Acculturation and outcomes among patients with heart failure

General practitioners' views on cardiovascular prevention for ethnic minorities-a qualitative study in the Netherlands

OBJECTIVES

While ethnic minorities in Europe are disproportionally affected by cardiovascular disease (CVD), little is known about how general practitioners (GPs) perceive differences in risk or care needs across ethnic minority groups. Therefore, we explored GPs' views on whether ethnicity influences cardiovascular risk, whether a culturally sensitive approach is warranted, on potential barriers in the provision of such care, and to find potential opportunities to improve cardiovascular prevention for these groups.

METHODS

We conducted a qualitative study by interviewing GPs practising in The Netherlands. The interviews were semistructured, audio-recorded, and analysed by 2 researchers using thematic analysis.

RESULTS

We interviewed 24 Dutch GPs (50% male). GPs' views on the impact of ethnicity on CVD risk varied widely, yet it was generally recognized as a relevant factor in cardiovascular prevention for most minority groups, prompting earlier case-finding of high-risk patients. While GPs were aware of sociocultural differences, they emphasized an individualized approach. Perceived limitations were language barriers and unfamiliarity with sociocultural customs, leading to a need for continuing medical education on culturally sensitive care and reimbursement of telephone interpreting services.

CONCLUSION

Dutch GPs have differing views on the role of ethnicity in evaluating and treating cardiovascular risk. Despite these differences, they emphasized the importance of a personalized and culturally sensitive approach during patient consultations and expressed a need for continuing medical education. Additional research on how ethnicity influences CVD risk may strengthen cardiovascular prevention in increasingly diverse primary care populations.

Automated digital counselling with social network support as a novel intervention for patients with heart failure: protocol for randomised controlled trial

INTRODUCTION

Heart failure (HF) symptoms improve through self-care, for which adherence remains low among patients despite the provision of education for these behaviours by clinical teams. Open Access Digital Community Promoting Self-Care, Peer Support and Health Literacy (ODYSSEE-vCHAT) combines automated digital counselling with social network support to improve mortality and morbidity, engagement with self-care materials, and health-related quality of life.

METHODS AND ANALYSIS

Use of ODYSSEE-vCHAT via Internet-connected personal computer by 162 HF patients will be compared with a control condition over 22 months. The primary outcome is a composite index score of all-cause mortality, all-cause emergency department visits, and HF-related hospitalisation at trial completion. Secondary outcomes include individual components of the composite index, engagement with self-care materials, and patient-reported measures of physical and psychosocial well-being, disease management, health literacy, and substance use. Patients are recruited from tertiary care hospitals in Toronto, Canada and randomised on a 1:1 ratio to both arms of the trial. Online assessments occur at baseline (t=0), months 4, 8 and 12, and trial completion. Ordinal logistic regression analyses and generalised linear models will evaluate primary and secondary outcomes.

ETHICS AND DISSEMINATION

The trial has been approved by the research ethics boards at the University Health Network (20-5960), Sunnybrook Hospital (5117), and Mount Sinai Hospital (21-022-E). Informed consent of eligible patients occurs in person or online. Findings will be shared with key stakeholders and the public. Results will allow for the preparation of a Canada-wide phase III trial to evaluate the efficacy of ODYSSEE-vCHAT in improving clinical outcomes and raising the standard of outpatient care.

TRIAL REGISTRATION NUMBER

NCT04966104.

Trends in Characteristics and Outcomes in Primary Heart Failure Hospitalizations Among Older Population in the United States, 2004-2018

BACKGROUND

Heart failure (HF) accounts for a significant proportion of morbidity, mortality, and health care costs among older adults in the United States. We evaluated trends in clinical outcomes and the economic burden of HF hospitalizations in older patients (≥80 years).

METHODS

This analysis included data from the National Inpatient Sample between January 2004 and December 2018. We examined the trends of clinical characteristics, inpatient mortality, and health care cost utilization in older US adults for HF hospitalizations.

RESULTS

We identified 6 034 951 weighted HF hospitalizations for older adults (3527 per 100 000 person-years). After an initial decline in HF hospitalizations per 100 000 older US older adults from 4211 in 2004 to 3089 in 2014, there was increase to 3388 in 2018 (P trend <0.001 for both). There was an overall increase in cardiometabolic and chronic comorbidities during the study period. Overall, inpatient mortality was 4.7%; the adjusted inpatient mortality decreased from 6.1% in 2004 to 3.6% in 2018 (P trend <0.001). There was a decrease in adjusted mean length of stay (from 6.0 days in 2004 to 4.7 days in 2018) and adjusted inflation-adjusted care costs (from $11 865 in 2004 to $9677 in 2018) during the study period (P trend <0.001 for both). In comparison with younger adults (<80 years), older adults had higher inpatient mortality (4.7% versus 2.2%) but lower inflation-adjusted care costs ($10 587 versus $14 088).

CONCLUSIONS

This 15-year national data suggests that despite a higher comorbidity burden and the recent increase in hospitalizations for HF in older patients, there has been an encouraging trend towards lower inpatient mortality, health care cost, and hospital length of stay among older adults in the United States.

Assessing the influence of patient language preference on 30 day hospital readmission risk from home health care: A retrospective analysis

BACKGROUND

In home health care, language barriers are understudied. Language barriers between patients and providers are known to affect a variety of patient outcomes. How a patient's language preference influences hospital readmission risk from home health care has yet to be determined.

OBJECTIVE

To determine if home care patients' language preference is associated with their risk for hospital readmission from home health care within 30 days of hospital discharge.

DESIGN

Retrospective cross-sectional study of hospital readmissions from an urban home health care agency's administrative records and the national electronic home health care record for the United States, captured between 2010 and 2015.

SETTING

New York City, New York, USA.

PARTICIPANTS

The dataset comprised 90,221 post-hospitalization patients and 6.5 million home health care visits.

METHODS

First, a Chi-square test was used to determine if there were significant differences in crude readmission rates based on language group. Inverse probability of treatment weighting was used to adjust for significant differences in known hospital readmission risk factors between to examine all-cause hospital readmission during a home health care stay. The final matched sample included 87,561 patients with a language preference of English, Spanish, Russian, Chinese, or Korean. English-speaking patients were considered the comparison group to the non-English speaking patients. A Marginal Structural Model was applied to estimate the impact of non-English language preference against English language preference on rehospitalization. The results of the marginal structural model were expressed as an odds ratio of likelihood of readmission to the hospital from home health care.

RESULTS

Home health patients with a non-English language preference had a higher hospital readmission risk than English-speaking patients. Crude readmission rate for the limited English proficiency patients was 20.4% (95% CI, 19.9-21.0%) overall compared to 18.5% (95% CI, 18.7-19.2%) for English speakers (p < 0.001). Being a non-English-speaking patient was associated with an odds ratio of 1.011 (95% CI, 1.004-1.018) in increased hospital readmission rates from home health care (p = 0.001). There were also statistically significant differences in readmission rate by language group (p < 0.001), with Korean speakers having the lowest rate and Spanish speakers having the highest, when compared to English speakers.

CONCLUSIONS

People with a non-English language preference have a higher readmission rate from home health care. Hospital and home healthcare agencies may need specialized care coordination services to reduce readmission risk for these patients. Tweetable abstract: A new US-based study finds that home care patients with language barriers are at higher risk for hospital readmission.

The NUDGE trial pragmatic trial to enhance cardiovascular medication adherence: study protocol for a randomized controlled trial

Background

Nearly half of patients do not take their cardiovascular medications as prescribed, resulting in increased morbidity, mortality, and healthcare costs. Mobile and digital technologies for health promotion and disease self-management offer an opportunity to adapt behavioral “nudges” using ubiquitous mobile phone technology to facilitate medication adherence. The Nudge pragmatic clinical trial uses population-level pharmacy data to deliver nudges via mobile phone text messaging and an artificial intelligent interactive chat bot with the goal of improving medication adherence and patient outcomes in three integrated healthcare delivery systems.

Methods

The Theory of mHealth, the Expanded RE-AIM/PRISM, and the PRECIS-2 frameworks were used for program planning, implementation, and evaluation, along with a focus on dissemination and cost considerations. During the planning phase, the Nudge study team developed and piloted a technology-based nudge message and chat bot of optimized interactive content libraries for a range of diverse patients. Inclusion criteria are very broad and include patients in one of three diverse health systems who take medications to treat hypertension, atrial fibrillation, coronary artery disease, diabetes, or hyperlipidemia. A target of approximately 10,000 participants will be randomized to one of 4 study arms: usual care (no intervention), generic nudge (text reminder), optimized nudge, and optimized nudge plus interactive AI chat bot. The PRECIS-2 tool indicated that the study protocol is very pragmatic, although there is variability across PRECIS-2 dimensions.

Discussion

The primary effectiveness outcome is medication adherence defined by the proportion of days covered (PDC) using pharmacy refill data. Implementation outcomes are assessed using the RE-AIM framework, with a particular focus on reach, consistency of implementation, adaptations, cost, and maintenance/sustainability. The project has limitations including limited power to detect some subgroup effects, medication complications (bleeding), and longer-term outcomes (myocardial infarction). Strengths of the study include the diverse healthcare systems, a feasible and generalizable intervention, transparent reporting using established pragmatic research and implementation science frameworks, strong stakeholder engagement, and planning for dissemination and sustainment.

Trial registration

ClinicalTrials.govNCT03973931. Registered on 4 June 2019. The study was funded by the NIH; grant number is 4UH3HL144163-02 issued 4/5/19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05453-9.

Impact of limited English proficiency on presentation and clinical outcomes of patients undergoing primary percutaneous coronary intervention

AIMS

To evaluate the association of limited English proficiency (LEP) with reperfusion times and outcomes in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

This cohort study included 5385 patients who underwent PPCI in 2013-2017 and were prospectively enrolled in the Victorian Cardiac Outcomes Registry. Data linkage to government administrative datasets was performed to identify patients' preferred spoken language, socioeconomic status, and ambulance utilization data. Patients who had a preferred spoken language other than English were defined as having LEP. Of the study cohort, 430 patients (8.0%) had LEP. They had longer mean symptom-to-door time (STDT) [164 (95% confidence interval, CI 149-181) vs. 136 (95% CI 132-140) min, P < 0.001] but similar mean door-to-balloon time [79 (95% CI 72-87) vs. 76 (95% CI 74-78) min, P = 0.41]. They also had higher major adverse cardiovascular and cerebrovascular events (MACCE; 13.5% vs. 9.9%; P = 0.02), severe left ventricular dysfunction (11.0% vs. 8.4%, P = 0.02), and heart failure (HF) hospitalizations within 30 days of PPCI (5.1% vs. 2.0%, P < 0.001). On multivariable analysis, LEP did not independently predict 30-day MACCE [odds ratio (OR) 1.16, 95% CI 0.79-1.69; P = 0.45] but was an independent predictor of both prolonged STDT ≥ 120 min (OR 1.25, 95% CI 1.02-1.52; P = 0.03) and 30-day HF hospitalizations (OR 2.01, 95% CI 1.21-3.36; P = 0.008).

CONCLUSION

Patients with LEP undergoing PPCI present later and are more likely to have HF readmissions within 30 days of percutaneous coronary intervention, but with similar short-term MACCE. More effort to provide education in varied languages on early presentation in STEMI is required.

Text Message Medication Adherence Reminders Automated and Delivered at Scale Across Two Institutions: Testing the Nudge System: Pilot Study

BACKGROUND

Medication refill behavior in patients with cardiovascular diseases is suboptimal. Brief behavioral interventions called Nudges may impact medication refill behavior and can be delivered at scale to patients using text messaging.

METHODS

Patients who were prescribed and filled at least one medication for hypertension, hyperlipidemia, diabetes, atrial fibrillation, and coronary artery disease were identified for the pilot study. Patients eligible for the pilot (N=400) were enrolled with an opportunity to opt out. In phase I of the pilot, we tested text message delivery to 60 patients. In phase II, we tested intervention feasibility by identifying those with refill gap of ≥7 days and randomized them to intervention or control arms. Patients were texted Nudges and assessed whether they refilled their medications.

RESULTS

Of 400 patients sent study invitations, 56 (14%) opted out. In phase I, we successfully delivered text messages to 58 of 60 patients and captured patient responses via text. In phase II, 207 of 286 (72.4%) patients had a medication gap ≥7 days for one or more cardiovascular medications and were randomized to intervention or control. Enrolled patients averaged 61.7 years old, were primarily male (69.1%) and White (72.5%) with hypertension being the most prevalent qualifying condition (78.7%). There was a trend towards intervention patients being more likely to refill at least 1 gapping medication (30.6% versus 18.0%; P=0.12) and all gapping medications (17.8% versus 10.0%; P=0.27).

CONCLUSIONS

It is possible to set up automated processes within health care delivery systems to identify patients with gaps in medication adherence and send Nudges to facilitate medication refills. Text message Nudges could potentially be a feasible and effective method to facilitate medication refills. A large multi-site randomized trial to determine the impact of text-based Nudges on overall CVD morbidity and mortality is now underway to explore this further. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03973931.

The impact of cultural and linguistic diversity on hospital readmission in patients hospitalized with acute heart failure

AIMS

Health services worldwide face the challenge of providing care for increasingly culturally and linguistically diverse (CALD) populations. The aims of this study were to determine whether CALD patients hospitalized with acute heart failure (HF) are at increased risk of rehospitalization and emergency department (ED) visitation after discharge, compared to non-CALD patients, and within CALD patients to ascertain the impact of limited English proficiency (LEP) on outcomes.

METHODS AND RESULTS

A cohort of 1613 patients discharged from hospital following an episode of acute HF was derived from hospital administrative datasets. CALD status was based on both country of birth and primary spoken language. Comorbidities, HF subtype, age, sex and socioeconomic status, and hospital readmission and ED visitation incidences, were compared between groups. A Cox proportional hazard model was employed to adjust for potential confounders. The majority of patients were classified as CALD [1030 (64%)]. Of these, 488 (30%) were designated as English proficient (CALD-EP) and 542 (34%) were designated CALD-LEP. Compared to non-CALD, CALD-LEP patients exhibited a greater cumulative incidence of HF-related readmission and ED visitation, as expressed by an adjusted hazard ratio (HR) [1.27 (1.02-1.57) and 1.40 (1.18-1.67), respectively]; this difference was not significant for all-cause readmission [adjusted HR 1.03 (0.88-1.20)]. CALD-EP showed a non-significant trend towards increased rehospitalization and ED visitation.

CONCLUSION

This study suggests that CALD patients with HF, in particular those designated as CALD-LEP, have an increased risk of HF rehospitalization and ED visitation. Further research to elucidate the underlying reasons for this disparity are warranted.

A cultural and gender-based approach to understanding patient adjustment to chronic heart failure

Background

Persons identifying as Black, Chinese, or South Asian make up the largest minority groups in Canada. Individuals with chronic heart failure (CHF) from these groups experience a greater rate of re-hospitalization and poorer quality of life. Although experts agree that culture can shape the experience of CHF, little is known about how patients from these minority populations define a good quality of life with CHF and what barriers they experience when carrying out self-care behaviours. The aim of this qualitative study was to examine cultural and gender-based influences on quality of life in patients with CHF.

Methods

Purposive sampling included 30 patients (67% male), 18 to 75 years of age, who self-identified as Black (n = 8), Chinese (n = 9), or South Asian (n = 6). Caucasians (n = 7) were included as a comparison group. Semi-structured interviews (see the online appendix), lasting approximately 60 min, were conducted, which focused on personal understanding of CHF and living with the disease, including impact on lifestyle and quality of life. An inductive qualitative approach with thematic content analysis was used to develop key insights into individual experience of CHF, as well as cultural and gender-based influences on self-care and quality of life. Descriptive statistics were generated from questionnaire responses.

Results

Five key themes emerged from the narrative analysis of participant interviews: (i) CHF as an emergent reality, (ii) quality of life and disruption of lifecourse milestones, (iii) the challenge to accept CHF and re-evaluation of quality of life; (iv) impact on social activities essential to quality of life, and (v) life with CHF as a commitment to culturally tailored self-care. Participants described the unique impact of CHF on their quality of life, including life trajectory milestones such as dating, parenting, and retirement planning, as well as the importance of accepting their diagnosis, and the reframing goals for living well with heart failure. Positive and negative impacts on social relationships were noted, including sexual intimacy and interactions with spouses, other family members, and co-workers.

Conclusions

Study findings highlight important lifespan, cultural, and gender considerations that can inform the improvement of patient care and quality of life for patients and their families.

Association of acculturation with cardiac structure and function among Hispanics/Latinos: a cross-sectional analysis of the echocardiographic study of Latinos

OBJECTIVE

Hispanics/Latinos, the largest immigrant population in the USA, undergo the process of acculturation and have a large burden of heart failure risk. Few studies have examined the association of acculturation on cardiac structure and function.

DESIGN

Cross-sectional.

SETTING

The Echocardiographic Study of Latinos.

PARTICIPANTS

1818 Hispanic adult participants with baseline echocardiographic assessment and acculturation measured by the Short Acculturation Scale, nativity, age at immigration, length of US residence, generational status and language.

PRIMARY AND SECONDARY OUTCOME MEASURES

Echocardiographic assessment of left atrial volume index (LAVI), left ventricular mass index (LVMI), early diastolic transmitral inflow and mitral annular velocities.

RESULTS

The study population was predominantly Spanish-speaking and foreign-born with mean residence in the US of 22.7 years, mean age of 56.4 years; 50% had hypertension, 28% had diabetes and 44% had a body mass index >30 kg/m². Multivariable analyses demonstrated higher LAVI with increasing years of US residence. Foreign-born and first-generation participants had higher E/e' but lower LAVI and e' velocities compared with the second generation. Higher acculturation and income >$20K were associated with higher LVMI, LAVI and E/e' but lower e' velocities. Preferential Spanish-speakers with an income <$20K had a higher E/e'.

CONCLUSIONS

Acculturation was associated with abnormal cardiac structure and function, with some effect modification by socioeconomic status.

Association between cultural factors and readmissions: the mediating effect of hospital discharge practices and care-transition preparedness

OBJECTIVES

The study examines whether hospital discharge practices and care-transition preparedness mediate the association between patients' cultural factors and readmissions.

METHODS

A prospective study of internal medicine patients (n=599) examining a culturally diverse cohort, at a tertiary medical centre in Israel. The in-hospital baseline questionnaire included sociodemographic, cultural factors (Multidimensional Health Locus of Control, family collectivism, health literacy and minority status) and physical, mental and functional health status. A follow-up telephone survey assessed hospital discharge practices: use of the teach-back method, providers' cultural competence, at-discharge language concordance and caregiver presence and care-transition preparedness using the care transition measure (CTM). Clinical and administrative data, including 30-day readmissions to any hospital, were retrieved from the healthcare organisation's data warehouse. Multiple mediation was tested using Hayes's PROCESS procedure, model 80.

RESULTS

A total of 101 patients (17%) were readmitted within 30 days. Multiple logistic regressions indicated that all cultural factors, except for minority status, were associated with 30-day readmission when no mediators were included (p<0.05). Multiple mediation analysis indicated significant indirect effects of the cultural factors on readmission through the hospital discharge practices and CTM. Finally, when the mediators were included, strong direct and indirect effects between minority status and readmission were found (B coefficient=-0.95; p=0.021).

CONCLUSIONS

The results show that the association between patients' cultural factors and 30-day readmission is mediated by the hospital discharge practices and care transition. Providing high-quality discharge planning tailored to patients' cultural characteristics is associated with better care-transition preparedness, which, in turn, is associated with reduced 30-day readmissions.

Inpatient care experiences differ by preferred language within racial/ethnic groups

Objective

To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups.

Data Source

2014‐2015 HCAHPS survey data.

Study Design

We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient‐mix adjusted overall, between‐ and within‐hospital differences in patient experience by language, using linear regression.

Data Collection Methods

Surveys from 5 480 308 patients discharged from 4517 hospitals 2014‐2015.

Principal Findings

Within each racial/ethnic group, mean reported experiences for non‐English‐preferring patients were almost always worse than their English‐preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within‐hospital differences by language were often larger than between‐hospital differences and were largest for Care Coordination. Where between‐hospital differences existed, non‐English‐preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English‐preferring counterparts.

Conclusions

Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non‐English‐preferring patients, focusing on cultural competence and language‐appropriate services.

Legalized marijuana: Language-associated knowledge of laws and risk perceptions among Latinos

This study examines the extent to which knowledge of recreational marijuana laws, health effects, and perceptions of risk for marijuana use differ between Spanish- and English-speaking Latino survey respondents from a registry of Colorado adults. Spanish-speaking Latino respondents (n = 47) had less accurate knowledge of laws permitting use of marijuana than English-speaking Latino respondents (n = 154), while reporting greater agreement with negative health effects and higher perception of risk associated with marijuana use. The results suggest that efforts to communicate health and informational messaging to the public about legalized marijuana should consider linguistic variations when tailoring campaigns for Latino audiences.

Investigating the effect of sociodemographic factors on 30-day hospital readmission among medical patients in Toronto, Canada: a prospective cohort study

OBJECTIVE

To examine the influence of patient-level sociodemographic factors on the incidence of hospital readmission within 30 days among medical patients in a large Canadian metropolitan city.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

Patients admitted to the General Internal Medicine service of an urban teaching hospital in Toronto, Canada participated in a survey of sociodemographic information. Patients were not surveyed if deemed medically unstable, receiving care in medical/surgical step-down beds or were isolated for infection control. Included in the final analysis was a diverse cohort of 1427 adult, non-palliative, patients who were discharged home.

MEASURES

Thirteen patient-level sociodemographic variables were examined in relation to time to unplanned all-cause readmission within 30 days. Illness level was accounted for by the following covariates: self-perceived health status, previous hospital utilisation, primary diagnosis case mix group, Charlson Comorbidity Index score and inpatient length of stay.

RESULTS

Approximately, 14.4% (n=205) of patients experienced readmission within 30 days. Sociodemographic factors were not significantly associated with time to readmission in unadjusted and adjusted analyses. Indicators of illness level, namely, previous hospitalisations, were the strongest risk factors for readmission within this cohort. One previous admission (adjusted HR 1.78; 95% CI 1.22 to 2.59, P<0.01) and at least four previous emergency department visits (adjusted HR 2.33; 95% CI 1.46 to 4.43, P<0.01) were associated with increased hazard of readmission within 30 days.

CONCLUSIONS

Patient-level sociodemographic factors did not influence the incidence of unplanned all-cause readmission within 30 days. Further research is needed to understand the generalisability of our findings and investigate whether contextual factors, such as access to universal health insurance coverage, attenuate the effects of sociodemographic factors.

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.

Patient Characteristics Predicting Readmission Among Individuals Hospitalized for Heart Failure

Heart failure is difficult to manage and increasingly common with many individuals experiencing frequent hospitalizations. Little is known about patient factors consistently associated with hospital readmission. A literature review was conducted to identify heart failure patient characteristics, measured before discharge, that contribute to variation in hospital readmission rates. Database searches yielded 950 potential articles, of which 34 studies met inclusion criteria. Patient characteristics generally have a very modest effect on all-cause or heart failure-related readmission within 7 to 180 days of index hospital discharge. A range of cardiac diseases and other comorbidities only minimally increase readmission rates. No single patient characteristic stands out as a key contributor across multiple studies underscoring the challenge of developing successful interventions to reduce readmissions. Interventions may need to be general in design with the specific intervention depending on each patient's unique clinical profile.

Heart failure care for patients who do not speak English

Heart failure affects 1-2% of the UK population with prevalence rates predicted to rise over the next decade. Ineffective education for patients with heart failure can lead to a failure to adhere to guidance, reduced self-care and increased hospital readmissions. The National Institute for Health and Care Excellence (NICE) and the World Health Organization (WHO) have issued clear guidelines on patient-centred care in heart failure, particularly in relation to patients' cultural and linguistic needs. Patients with heart failure should have access to an interpreter or advocate if needed. Furthermore, heart failure educational materials should be tailored to suit the individual and be accessible to people who do not speak or read English. This article explores the practice recommendations for these patients with heart failure and provides an overview of current guidelines associated with optimal patient outcomes. It also includes practical advice on translation services, and information and educational materials available for patients with heart failure who do not speak English.

Language barriers in Hispanic patients: relation to upper-extremity disability

BACKGROUND

Although upper-extremity disability has been shown to correlate highly with various psychosocial aspects of illness (e.g., self-efficacy, depression, kinesiophobia, and pain catastrophizing), the role of language in musculoskeletal health status is less certain. In an English-speaking outpatient hand surgery office setting, we sought to determine (1) whether a patient's primary native language (English or Spanish) is an independent predictor of upper-extremity disability and (2) whether there are any differences in the contribution of measures of psychological distress to disability between native English- and Spanish-speaking patients.

METHODS

A total of 122 patients (61 native English speakers and 61 Spanish speakers) presenting to an orthopaedic hand clinic completed sociodemographic information and three Patient-Reported Outcomes Measurement Information System (PROMIS)-based computerized adaptive testing questionnaires: PROMIS Pain Interference, PROMIS Depression, and PROMIS Upper-Extremity Physical Function. Bivariate and multivariable linear regression modeling were performed.

RESULTS

Spanish-speaking patients reported greater upper-extremity disability, pain interference, and symptoms of depression than English-speaking patients. After adjusting for sociodemographic covariates and measures of psychological distress using multivariable regression modeling, the patient's primary language was not retained as an independent predictor of disability. PROMIS Depression showed a medium correlation (r = -0.35; p < 0.001) with disability in English-speaking patients, while the correlation was large (r = -0.52; p < 0.001) in Spanish-speaking patients. PROMIS Pain Interference had a large correlation with disability in both patient cohorts (Spanish-speaking: r = -0.66; p < 0.001; English-speaking: r = -0.77; p < 0.001). The length of time since immigration to the USA did not correlate with disability among Spanish speakers.

CONCLUSION

Primary language has less influence on symptom intensity and magnitude of disability than psychological distress and ineffective coping strategies. Interventions to optimize mood and to reduce pain interference should be considered in patients of all nationalities.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Racial differences in clinical treatment and self-care behaviors of adults with chronic heart failure

BACKGROUND

In the United States, the highest prevalence of heart failure (HF) is in blacks followed by whites. Compared with whites, blacks have a higher risk of HF-related morbidity and mortality and HF-related hospitalization. Little research has focused on explaining the reasons for these disparities. The purpose of this study was to examine racial differences in demographic and clinical characteristics in blacks and whites with HF and to determine if these characteristics influenced treatment, or together with treatment, influenced self-care behaviors.

METHODS AND RESULTS

This was a secondary analysis of existing data collected from adults (n=272) with chronic HF enrolled from outpatient sites in the northeastern United States and followed for 6 months. After adjusting for sociodemographic and clinical characteristics within reduced (HFrEF) and preserved ejection fraction (HFpEF) groups, there were 2 significant racial differences in clinical treatment. Blacks with HFrEF were prescribed ACE inhibitors and hydralazine and isosorbide dinitrate (H-ISDN) more often than whites. In the HFpEF group, blacks were taking more medications and were prescribed digoxin and a diuretic when symptomatic. Deficits in HF knowledge and decreased medication adherence, objectively measured, were more prominent in blacks. These racial differences were not explained by sociodemographic or clinical characteristics or clinical treatment variables. Premorbid intellect and the quality of support received contributed to clinical treatment and self-care.

CONCLUSION

Although few differences in clinical treatment could be attributed solely to race, knowledge about HF and medication adherence is lower in blacks than whites. Further research is needed to explain these observations, which may be targets for future intervention research.

Short- and long-term rehospitalization and mortality for heart failure in 4 racial/ethnic populations

Background

The degree to which outcomes following hospitalization for acute heart failure (HF) vary by racial and ethnic groups is poorly characterized. We sought to compare 30‐day and 1‐year rehospitalization and mortality rates for HF among 4 race/ethnic groups.

Methods and Results

Using the Get With The Guidelines–HF registry linked with Medicare data, we compared 30‐day and 1‐year outcomes between racial/ethnic groups by using a multivariable Cox proportional hazards model adjusting for clinical, hospital, and socioeconomic status characteristics. We analyzed 47 149 Medicare patients aged ≥65 years who had been discharged for HF between 2005 and 2011: there were 39 213 whites (83.2%), 4946 blacks (10.5%), 2347 Hispanics (5.0%), and 643 Asians/Pacific Islanders (1.4%). Relative to whites, blacks and Hispanics had higher 30‐day and 1‐year unadjusted readmission rates but lower 30‐day and 1‐year mortality; Asians had similar 30‐day readmission rates but lower 1‐year mortality. After risk adjustment, blacks had higher 30‐day and 1‐year CV readmission than whites but modestly lower short‐ and long‐term mortality; Hispanics had higher 30‐day and 1‐year readmission rates and similar 1‐year mortality than whites, while Asians had similar outcomes. When socioeconomic status data were added to the model, the majority of associations persisted, but the difference in 30‐day and 1‐year readmission rates between white and Hispanic patients became nonsignificant.

Conclusions

Among Medicare patients hospitalized with HF, short‐ and long‐term readmission rates and mortality differed among the 4 major racial/ethnic populations and persisted even after controlling for clinical, hospital, and socioeconomic status variables.

The effect of neighborhood and individual characteristics on pediatric critical illness

The relationship between neighborhood/individual characteristics and pediatric intensive care unit (PICU) outcomes is largely unexplored. We hypothesized that individual-level racial/ethnic minority status and neighborhood-level low socioeconomic status and minority concentration would adversely affect children's severity of illness on admission to the PICU. Retrospective analyses (1/1/2007-5/23/2011) of clinical, geographic, and demographic data were conducted at an academic, tertiary children's hospital PICU. Clinical data included age, diagnosis, insurance, race/ethnicity, Pediatric Index of Mortality 2 score on presentation to the PICU (PIM2), and mortality. Residential addresses were geocoded and linked with 2010 US Census tract data using geographic information systems geocoding techniques. Repeated measures models to predict PIM2 and mortality were constructed using three successive models with theorized covariates including the patient's race/ethnicity, the predominant neighborhood racial/ethnic group, interactions between patient race/ethnicity and neighborhood race/ethnicity, neighborhood socioeconomic status, and insurance type. Of the 5,390 children, 57.8% were Latino and 70.1% possessed government insurance. Latino children (β = 0.31; p < 0.01), especially Latino children living in a Latino ethnic enclave (β = 1.13; p < 0.05), had higher PIM2 scores compared with non-Latinos. Children with government insurance (β = 0.29; p < 0.01) had higher PIM2 scores compared to children with other payment types and median neighborhood income was inversely associated with PIM2 scores (β = -0.04 per $10,000/year of income; p < 0.05). Lower median neighborhood income, Latino ethnicity, Latino children living in a predominantly Latino neighborhood, and children possessing government insurance were associated with a higher severity of illness on PICU admission. The reasons why these factors affect critical illness severity require further exploration.

Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association

BACKGROUND

Heart failure (HF) is an important contributor to both the burden and cost of national healthcare expenditures, with more older Americans hospitalized for HF than for any other medical condition. With the aging of the population, the impact of HF is expected to increase substantially.

METHODS AND RESULTS

We estimated future costs of HF by adapting a methodology developed by the American Heart Association to project the epidemiology and future costs of HF from 2012 to 2030 without double counting the costs attributed to comorbid conditions. The model assumes that HF prevalence will remain constant by age, sex, and race/ethnicity and that rising costs and technological innovation will continue at the same rate. By 2030, >8 million people in the United States (1 in every 33) will have HF. Between 2012 and 2030, real (2010$) total direct medical costs of HF are projected to increase from $21 billion to $53 billion. Total costs, including indirect costs for HF, are estimated to increase from $31 billion in 2012 to $70 billion in 2030. If one assumes all costs of cardiac care for HF patients are attributable to HF (no cost attribution to comorbid conditions), the 2030 projected cost estimates of treating patients with HF will be 3-fold higher ($160 billion in direct costs).

CONCLUSIONS

The estimated prevalence and cost of care for HF will increase markedly because of aging of the population. Strategies to prevent HF and improve the efficiency of care are needed.