Psychometric testing of the Duke Activity Status Index in patients with heart failure

Assessment of patient-reported outcomes measures in heart failure: a systematic review

Heart failure (HF) is a prevalent global disease, particularly impacting developed countries. With the world's aging population, HF's impact on the quantity and quality of life is expected to grow. This review aims to ascertain the frequency, characteristics, and properties of all patient-reported outcomes measures (PROMs) studied in HF patients. We searched Ovid/Medline and Web of Science for original articles about PROMs performed in adults with HF. Using pre-established quality criteria for measurement properties, an overall rating was assigned to evaluate and compare different instruments. The quality of evidence was assessed with the COSMIN risk of bias checklist. Of 4283 records identified, we reviewed 296 full-text documents and included 64 papers, involving 30,185 participants. Thirty different PROMs were identified, with 14 specifically designed for HF being the most commonly used. Minnesota Living with Heart Failure (MLHF) and Kansas City Cardiomyopathy Questionnaire (KCCQ) were evaluated 16 and 13 times, respectively, demonstrating good psychometric properties. The MacNew Heart Disease Health-Related Quality of Life Questionnaire, a common heart disease-specific instrument, exhibited negative performances across various psychometric measures. Evidence for generic instruments was scant and unremarkable and they proved to be less responsive in HF populations. MLHF and KCCQ emerged as the most commonly used and well-supported PROMs, with robust overall evidence. They are comprehensive and accurate instruments, particularly suitable for application in clinical practice and research. Future research should explore how computer-adapted instruments can enhance precision, reduce respondent burden, and improve communication between clinicians and patients, thereby promoting more efficient and patient-centered services.

Perceived Control, Functional Status, Depressive Symptoms, and Anxiety: Mediating and Moderating Influences on Health-Related Quality of Life in Patients With Heart Failure

BACKGROUND

Health-related quality of life (HRQoL) is poor in patients with heart failure. Psychological (ie, depressive symptoms [DS], anxiety, and perceived control) and physical (ie, functional status) factors are associated with HRQoL. The dynamic relationships among these variables and their impact on HRQoL remain unclear, limiting the ability to design effective interventions.

PURPOSE

Our aim was to evaluate a moderated mediation model, in which the association between perceived control and HRQoL was hypothesized to be mediated by DS and anxiety in the presence of a moderator, functional status.

METHODS

Patients (N = 426) with heart failure completed the Control Attitudes Scale-Revised to measure perceived control, Duke Activity Status Index for functional status, Patient Health Questionnaire-9 for DS, Brief Symptom Inventory for anxiety, and Minnesota Living with Heart Failure Questionnaire for HRQoL. We performed a moderated parallel mediation analysis.

RESULTS

Higher levels of perceived control were associated with better HRQoL through lower levels of anxiety and DS in the presence of functional status (index of moderated mediation for DS, b = 0.029; 95% confidence interval, 0.016-0.045; for anxiety: b = 0.009, 95% confidence interval, 0.002-0.018). The effect of perceived control on psychological symptoms was stronger at low and moderate functional statuses; however, this effect diminished with increasing functional status.

CONCLUSION

Functional status moderated the indirect effects of perceived control on HRQoL through DS and anxiety in patients with heart failure. Efforts to improve HRQoL by targeting perceived control may be more effective when considering DS and anxiety in patients with low to moderate levels of functional status.

Preoperative exercise training decreases complications of minimally invasive lung cancer surgery: A randomized controlled trial

OBJECTIVE

Limited evidence exists regarding the efficacy of preoperative exercise in reducing short-term complications after minimally invasive surgery in patients with non-small cell lung cancer. This study aims to investigate the impact of preoperative exercise on short-term complications after minimally invasive lung resection.

METHODS

In this prospective, open-label, randomized (1:1) controlled trial at Xiangya Hospital, China (September 2020 to February 2022), patients were randomly assigned to a preoperative exercise group with 16-day alternate supervised exercise or a control group. The primary outcome assessed was short-term postoperative complications, with a follow-up period of 30 days postsurgery.

RESULTS

A total of 124 patients were recruited (preoperative exercise group n = 62; control n = 62). Finally, 101 patients (preoperative exercise group; n = 51 and control; n = 50) with a median age of 56 years (interquartile range, 50-62 years) completed the study. Compared with the control group, the preoperative exercise group showed fewer postoperative complications (preoperative exercise 3/51 vs control 10/50; odds ratio, 0.17; 95% CI, 0.04-0.86; P = .03) and shorter hospital stays (mean difference, -2; 95% CI, -3 to -1; P = .01). Preoperative exercise significantly improved depression, stress, functional capacity, and quality of life (all P < .05) before surgery. Furthermore, preoperative exercise demonstrated a significantly lower minimum blood pressure during surgery and lower increases in body temperature on day 2 after surgery, neutrophil-to-lymphocyte ratio, and neutrophil count after surgery (all P < .05). Exploratory research on lung tissue RNA sequencing (5 in each group) showed downregulation of the tumor necrosis factor signaling pathway in the preoperative exercise group compared with the control group.

CONCLUSIONS

Preoperative exercise training decreased short-term postoperative complications in patients with non-small cell lung cancer.

Translation, cross-cultural adaptation, reliability, and validity of the Turkish version of the Duke Activity Status Index in patients with pulmonary hypertension

BACKGROUND AND OBJECTIVES

In patients with pulmonary hypertension (PH), shortness of breath, fatigue, chest pain, and syncope limit exercise capacity. Exercise tests are often time-consuming, expensive, and some patients may not be able to perform such procedures and they are also difficult to apply in the studies including large samples. The aim of this study was to translate and culturally adapt the DASI into Turkish and to investigate its reliability and validity in patients with PH.

METHODS

The final Turkish version of the DASI questionnaire was applied to 109 clinically stable patients with a diagnosis of PH. Exercise capacity of the patients was determined by maximal VO 2 achieved in the 6-minute walk test (6MWT) and quality of life by the EmPHasis-10 questionnaire. Cronbach alpha (internal consistency) was used to assess the questionnaire's reliability. The validity assessment was performed by using Spearman correlation.

RESULTS

Internal consistency of the DASI was high (Cronbach's alpha = 0.99) and the test-retest reliability was excellent (ICC = 0.98). Validity was supported by significant correlations of DASI-VO 2 scores with estimated VO 2 (6MWT) scores (r = 0.58, p < 0.0001) and EmPHasis-10 (= -0.62, p < 0.0001). No floor or ceiling effect was present for the questionnaire.

CONCLUSIONS

The Turkish version of the culturally adapted DASI questionnaire was found to be a valid and reliable assessment tool. It is a rapidly administered, simple-toscore questionnaire for assessing the functional ability of individuals with PH. The use of the DASI to assess exercise capacity in patients with PH may assist researchers and clinicians detecting functional impairment in these patients.

Prognostic Value of Self-Reported Subjective Exercise Capacity in Patients With Acute Dyspnea

Background

Self-reported exercise capacity is a well-established prognostic measure in stable ambulatory patients with cardiac and pulmonary disease.

Objectives

The authors aimed to directly compare the prognostic accuracy of quantified self-reported exercise capacity using the Duke Activity Status Index (DASI) with the established objective disease-severity marker B-type natriuretic peptide (BNP) in patients presenting with acute dyspnea to the emergency department.

Methods

The DASI was obtained in a prospective multicenter diagnostic study recruiting unselected patients presenting with acute dyspnea to the emergency department. The prognostic accuracy of DASI and BNP for 90-day and 720-day all-cause mortality was evaluated using C-index.

Results

Among 1,019 patients eligible for this analysis, 75 (7%) and 297 (29%) patients died within 90 and 720 days after presentation, respectively. Unadjusted hazard ratios (HRs) and multivariable adjusted hazard ratios (aHRs) for 90- and 720-day mortality increased continuously from the fourth (best self-reported exercise capacity) to the first DASI quartile (worst self-reported exercise capacity). For 720-day mortality the HR of the first quartile vs the fourth was 9.1 (95% CI, 5.5-14.9) vs (aHR: 6.1, 95% CI: 3.7-10.1), of the second quartile 6.4 (95% CI: 3.9-10.6) vs (aHR: 4.4, 95% CI: 2.6-7.3), while of the third quartile the HR was 3.2 (95% CI: 1.9-5.5) vs (aHR: 2.4, 95% CI: 1.4-4.0). The prognostic accuracy of the DASI score was high, and higher than that of BNP concentrations (720-day mortality C-index: 0.67 vs 0.62; P = 0.024).

Conclusions

Quantification of self-reported subjective exercise capacity using the DASI provides high prognostic accuracy and may aid physicians in risk stratification. (Basics in Acute Shortness of Breath EvaLuation [BASEL V] Study [BASEL V]; NCT01831115).

Self-reported engagement in exercise is associated with longer event-free survival in heart failure patients with poor functional capacity

AIMS

Despite evidence-based recommendations for clinically stable patients with heart failure (HF) to engage in unsupervised exercise, the minimum cumulative dose of exercise per week associated with improvement in HF outcomes, especially in patients with poor functional capacity, has not been examined. We examined whether patients with HF and poor functional capacity who reported engagement in a guideline-recommended minimum weekly exercise had longer event-free survival than patients who did not exercise.

METHODS AND RESULTS

This analysis included 310 patients with HF who had completed the Duke Activity Status Index (DASI) and reported their level of engagement in exercise. Patients were grouped into good and poor functional capacity using a DASI cut-point of ≥19 and then further stratified based on their self-reported exercise level: high (≥60 min/week) and low (<60 min/week). Cox regression modelling was used to predict event-free survival for the four groups after adjusting for covariates. Patients (mean age = 61.6 ± 11.4 years, 30.3% female, 44.2% NYHA Classes III-IV) were followed for a median of 362 days. There were eight deaths and 108 all-cause hospitalizations. Patients with poor functional capacity who reported high exercise engagement had a 36% lower risk of all-cause hospitalization or mortality compared with patients with poor functional capacity who reported low exercise engagement (hazard ratio: 0.64, P = 0.028).

CONCLUSION

Self-reported engagement in a minimum of 60 min of exercise per week was associated with a significant improvement in event-free survival, even in patients with HF with low functional capacity. These results provide evidence that this dose of exercise is beneficial in patients with HF and poor functional capacity.

Construct validity and responsiveness of the Duke Activity Status Index (DASI) as a measure of recovery after colorectal surgery

BACKGROUND

Returning to preoperative levels of physical function is highly valued by patients recovering from surgery. The Duke Activity Status Index (DASI, a 12-item questionnaire) may be a simple yet robust tool to assess postoperative recovery of functional capacity. This study assessed construct validity and responsiveness of the DASI as a measure of recovery after colorectal surgery.

METHODS

Data from a trial on early mobilization after colorectal surgery were analyzed. Patients completed the DASI questionnaire preoperatively and at postoperative weeks (POW) 2 and 4. Construct validity was assessed by testing the primary a priori hypotheses that postoperative DASI scores (1) are higher in patients without vs with postoperative complications and (2) correlate with six-minute walk test distance (6MWD). Exploratory analyses assessed the association between DASI scores and (1) preoperative physical status [higher (ASA ≤ 2) vs lower (ASA > 2)], (2) stoma creation (no stoma vs stoma), (3) age [younger (≤ 75 years) vs older (> 75 years)], (4) time to readiness for discharge [shorter (≤ 4 days) vs longer (> 4 days)], and (5) surgical approach (laparoscopic vs open). Responsiveness was assessed by testing a priori hypotheses that DASI scores are higher (1) preoperatively vs at POW2 and (2) at POW4 vs POW2. Mean differences in DASI scores were obtained using linear regression. The association between DASI and 6MWD was assessed via Pearson correlation.

RESULTS

We analyzed data from 100 patients undergoing colorectal surgery (mean age 65; 57% male; 81% laparoscopic). Mean DASI scores were 47.9 ± 12.1 preoperatively, 22.4 ± 12.7 at POW2, and 33.2 ± 15.7 at POW4. The data supported our two primary construct validity hypotheses, as well as 3/5 exploratory hypotheses. Both responsiveness hypotheses were supported.

CONCLUSIONS

Our findings support that the DASI questionnaire can be a useful tool to assess postoperative recovery of functional capacity in research and clinical practice.

Measurement Properties of the Duke Activity Status Index in Arab Patients with Cardiovascular Disease

The aim of the study was to examine the measurement properties of the Arabic version of the Duke Activity Status Index (DASI) in patients with cardiovascular disease (CVD). A sample of 100 Arab patients with CVD completed the Arabic version of the DASI and underwent an exercise stress test (EST) on the first visit, and the metabolic equivalent (MET) was obtained from each outcome measure. On the second visit, patients with CVD completed the Arabic version of the DASI along with the global rating of change scale (GRC). Reliability, including the internal consistency, test-retest reliability, and construct validity, were examined. Patients with CVD (86 males), mean (SD) age 54.98 (10.2) years, completed the study. The Cronbach's alpha was 0.87, and the intraclass correlation coefficient (ICC_2,1) was 0.93. The estimated MET and peak VO₂ obtained from the DASI were correlated with the estimated MET and peak VO₂ obtained from the EST (r = 0.58, r = 0.56, all p-values < 0.001). The Arabic version of the DASI is a simple, quick, reliable, and valid measure of functional capacity in Arabic-speaking patients with CVD. The DASI may serve as a screening tool for functional capacity in patients with CVD in clinical settings.

Providers' accuracy in decision-making with assessing NYHA functional class of patients with heart failure after use of a classification guide

BACKGROUND

Correct assignment of New York Heart Association Functional Classification (NYHA-FC) I-IV is essential in applying guideline directed care.

OBJECTIVE

Examine the validity, reliability, and accuracy of HF and primary care (PC) provider's assignment of NYHA-FC using the NYHA-FC Guide.

METHODS

Study utilized a cross-sectional, quasi-experimental known-groups design with validated vignettes. Providers (n = 75) used the Guide to assign NYHA-FC. Known-group validity comparisons (HF specialist/Non-HF specialist - PC provider) and interrater reliability were used to evaluate validity and reliability of the NYHA-FC Guide.

RESULTS

HF provider's accuracy total mean scores were significantly higher compared to PC (M = 6.0 vs. 5.4, p = 0.020). HF (62%) and PC providers (80%) reported that the Guide assisted them with deciding HF class.

CONCLUSION

The NYHA-FC Guide showed promise for facilitating accuracy of assignment. Further research to evaluate the accuracy of using the NYHA-FC Guide compared to the gold standard six minute walk test is warranted.

Exploring the Relationship between Frailty, Functional Status, Polypharmacy, and Quality of Life in Elderly and Middle-Aged Patients with Cardiovascular Diseases: A One-Year Follow-Up Study

The association between frailty, disability in activities of daily living (ADL), polypharmacy, and quality of life (QoL) in middle-aged patients with cardiovascular disease (CVD) is little investigated. This study sought (a) to explore this association comparatively in elderly and middle-aged hospitalized patients with CVD and (b) to determine which domains of ADL and QoL might improve the frailty prediction. A one-year follow-up study including 90 elderly (≥65 years old) and 89 middle-aged patients (40-65 years old) was conducted. At baseline, frailty assessment was performed based on the Fried criteria; Barthel Index (BI) and Duke Activity Status Index (DASI) were used for ADL, and European Quality of Life-5 dimensions (EQ-5D) for QoL. At follow-up, data were collected via telephone. At baseline, 79 patients (51 elderly and 28 middle-aged) were frail. The CVD frail patients showed functional dependency and a poor QoL compared to the non-frail (p < 0.001) and within each subgroup at follow-up. Mobility was found to predict frailty in both elderly (OR = 2.34) (C.I. (1.03-5.29)) and middle-aged patients (OR = 2.58) (C.I. (1.15-5.78)). The ADL assessment and self-reported QoL may help to identify an aggravation or an advanced frailty condition in hospitalized elderly and middle-aged CVD patients.

Depressive symptoms and their associated factors in heart failure patients

Objectives

Depressive symptoms are common in heart failure (HF) patients and they may exacerbate the progression of HF. Thus, identifying associations with depressive symptoms is essential to develop effective interventions to alleviate patients’ depressive symptoms. Therefore, this study aimed to explore the factors related to HF patients’ depressive symptoms.

Methods

Potential hospitalized patients were recruited from a university-affiliated hospital by convenience sampling. This study included 321 HF patients who had completed information about depressive symptoms, functional capacity, social support, dispositional optimism, self-care confidence, and health literacy. Descriptive statistics were used to characterize the sample. Independent group t-tests and one-way analysis of variance were used to assess the difference in depressive symptoms score in demographic and clinical characteristics, while Pearson's correlation was used to assess the associations among continuous variables.

Results

The scores for functional capacity, social support, dispositional optimism, self-care confidence, and health literacy were negatively associated with the score for depressive symptoms. The interaction effect between the functional capacity and the dispositional optimism on depressive symptoms was significant.

Conclusions

Interventions targeted improving the above-mentioned factors may be beneficial to reduce depressive symptoms in HF patients.

Providers' assignment of NYHA functional class in patients with heart failure: A vignette study

BACKGROUND

Accuracy of New York Heart Association Functional Classification (NYHA-FC) I-IV assessment is critical to promoting guideline directed care.

OBJECTIVE

Examine providers' accuracy when diagnosing NYHA-FC I-IV in patients with heart failure (HF).

METHODS

A web-based survey using validated vignettes was conducted with 244 physicians, nurse practitioners (NP), clinical nurse specialists (CNS) and physician assistants (PA) who provide care to patients with HF.

RESULTS

Providers comprised of 65% NPs, 19% physicians, 14% CNSs, 2% PAs with an average of 15 years working with HF patients. Accuracy ranged from 36.9% for Class IV to 78.7% for Class I. Increased HF patient volume seen (p=0.024), physician vs. NP/PA/CNS (p=0.021), and typically assigned a HF stage (p<0.001) were associated with increased total correct score accuracy in multivariable modeling.

CONCLUSION

It is critical that NYHA-FC is accurately assigned to promote optimal outcomes. Research in the future should focus on improving accuracy in assigning NYHA-FC.

Optimizing hospital-to-home transitions for older persons in rural communities: a participatory, multimethod study protocol

BACKGROUND

Transitional care involves time-limited interventions focusing on the continuity of care from hospital to home, to optimize patient functioning and management. Providing interventions, as part of transitional care, that optimize the functioning of older people with dementia is critical due to the small window of opportunity in which they can return to their baseline levels of functioning. Yet prior research on transitional care has not included interventions focused on functioning and did not target older people with dementia in rural communities, limiting the applicability of transitional care to this population. Accordingly, the goal of this study is to align hospital-to-home transitional care with the function-related needs of older people with dementia and their family-caregivers in rural communities.

METHODS

In this multimethod study, two phases of activities are planned in rural Ontario and Nova Scotia. In phase I, a purposive sample of 15-20 people with dementia and 15-20 family-caregivers in each province will rate the acceptability of six evidence-based interventions and participate in semi-structured interviews to explore the interventions' acceptability and, where relevant, how to improve their acceptability. Acceptable interventions will be further examined in phase II, in which a purposive sample of healthcare providers, stratified by employment location (hospital vs. homecare) and role (clinician vs. decision-maker), will (1) rate the acceptability of the interventions and (2) participate in semi-structured focus group discussions on the facilitators and barriers to delivering the interventions, and suggestions to enable their incorporation into rural transitional care. Two to three focus groups per stratum (8-10 healthcare providers per focus group) will be held for a total of 8-12 focus groups per province. Data analysis will involve qualitative content analysis of interview and focus group discussions and descriptive statistics of intervention acceptability ratings.

DISCUSSION

Findings will (1) include a set of acceptable interventions for rural transitional care that promote older patients' functioning and family-caregivers' ability to support patients' functioning, (2) identify resources needed to incorporate the interventions into rural transitional care, and (3) provide high-quality evidence to inform new transitional care practices and policies and guide future research.

Does Duke Activity Status Index help predicting functional exercise capacity and long-term prognosis in patients with pulmonary hypertension?

BACKGROUND

To investigate the association of Duke Activity Status Index (DASI) with 6-minute walk test (6MWT) and WHO-Functional Class (WHO-FC) in patients with pulmonary hypertension (PH), as well as exploring whether DASI can discriminate between the patients with better and worse long-term prognosis according to 400 m cut-off score in 6MWT.

METHODS

Eighty-five medically stable PH patients who met eligibility criteria were included. All patients were evaluated using 6MWT and DASI. The prognostic utility of the DASI was assessed using univariate linear regression and receiver operating characteristic (ROC) curve analysis.

RESULTS

The DASI was an independent predictor for both 6MWT and WHO-FC, explaining 50% of variance in 6MWT and 30% of variance in WHO-FC class (p < 0.001). In addition, DASI significantly correlated to 6MWT (r = 0.702) and WHO-FC class (r = 0.547). The ROC curve analysis revealed that the DASI had a discriminative value for identifying the patients with better long-term prognosis (p < 0.001), with an area under ROC curve of 0.867 [95% CI = 0.782-0.952]. The DASI ≥26 was the optimal cut-off value for better long-term prognosis, having sensitivity of 0.74 and a specificity of 0.88.

CONCLUSIONS

The DASI is a valid tool reflecting functional exercise capacity in patients with PH. Considering its ability to discriminate between the patients with better or worse long-term prognosis, it may help identifying the patients at higher risk.

Functional status mediates the association of nutritional status with depressive symptoms in patients with heart failure

AIMS

The decline of nutritional status and depressive symptoms are pandemic in heart failure patients and functional status may play a pivotal role between these. This study aimed to determine whether nutritional status is associated with depressive symptoms and whether functional status mediates this relationship in heart failure patients.

DESIGN

This was a secondary analysis of a cross-sectional study.

METHODS

The data were collected from November 2015-April 2016. Heart failure patients (N = 254) being hospitalized were included in this secondary analysis. The Depression Sub-Scale of the Hospital Anxiety and Depression Scale and the Duke Activity Status Index were used to assess patients' depressive symptoms and functional status. The nutritional status of patients was calculated using the Geriatric Nutritional Risk Index.

RESULTS

In this study, the average scores of depressive symptoms, nutritional status and functional status were 4.91 (SD 3.12), 102.38 (SD 6.57) and 20.58 (SD 8.96) respectively. Out of the 254 patients, 46 patients (18.1%) had significant depressive symptoms (the score of Depression Sub-Scale of the Hospital Anxiety and Depression Scale ≥ 8) and 55 (21.7%) suffered from malnutrition (the score of Geriatric Nutritional Risk Index ≤ 98). In the multiple regression analyses, nutritional status was negatively associated with depressive symptoms (β = -0.142, p = .02) and functional status mediated the relationship between nutritional status and depressive symptoms.

CONCLUSIONS

Many patients with heart failure have malnutrition and depressive symptoms. Functional status plays a mediating role in the relationship between nutritional status and depressive symptoms.

IMPACT

To relieve depressive symptoms in patients with heart failure, it is of importance to improve the functional status, especially for those with poor nutritional status.

Translation, cultural adaptation, and validation of the duke activity status index in the hindi language

Background:

The Duke Activity Status Index (DASI) is a validated questionnaire in English to assess the functional capacity (FC) of patients with cardiovascular disease (CVD).

Aim:

The aim of the study is to translate, cross-culturally adapt, and validate the DASI in Hindi.

Settings and Study Design:

Observational validation study.

Methodology:

Different translators translated the DASI into Hindi and then back-translated it into English. Validation for feasibility and psychometric properties of translated questionnaire was done on 200 adults, Hindi-speaking patients with CVD, who were advised exercise testing by a cardiologist.

Statistical Analysis:

Internal consistency (Cronbach's α) and test–retest reliability (Pearson's correlation coefficient) were calculated. Construct (correlation with the Canadian Cardiovascular Society Classification [CCSC] for angina and exercise capacity with treadmill testing [TMT]) and content validity (time taken to fill the questionnaire, ease of understanding the questionnaire items, and comprehensibility) were calculated. P < 0.05 was considered significant.

Results:

The Cronbach's α for internal consistency was 0.78, which indicates adequate relatedness among the items of questionnaire, and the test–retest reliability was 0.65 (P < 0.05). A significant correlation between CCSC (r = −0.60) and TMT (r = 0.56) was found. The median time taken by the respondents to fill the questionnaire was 4 min. Of all the respondents, 95.74% of the respondents agreed that the Hindi questionnaire was easy to comprehend and 97.87% patients correlated the translated items to their daily physical activity.

Conclusions:

The Hindi translated and culturally adapted version of the DASI is reliable, valid, and feasible to assess the FC in the Hindi-speaking CVD patients.

Acceptance of illness mediate the effects of health literacy on self-management behaviour

Background:

Self-management is crucial for blood pressure control and subsequent disease prevention. Health literacy and acceptance of illness may contribute to self-management behaviour; in addition, acceptance of illness may mediate the effects of health literacy on self-management behaviour among patients with hypertension.

Objective:

The aims of the research were to examine whether health literacy and acceptance of illness were associated with both pharmacological and non-pharmacological management behaviour and examine the possible mediating effects of the acceptance of illness in patients with hypertension.

Methods:

Hierarchical regression analysis was conducted to analyse the relationships between health literacy, acceptance of illness, pharmacological and non-pharmacological management behaviours. Mediation effects were examined by the PROCESS macro.

Results:

This was a cross-sectional study. A total of 478 hypertensive patients completed measures of health literacy, acceptance of illness, self-management, social support, depression, physical function and demographic and clinical characteristics. Functional, communicative, critical health literacy and acceptance of illness showed positive associations to pharmacological and non-pharmacological management behaviour. Acceptance of illness mediated the relationships between three types of health literacy, pharmacological and non-pharmacological management but the effects size and pathway differed. In detail, functional health literacy influenced pharmacological and non-pharmacological management behaviour mainly by indirect effects mediated by the acceptance of illness, but communicative and critical health literacy influenced pharmacological and non-pharmacological management behaviour mainly by direct effects.

Conclusions:

Acceptance of illness mediated the relationships between three types of health literacy and self-management. Health literacy and acceptance of illness should be addressed when taking measures to improve patients’ self-management behaviour.

The Association Between Depressive Symptoms and N-Terminal Pro-B-Type Natriuretic Peptide With Functional Status in Patients With Heart Failure

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) and depressive symptoms are each associated with functional status in patients with heart failure (HF), but their association together with functional status has not been examined.

OBJECTIVE

The aim of this study was to determine whether functional status scores differ as a function of depressive symptoms and NT-proBNP levels considered together.

METHODS

We studied 284 patients with HF who were divided into 4 groups based on the median split of NT-proBNP levels and cut point for depressive symptoms (Beck Depression Inventory ≥ 14): (1) low NT-proBNP of 562.5 pg/mL or less without depressive symptoms, (2) low NT-proBNP of 562.5 pg/mL or less with depressive symptoms, (3) high NT-proBNP of greater than 562.5 pg/mL without depressive symptoms, and (4) high NT-proBNP of greater than 562.5 pg/mL with depressive symptoms. The Duke Activity Status Index was used to assess functional status.

RESULTS

Nonlinear regression demonstrated that patients without depressive symptoms were more than twice as likely to have higher (better) functional status scores than patients with depressive symptoms regardless of NT-proBNP levels after controlling for age, gender, prescribed antidepressants, and body mass index. Functional status levels of patients with low NT-proBNP did not differ from those with high NT-proBNP in the presence of depressive symptoms.

CONCLUSION

When examined together, depressive symptoms rather than NT-proBNP levels predicted functional status.

CLINICAL IMPLICATIONS

Adequate treatment of depressive symptoms may lead to better functional status regardless of HF severity.

Duke Activity Status Index cut-off scores for assessing functional capacity after stroke

PURPOSE

To determine the Duke Activity Status Index (DASI) cut-off scores and verify if they would be able to discriminate between chronic stroke individuals, who had poor, from those who had good functional capacity (FC).

MATERIALS AND METHODS

Cross-sectional study, where 92 individuals with chronic stroke had their FC measured by DASI scores and were classified into community and non-community walkers. Both the receiver operating characteristic and the area under the curve were used to determine the best DASI cut-off values that could discriminate between individuals, who had poor, from those who had good FC. Binary logistic regression analysis is used to investigate the ability of DASI scores in predicting community walkers.

RESULTS

DASI cut-off value of 31.95 showed to be sensitive and specific to differentiate between individuals, who had poor from good FC. The regression analysis revealed that the chance of individuals, who had better FC (≥ 31.95) be community walkers was 10.69 (95%CI:4-32.75) times higher than that of those who had poor FC (< 31.95). The model demonstrated good predictive ability.

CONCLUSIONS

The DASI cut-off value of 31.95 showed to be sensitive and specific to distinguish between chronic stroke individuals, who had poor, from those who had good FC.IMPLICATIONS FOR REHABILITATIONThe identification of individuals, who have good and poor functional capacity, is important for clinical reasoning and decision-making in stroke rehabilitation.The Duke Activity Status Index (DASI) is a clinically useful tool for the assessment of functional capacity, based upon the performance of common daily living activities.The DASI cut-off of 31.95 points was able to discriminate between individuals with stroke, who had poor, from those who had good functional capacity.The chance of individuals, who had good functional capacity (DASI ≥ 31.95) be community walkers was 10.69 times higher than that of those who had poor functional capacity (DASI < 31.95).The findings support the use of the DASI as a simple tool for the assessment of functional capacity, especially in low-resource settings.

Adaption and validation of Nijmegen continuity questionnaire to recognize the influencing factors of continuity of care for hypertensive patients in China

Background

Continuity of care (COC) has become a primary point of concern for care providers in both developed and developing countries, which is regarded as the “cornerstone of care” and an “essential element” of good health care. A robust and proper instrument is of necessity to identify problems and evaluate intervention aimed at improving continuity of care. This study aimed to adapt Nijmegen continuity questionnaire (NCQ) into a Chinese version (NCQ-C) and to delineate the status of COC as well as explore its influencing factors for hypertensive patients in China.

Methods

A forward-back-translation procedure was adopted for the determination of the adaption of NCQ. Then a total of 448 patients completed questionnaires and 24-h ambulatory blood pressure monitoring (ABPM). Proper indexes were calculated to test the reliability and validity of NCQ-C. Logistic analysis were used to detect the influencing factors of COC.

Results

The NCQ-C had excellent intraclass correlation coefficient of 0.855 and internal consistency of seven dimensions varied from 0.907 to 0.944. The item-content validity index ranged from 0.71 to 1.00. For construct validity, seven-factor structure was confirmed as original questionnaire and all the fit indices indicated acceptable levels. Gender, education level, medical insurance and frequency of family visits, blood pressure level, depression status as well as general health perception were demonstrated to be statistically related to COC.

Conclusions

In addition, all the parameters of ABPM were negatively significant with COC. The NCQ-C has shown acceptable level of reliability and validity. The related factors of COC should arouse care providers’ attention.

Functional status measures for the COPD patient: A practical categorization

The objective of this study is to review available functional status measures (FSMs) validated for use in the chronic obstructive pulmonary disease (COPD) population and categorizing the measures by their commonalities to formulate a framework that supports clinicians in the selection and application of FSMs. A literature review identifying valid and reliable measures of functional status for people with COPD was undertaken. Measures were thematically analyzed and categorized to develop a framework for clinical application. A variety of measures of activity levels exist, with 35 included in this review. Thematic categorization identified five categories of measures: daily activity, impact, surrogate, performance-based, and disability-based measures. The vast variety of FSMs available for clinicians to apply with people who have COPD may be overwhelming, and selection must be thoughtfully based on the nature of the population being studied/evaluated, and aims of evaluation being conducted, not simply as a standard measure used at the institution. Psychometric testing is a critical feature to a strong instrument and issues of reliability, validity, and responsiveness need to be understood prior to measurement use. Contextual nature of measures such as language used and activities measured is also important. A categorical framework to support clinicians in the selection and application of FSMs has been presented in this article.

An Exercise Counseling Intervention in Minority Adults With Heart Failure

PURPOSE

The primary aim of this study was to assess the feasibility of an exercise counseling intervention for adults of diverse race/ethnicity with heart failure (HF) and to assess its potential for improving overall physical activity, functional capacity, and HF self-care.

DESIGN

This study was a quasi-experimental, prospective, longitudinal cohort design.

METHODS

Twenty adults were enrolled and completed the 6-minute walk and standardized instruments, followed by exercise counseling using motivational interviewing. Each received an accelerometer, hand weights, and a diary to record self-care behaviors. Participants were followed via phone for 12 weeks to collect step-counts, review symptoms, and plan the following week's step goal.

FINDINGS

Results indicate that this intervention was feasible for most participants and resulted in improvements in physical activity, functional capacity, and self-care behaviors.

CONCLUSION/CLINICAL RELEVANCE

Brief exercise counseling may be an appropriate option to improve outcomes for stable patients with HF and may be tailored to fit different settings.

Frequency of and Significance of Physical Frailty in Patients With Heart Failure

Physical frailty is an important prognostic indicator in heart failure (HF); however, few studies have examined the relation between physical frailty and invasive hemodynamics among adults with HF. The purpose of this study was to characterize physical frailty in HF in relation to invasive hemodynamics. We enrolled 49 patients with New York Heart Association class II to IV HF when participants were scheduled for a right-sided cardiac heart catheterization procedure. Physical frailty was measured according to the "frailty phenotype": shrinking, weakness, slowness, physical exhaustion, and low physical activity. Markers of invasive hemodynamics were derived from a formal review of right-sided cardiac catheterization tracings, and projected survival was calculated using the Seattle HF model. The mean age of the sample (n = 49) was 57.4 ± 9.7 years, 67% were men, 92% had New York Heart Association class III/IV HF, and 67% had nonischemic HF. Physical frailty was identified in 24 participants (49%) and was associated with worse Seattle HF model 1-year projected survival (p = 0.007). After adjusting for projected survival, physically frail participants had lower cardiac index (by both thermodilution and the Fick equation) and higher heart rates compared with those not physically frail (all p <0.05). In conclusion, physical frailty is highly prevalent in patients with HF and is associated with low-output HF.

Valued Life Activities, Smoking Cessation, and Mood in Post-Acute Coronary Syndrome Patients

BACKGROUND

Continued engagement in valued life activities is a protective factor for depression and has been linked to readiness to quit smoking in medical populations but has never been examined among acute coronary syndrome (ACS) patients.

PURPOSE

The purpose of this study is to investigate relationships among valued life activities, mood, and smoking post-ACS.

METHODS

Participants were 54 post-ACS patients who were smoking before ACS hospitalization. Data on mood, smoking status, engagement in valued activities, restriction of valued activities, and satisfactory replacement of restricted activities was collected 1-12 months post-ACS.

RESULTS

Depressive symptoms were associated with both less valued activity engagement and greater valued activity restriction. Positive affect was associated with greater valued activity engagement and negative affect was associated with greater valued activity restriction. Satisfactory replacement of restricted activities was associated with greater positive affect, fewer depressive symptoms, and quitting smoking post-ACS. The majority of these relationships remained significant after controlling for relevant covariates, including physical functioning.

CONCLUSIONS

Valued activity restriction and engagement may contribute to depressed mood and failure to quit smoking in ACS patients. Psychotherapies that target greater engagement in valued life activities deserve further investigation in ACS patients.

Predictors of memory performance among Taiwanese postmenopausal women with heart failure

BACKGROUND

There are no studies describing the nature of memory deficits among women with heart failure (HF).

OBJECTIVES

The aims of this study were to examine memory performance among Taiwanese women with HF compared with age- and education-matched healthy women, and to evaluate factors that explain memory performance in women with HF.

METHODS AND RESULTS

Seventy-six women with HF and 64 healthy women were recruited in Taiwan. Women completed working, verbal, and visual memory tests; HF severity was collected from the medical records. Women with HF performed significantly worse than healthy women on tests of working memory and verbal memory. Among women with HF, older age explained poorer working memory, and older age, higher HF severity, more comorbidities, and systolic HF explained poorer verbal memory. Menopausal symptoms were not associated with memory performance.

CONCLUSIONS

Results of the study validate findings of memory loss in HF patients from the United States and Europe in a culturally different sample of women. Working memory and verbal memory were worse in Taiwanese women with HF compared with healthy participants. Studies are needed to determine mechanisms of memory deficits in these women and develop interventions to improve memory.