%, and 48%, respectively, with increasing adequacy among the higher educated (P < 0.001). Overall, HF illness beliefs were considered to be "inaccurate" (mean score [SD] on a 4-point Likert scale: 2.8 [0.3]) but did correlate positively with improved HL (r = 0.26; P = 0.008).

CONCLUSION

In this cohort of relatively young, predominantly African-American patients with acute HF, HL was positively correlated with level of education and negatively associated with age and was an important determinant of disease-specific illness beliefs.

Participation in Care Encounters in Heart Failure Home-Care

The purpose of this qualitative study was to observe care encounters during home visits in Heart failure (HF) home-care to identify and describe participation in care. Seventeen patients diagnosed with HF, and 10 registered nurses participated. Data from 19 video-recorded home visits were analyzed using qualitative content analysis. Two themes were identified: (a) Participation in the care encounter is made possible by interaction, including exchanging care-related information, care-related reasoning, collaboration; and (b) participation in the care encounter is made possible by an enabling approach, including the patients expressing their own wishes, showing an active interest, while the nurse is committed and invites to having a dialogue. The HF home-care context showed good potential for patient participation. Room for discussions and collaboration facilitated for the patients to be active partners in their care, which in turn may have positive effects on outcomes.

Depression and self-care maintenance in patients with heart failure: A moderated mediation model of self-care confidence and resilience

BACKGROUND

Despite the recognition of the negative effects of depressive symptoms on self-care confidence and self-care maintenance in patients with heart failure, little is known about the moderating role of resilience underlying these relations.

AIMS

To explore whether depressive symptoms affect self-care maintenance through self-care confidence and whether this mediating process was moderated by resilience.

METHODS

The sample comprised 201 community-dwelling and medically stable patients with echocardiographically documented heart failure. A moderated mediation model was conducted to test whether self-care confidence mediated the association between depressive symptoms and self-care maintenance, and whether resilience moderated the direct and indirect effects of depressive symptoms after adjustment for covariates.

RESULTS

Depressive symptoms reduced self-care maintenance indirectly by decreasing self-care confidence (indirect effect: -0.22, 95% confidence interval: -0.36, -0.11), and this pathway was only significant for patients with moderate and high levels and not with low levels of resilience. Resilience also moderated the direct effects of depressive symptoms on self-care maintenance such that the negative association between depressive symptoms and self-care maintenance was reversed by the existence of high resilience.

CONCLUSIONS

Resilience moderated the direct and indirect effects of depressive symptoms through self-care confidence on self-care maintenance in heart failure patients. Efforts to improve self-care maintenance by targeting depressive symptoms may be more effective when considering self-care confidence in patients with moderate to high levels of resilience.

The Association of Sleep Disturbances With Quality of Life in Heart Failure Patient–Caregiver Dyads

Sleep disturbance is common in patients with heart failure and their family caregivers. The purpose of this study was to determine whether sleep disturbances of patients and their spousal caregivers predicted their own and their partners’ quality of life (QoL) in 78 heart failure patient–spousal caregiver dyads. Sleep disturbance was assessed using a composite score of four common sleep complaints. QoL was assessed by the physical and mental well-being subscales of the Short-Form 12 Health Survey. The multilevel dyadic actor–partner interdependence model analysis was used to determine the association between sleep disturbance and QoL. Each individual’s sleep disturbance predicted their own poor physical and mental well-being while spousal caregivers’ sleep disturbance predicted their partners’ mental well-being. Results indicated that patients’ mental well-being is sensitive to their spouses’ sleep disturbance. Interventions targeting improving sleep and QoL may have to include both patients and spousal caregivers.

Studying Associations Between Heart Failure Self-Management and Rehospitalizations Using Natural Language Processing

This study developed an innovative natural language processing algorithm to automatically identify heart failure (HF) patients with ineffective self-management status (in the domains of diet, physical activity, medication adherence, and adherence to clinician appointments) from narrative discharge summary notes. We also analyzed the association between self-management status and preventable 30-day hospital readmissions. Our natural language system achieved relatively high accuracy ( F-measure = 86.3%; precision = 95%; recall = 79.2%) on a testing sample of 300 notes annotated by two human reviewers. In a sample of 8,901 HF patients admitted to our healthcare system, 14.4% ( n = 1,282) had documentation of ineffective HF self-management. Adjusted regression analyses indicated that presence of any skill-related self-management deficit (odds ratio [OR] = 1.3, 95% confidence interval [CI] = [1.1, 1.6]) and non-specific ineffective self-management (OR = 1.5, 95% CI = [1.2, 2]) was significantly associated with readmissions. We have demonstrated the feasibility of identifying ineffective HF self-management from electronic discharge summaries with natural language processing.

Self-care in rural residents with heart failure: What we are missing

BACKGROUND

As heart failure (HF) is a progressive, debilitating condition, life-long self-care is required to achieve good outcomes. Rural residents with HF encounter more challenges with adherence to self-care than their urban counterparts because of rural-urban inequalities related to socioeconomic resources and access to health care. To date, investigators have focused on self-care in HF patients in urban settings, although factors related to self-care may be different between rural and urban residents.

AIM

The aim of this study was to explore the variables related to self-care in HF patients living in rural areas.

METHODS

A total of 580 patients in the USA were included in this analysis. We included 12 variables reflecting four aspects that affect patients' decisions to perform self-care: health literacy, psychosocial status, current symptom status, and aging status. We measured self-care using the European Heart Failure Self-Care Scale-9.

RESULTS

Depressive symptoms (β = 0.28, 95% confidence interval (CI): 0.16 to 0.45), lower perceived control (β = -0.15, 95% CI: -0.32 to -0.08), better symptom status (β = -0.11, 95% CI: -0.13 to -0.003), and annual income of <$20,000 (β = 0.11, 95% CI: 0.38-2.97) were negatively associated with self-care in rural residents with HF. The model with 12 variables explained 7.1% of the variance in self-care.

CONCLUSIONS

The variables included in the model did not sufficiently explain self-care among rural dwellers with HF. Given that all variables in the model were intrapersonal-level factors, more investigations that incorporate interpersonal factors (e.g. cultural beliefs and access to care) are needed in order to improve our understanding of self-care in HF patients living in rural areas.

Marital status and living condition as predictors of mortality and readmissions among African Americans with heart failure

Socioeconomic factors, including social support, may partially explain why African Americans (AA) have the highest prevalence of heart failure and with worse outcomes compared to other races. AA are more likely to be hospitalized and readmitted for heart failure and have higher mortality. The purpose of this study is to determine whether the social factors of marital status and living condition affect readmission rates and all-cause mortality following hospitalization for acute decompensated heart failure (ADHF) in AA patients.

METHODS

Medical records from 611 AA admitted to Einstein Medical Center Philadelphia from January, 2011 to February, 2013 for ADHF were reviewed. Patient demographics including living condition (nursing home residents, living with family or living alone) and marital status (married or non-married -including single, divorced, separated and widowed) were correlated with all-cause mortality and readmission rates.

RESULTS

In this cohort (53% male, mean age 65±15, mean ejection fraction 32±16%) 25% (n=152) of subjects were unmarried. Unmarried patients had significantly higher 30-day readmission rates (16% vs. 6% p=0.0002) and higher 1-year mortality (17% vs. 11% p=0.047) compared with married patients. Fifty percent (n=303) of subjects were living with family members, while 40% (n=242) and 11% (n=66) were living alone or in a nursing facility, respectively. Patients living with family members had significantly lower 30-day readmission rates when compared with those living alone or in a nursing facility (7% vs 21% vs. 18% p=<0.0001). Furthermore, they had the lowest 1-year mortality (14% vs 32% for nursing facility patients and 17% for those living alone (p=0.0007). After controlling for traditional risk factors (age, gender, body mass index, peak troponin I, left ventricular ejection fraction, B-type natriuretic peptide, hypertension, diabetes mellitus, hyperlipidemia, and coronary artery disease), being married was an indpendent predictor of 1-year mortality (OR 0.50 p=0.019) and living alone for 30-day readmission (OR 2.86 p=<0.001).

CONCLUSION

The socioeconomic factors of marital status and living condition significantly correlated with mortality and 30-day readmission rate in AA heart failure patients. Specifically, being married and living with family independently predict lower mortality and fewer readmissions. Surprisingly, living in a nursing facility was associated with significantly higher mortality than living alone or with family.

The Association Between Mild Cognitive Impairment and Self-care in Adults With Chronic Heart Failure: A Systematic Review and Narrative Synthesis

BACKGROUND

Emerging evidence suggests that heart failure (HF) patients who have mild cognitive impairment (MCI) may experience greater difficulty with self-care.

OBJECTIVE

This article reports a systematic review that addressed the objective "What is the evidence for an association between MCI and self-care, measured in 1 or more of the self-care domains related to HF, in adults who have a diagnosis of chronic HF?"

METHOD

We adopted Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the review and synthesis of quantitative research studies that formally measured both cognitive function and self-care in HF patients and sought to describe the relationship between these factors.

RESULTS

Ninety-one potentially relevant studies were located; 10 studies (2006-2014) were included. Because of heterogeneity in the retrieved studies, meta-analysis was not possible. Narrative synthesis found growing evidence regarding the association between MCI and adverse effects on self-care in HF. Nine studies reported significant positive associations between MCI and self-care in HF, either specifically in relation to medication adherence or more generic measures of self-care activity. One study reported a significant, negative correlation between cognitive function and self-care, suggesting that worse cognitive function was associated with better self-care; however, this is partially explained by a small sample size and mixed methodology.

CONCLUSIONS

These findings have implications for clinical practice. It is known that HF patients have difficulty with self-care, and the influence of cognitive function needs to be considered when providing professional support. Further research to determine the feasibility and acceptability of cognitive assessment in routine clinical care is recommended.