Family member accompaniment to routine medical visits is associated with better self-care in heart failure patients

Strategies and sacrifices of family caregiving in the Somali-American community: a qualitative study

BACKGROUND

Among the many pressing concerns of the Somali-American community, and other similar immigrant and refugee communities as they grow in the United States, is the provision of care for older adults and adults with disabilities. The implications of effective caregiving range from the facilitation of community building and place-making to the delivery and management of healthcare on a systemic level. However, little is currently known about Somali-American family caregivers, including their duties and responsibilities, primary concerns, and the impacts of surrounding influences on their ability to fulfill their role.

METHODS

Semi-structured interviews were conducted with 10 Somali-American family caregivers in Somali language. The resulting transcripts were translated into English by a professional interpreter and analyzed using an inductive thematic analysis approach. A key informant from the community was additionally consulted for insights regarding cultural nuances and interpretations of idiomatic expressions and concepts.

RESULTS

Thematic analysis of the reports revealed the principal themes of visitation, patient accompaniment, and self-sacrifice through acceptance and God-consciousness as pervasive and salient concerns across participants. Furthermore, the heightened stresses of the COVID-19 pandemic revealed just how severe the consequences can be when access to culturally habituated navigational tools and coping mechanisms are restricted.

CONCLUSIONS

In light of our findings, the growing concern for discrimination and sociocultural discord in the Somali-American community presents a particularly prescient threat to the well-being and sustainability of family caregivers. Their experiences must be understood and used to promote education and partnership between the healthcare system and the community in order to build trust and ensure a healthy future for this indispensable population.

Individual and systems-related factors associated with heart failure self-care: a systematic review

BACKGROUND

Heart failure (HF) is a prevalent condition worldwide. HF self-care is a set of behaviors necessary for improving patient outcomes. This study aims to review and summarize the individual and system-related factors associated with HF self-care published in the last seven years (Jan 2015 - Dec 2021) using the Socioecological Model as a review framework.

METHODS

An experienced nursing librarian assisted authors in literature searches of CINAHL Plus with Full Text, Ovid Nursing, PsychINFO, and PubMed databases for peer-reviewed descriptive studies. Inclusion criteria were HF sample with self-care as the outcome variable, and a quantitative descriptive design describing individual and/or system-level factors associated with self-care. Exclusion criteria were interventional or qualitative studies, reviews, published before 2015, non-English, and only one self-care behavior as the outcome variable. The search yielded 1,649 articles. Duplicates were removed, 710 articles were screened, and 90 were included in the full-text review.

RESULTS

A subset of 52 articles met inclusion and exclusion criteria. Study quality was evaluated using modified STROBE criteria. Study findings were quantitated and displayed based on socioecological levels. Self-care confidence, HF knowledge, education level, health literacy, social support, age, depressive symptoms, and cognitive dysfunction were the most frequently cited variables associated with self-care. Most factors measured were at the individual level of the Socioecological Model. There were some factors measured at the microsystem level and none measured at the exosystem or macrosystem level.

CONCLUSION

Researchers need to balance the investigation of individual behaviors that are associated with HF self-care with system-level factors that may be associated with self-care to better address health disparities and inequity.

Relatives' experiences of visiting restrictions during the COVID-19 pandemic's first wave: a PREMs study in Valais Hospital, Switzerland

BACKGROUND

During the COVID-19 pandemic, most countries introduced temporary visiting restrictions on the relatives of acute care hospital patients, whether or not they were infected with SARS-CoV-2. This affected relatives' psychological and emotional states and how closely they could be involved in their loved one's hospitalization.

STUDY AIMS

Investigate relatives' experiences of visiting restrictions during the COVID-19 pandemic's first wave and the support offered by Valais Hospital's healthcare staff.

METHODS

Relatives and patients who had been discharged between February 28 and May 13, 2020, were asked to complete a patient-reported experience measures (PREMs) questionnaire, whether or not they had been infected by SARS-CoV-2. Relatives were asked about how visiting restrictions had affected them, their perceptions of the severity of the COVID-19 pandemic, the quality of communication concerning their loved ones' health status during their hospitalization, and the information received from healthcare staff. Descriptive and inferential statistics were computed.

RESULTS

Of 866 PREMs questionnaires returned, 818 were analyzable, and 543 relatives had experienced visiting restrictions to their loved ones: 92 relatives (87%) of COVID-19 patients and 451 relatives (66%) of non-infected patients, with heterogenous effects on their psychological and affective status. Overall, whether or not relatives were subjected to visiting restrictions, they perceived themselves to be well treated, well informed, and that communication with hospital healthcare staff was satisfactory. However, relatives subjected to visiting restrictions reported significantly lower scores on the quality of communication than other relatives. The relatives of patients in gynecology/obstetrics and internal medicine wards were significantly more affected by visiting restrictions than were the relatives of patients in other wards. Numerous relatives subjected to visiting restrictions reported regular communication with their loved ones or with healthcare staff, at least once a day (n = 179), either via videoconferences using FaceTime®, WhatsApp®, Zoom®, or Skype® or via mobile phone text messages.

CONCLUSION

Visiting restrictions affected relatives differently depending on the wards their loved ones were hospitalized. Healthcare institutions should investigate the utility of visiting restrictions on patients, how they affect relatives, and how to improve personalized patient-relative communications. Future research should attempt to develop reliable, validated measurement instruments of relatives' experiences of acute-care visiting restrictions during pandemics.

Care Providers' Perspectives on Quality Prenatal Care in High-risk Pregnancies: A Qualitative Study

Background

A high-risk pregnancy (HRP) is adversely affects the health of the mother, baby, or both. Most prenatal care research, rather than quality concepts, focuses on the adequacy of prenatal care and describes the emotional-psychological experiences of women with HRP. The main purpose of this study was to explore the perspectives of healthcare professionals regarding the quality of prenatal care for women with HRP.

Methods

This qualitative study was conducted in three university hospitals and 12 comprehensive health centers in Ahvaz (Iran) from December 2020 to May 2021. In the present study, 10 midwives, 2 executive directors, and 7 specialists were purposefully selected with maximum diversity. In-depth semi-structured individual interviews were used to collect the data. Data were analyzed concurrently using Elo and Kinga's content analysis. The MAXQDA software version 10 was used for data analysis.

Results

During data analysis, the 6 main categories "infrastructure for care provision", "optimal clinical care", "organizing referrals", "preconception care", "risk assessment", and "family-centered care" and 14 subcategories were identified.

Conclusion

Our findings showed that professional groups focused on the technical aspects of caring. The findings from this study highlight several conditions that can affect the quality of prenatal care for women with HRP. Healthcare providers can use these factors to effectively manage HRPs, thereby improving pregnancy outcomes among women with HRPs.

Comparing the effectiveness of Family Support for Health Action (FAM-ACT) with traditional community health worker-led interventions to improve adult diabetes management and outcomes: study protocol for a randomized controlled trial

BACKGROUND

Diabetes self-management education and support (DSMES) programs have struggled to deliver sustainable, effective support for adults with diabetes (AWDs) to improve self-management behaviors, achieve glycemic goals, and reduce risk for complications. One largely untapped resource for this support is AWDs' social networks. Fifty to 75% of AWDs have an unpaid family member or friend ("support person") who provides ongoing help with diabetes management. However, DSMES interventions to date lack structured and effective approaches to directly engage support persons in AWDs' diabetes management.

METHODS

This parallel arm randomized trial is designed to determine the effectiveness of Family Support for Health Action (FAM-ACT), a novel community health worker (CHW)-delivered program focused on educating and supporting patients with type 2 diabetes (T2D) and their support persons (SPs), relative to an established, CHW-delivered, individual patient-focused DSMES and care management (I-DSMES) intervention. Both interventions were developed using a community-based participatory research (CBPR) approach. The study will be conducted in partnership with an urban Federally Qualified Health Center (FQHC) serving a low-income, Latino/a community, with target enrollment of 268 dyads consisting of an FQHC patient with T2D with high HbA1c and an SP. Patient-SP dyads will be randomized to receive FAM-ACT or I-DSMES over 6 months. The primary outcome is change in patient HbA1c from baseline to 6 months. Secondary patient outcomes include 12-month change in HbA1c, changes in patient blood pressure, diabetes self-management behaviors, diabetes distress, patient activation, diabetes self-efficacy, and perceptions of and satisfaction with SP support for diabetes. Secondary SP outcomes include self-efficacy for helping the patient with diabetes management and SP distress about the patient's diabetes. We also will assess the effect of the COVID-19 pandemic on patient's ability to manage diabetes.

DISCUSSION

This study will inform scalable, evidence-based approaches that leverage family support to help AWDs improve and sustain self-management strategies that underpin optimal management of multiple diabetes complication risk factors. The protocol is designed for and evaluated with a low-income and predominantly Latino/a community, which may increase applicability to other similar communities. The COVID-19 pandemic presented several challenges to study protocol and intervention delivery; modifications made to address these challenges are described.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03812614. Registered on 18 January 2019.

[Influence of the companion in Primary Care consultations on communication skills and interview time]

OBJETIVES

To know the influence of the companion in triadic clinical encounter on the quality of doctor-patient communication and the duration of the interview.

DESIGN

Cross-sectional descriptive study.

LOCATION

10 Primary Care Centers.

PARTICIPANTS

Resident doctors of Family and Community Medicine.

INTERVENTIONS

Peer review of video recordings of clinical demand consultations.

MAIN MEASUREMENTS

CICAA-2 questionnaire to assess communication skills (improvable, acceptable or adequate); age and sex, reasons for consultation and duration of the interview. Bivariate and multivariate analyses. Ethical authorization, oral informed consent and custody of the video recordings.

RESULTS

73 RD (53.8% women, 32.9±7.7 years) participated with 260 interviews (60.3% women and 2.1±1.0 clinical demands). 27.7% of consultations with a companion (female sex 65.3%). The mean duration of the interviews was 8.5±4.0min. Clinical encounters lasted longer when a companion attended (2.7±0.5min more; p<.001 Student t) and with a greater number of clinical demands (40% with ≥3 reasons, p=0.048 X²). The mean value of the total score of the CICAA-2 scale (46.9±16.5; difference 4.6±2.3) and Task 2 (39.3±15.8 with difference 4.4±2.2) were higher when companion was present (p<.05 Student t). The model obtained with logistic regression shows a longer duration of the consultation with a companion (OR 1.2; CI [1.1-1.3]) and possibly a better score in Task 2 communication skills (OR 1.02; CI [0.99-1.1]).

CONCLUSIONS

Triadic communications challenge the clinician's communication skills, improving their abilities to identify and understand patient problems, albeit at the cost of a greater investment of time.

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

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

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

Patient Experiences Align with The Familial Hypercholesterolemia Global Call to Action

Objective

To explore alignment of perspectives from individuals and families with familial hypercholesterolemia (FH) to the FH Global Call to Action recommendations.

Methods

Interviews and focus groups were conducted with individuals and families with FH from multiple U.S. health systems and the Family Heart Foundation community to capture lived experiences and to identify barriers to diagnosis, cascade testing, and treatment. Participant perspectives were examined and classified, according to their alignment to recommendations of the FH Global Call to Action.

Results

A total of 75 lived experiences were analyzed. Participants were majority female, mostly white, older, and well-educated. Participants most frequently mentioned recommendations were family-based care (84%) and screening, testing, & diagnosis (84%), followed by treatment (69%), advocacy (60%), cost & value (59%), awareness (56%), research & registries (43%), and severe & homozygous FH (11%). An average of 4.65 (SD 1.76) recommendations were mentioned.

Conclusions

The FH Global Call to Action was driven by the persistent unmet needs of those living with FH in receiving a timely diagnosis, appropriate care, and support to prevent early morbidity and mortality. Patient- and family-centric perspectives suggest the FH Global Call to Action captures these concerns. Acting on recommendations, particularly improvements in screening and family-based care, will address patient, and public health, concerns.

Examining Information Needs of Heart Failure Patients and Family Companions Using a Previsit Question Prompt List and Audiotaped Data: Findings From a Pilot Study

BACKGROUND

Question prompt lists (QPLs) are an effective tool for improving communication during medical visits. However, no studies have attempted to correlate intentions related to question asking and actual questions asked during visits. Moreover, few studies have used QPLs with patients with heart failure (HF) or family companions who accompany them to visits. We examined the use of a previsit QPL for patients with HF and their family companions intended to enhance engagement in HF care. The aim of this research was to assess which questions from the QPL patients and companions selected most frequently to ask and compare this item with which questions were actually asked during the medical visit.

METHODS AND RESULTS

This secondary analysis of QOLs and audiotaped visit data from a pilot study enrolled and consented patients with HF, family companions, and HF clinicians. A single group of 30 patients with HF and 23 family companions received the QPL to complete in the waiting room immediately before their cardiology visit. To meet our aims, we calculated the frequencies for each question selected and asked from the QPL, using data derived from completed prompt lists and audiotaped medical visits. A follow-up survey was administered 2 days after the appointment to assess differences in how participants filled out and used the prompt list. Patients and companions primarily selected and asked questions from the QPL regarding the management and treatment of the disease, general questions about HF, and questions about prognosis. Participants rarely asked questions about support for family and friends or health care team roles and responsibilities. Patients and companions did not ask many of the questions they reported wanting to ask.

CONCLUSIONS

Prompt lists may empower patients and companions to communicate with their clinician by identifying important questions to help overcome patients' and companions' knowledge gaps. More research is needed to understand the true impact of prompt lists on patient-family-clinician communication and subsequent HF outcomes, and how best to implement them in clinical workflows to increase their potential usefulness.

A bio-what? Medical companions' perceptions towards biosimilars and information needs in rheumatology

Patient perceptions influence biosimilar uptake in non-mandatory transitions. Companions (support people) are often actively involved in the patient's medical journey and are likely to have unique perceptions of biosimilars, which may shape patient attitudes. This study explores the congruence between patient and companion perceptions towards biosimilars and their information needs. Patients taking bio-originators for rheumatic diseases (59% for rheumatoid arthritis) and their companions received an explanation about biosimilars. Participants (N = 78) completed questionnaires assessing their familiarity with biosimilars, perceptions, concerns, and benefits of being accompanied. Contingency tables and paired sample t-tests were used to explore differences in familiarity, confidence in knowledge, and perceptions. Intra-class correlation coefficients were calculated to assess the degree of congruence for perceptions towards biosimilars. Companions were significantly less familiar with biosimilars (p = 0.014, Cramer's V = 0.28) and reported lower confidence in their knowledge (p = 0.006, Cohen's d = 0.47) than patients. Companions and patients had moderate to good congruency for perceptions toward confidence in biosimilar use and safety, efficacy, and side-effect expectations (intra-class correlation coefficients ranging from 0.75 to 0.81). Companions and patients were most concerned about safety and effectiveness. Companions also reported concerns about cost savings driving the transition, while patients had concerns about uncertainty and testing. Patients reported the ability for discussion, improved understanding, and validation as benefits of being accompanied. Companions and patients have similar levels of perceptions and expectations towards biosimilars but report some unique information needs. Future educational interventions should involve companions and address their concerns to help improve biosimilar acceptance.

Japanese women's reasons for accompaniment status to hereditary breast and ovarian cancer-focused genetic counseling

Genetic counselors routinely assess and understand clients' needs at the beginning of a session. Attending a genetic counseling session with or without companions is an objective sign that genetic counselors can easily notice. This study focused on clients' reasons for their accompaniment status for genetic counseling, which we categorize into attending with or without a companion(s). A questionnaire survey and interviews were conducted using snowball sampling, starting with the chief executive officer (CEO) of the Japanese hereditary breast and ovarian cancer (HBOC) support group. Of 32 participants, 19 continued with an in-depth interview after answering the questionnaire. Five themes were identified from the interview: (1) personal confidence, (2) decision-making style, (3) family members' habits and time availability, (4) considerations and conflicts with family members, and (5) healthcare provider's suggestion. Our data suggested that the clients expected their companion(s) to play certain roles. This indicates that the reasons of accompaniment status will be helpful for genetic counselors to understand both clients' and their families' motivations, personalities, habits, and psychosocial backgrounds. In a high-context culture such as that of Japan, accompaniment status may be a helpful sign to understand clients' true worries. In addition, some companions may be future clients in genetic counseling, due to the genetic nature of the disease. In conclusion, our study indicated that it is important for genetic counselors to record accompaniment status before the initial genetic counseling and to pay attention to its reasons at the beginning of the session, which may lead them to understand the client's psychosocial background to facilitate better client-centered genetic counseling.

Is Three a Crowd? The Influence of Companions on a Patient's Decision to Transition to a Biosimilar

BACKGROUND

Involving patients in treatment decisions is commonplace in healthcare, and patients are frequently accompanied by a companion (support person). Companions are often actively involved in medical consultations, yet their impact on decisions to change medications is unknown.

PURPOSE

This study examines the influence of companions on a patient's decision to transition from their bio-originator therapy to a biosimilar.

METHODS

A parallel, two-arm randomized controlled trial was conducted with 79 patients taking a bio-originator for rheumatic diseases who regularly attend clinic with a companion. Patients were randomized to receive an explanation about a hypothetical transition to a biosimilar alone or with their companion. Patients reported willingness to transition, risk perceptions, difficulty understanding, social support, and completed the Decisional Conflict Scale and Satisfaction with Decision Scale.

RESULTS

Companions did not influence decisions to transition to biosimilars or cognitive and affective risk perceptions. Accompanied patients reported more difficulty understanding the explanation (p = .006, Cohen's d = .64) but thought it was more important to receive information with companions (p = .023, Cohen's d = -.52). Companions did not impact decision satisfaction or decisional conflict. Receiving emotional, but not practical support, was associated with less decisional conflict in accompanied patients (p = .038, r  2 = 0.20).

CONCLUSIONS

The presence of companions does not seem to influence risk perceptions or decisions about transitioning to biosimilars. Companions, however, impact the patient's reporting of their ability to understand treatment explanations. Providers should check understanding in all patients but may need to provide additional time or educational resources to accompanied patients and companions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry: ACTRN12619001435178.

The Critical Need to Recognize That Families Matter for Adult Health: A Systematic Review of the Literature

A systemic approach to researching families and health should capture the complex network within which family members are embedded, including multiple family relationships and larger systems of health care. However, much of the families and health research focused on adult family members has focused solely on intimate partnerships, usually the marital relationship. This neglects the remainder of the powerfully influencing family relationships adults retain, and may increasingly focus on as they age. We conducted a systematic review of the families and adult health literature, retaining 72 articles which were subsequently thematically coded to highlight main foci of this area of research. Results highlight six themes, which include family relationship quality, family composition, behavioral factors in health and health care, psychophysiological mediators, caregiving, and aging health. Findings support an underrepresentation of family members, other than the intimate partner, in research on adult health.

The association of health status and cancer history of young adult survivors of childhood cancer with parental accompaniment to survivorship clinic visits

PURPOSE

Adult childhood cancer survivors are frequently accompanied by a parent to survivorship clinic. From clinical evaluations among young adult survivors of childhood cancer we aimed to (1) investigate the association between accompaniment and the survivors' health complexity; and (2) determine whether accompaniment is associated with adherence to recommended surveillance tests and follow-up in clinic.

METHODS

This was a cross-sectional study of all patients ≥ 18 years old at their first visit to the regional Yale Childhood Cancer Survivorship Clinic from 2003 to 2018. Patients underwent standardized evaluations for medical, neurocognitive, and emotional late effects of therapy; individuals accompanying patients were documented.

RESULTS

The 168 patients were a median of 12.0 (range: 0-17.9) years at diagnosis and 22.7 (range: 18.1-39.9) years at evaluation, and 45.8% were accompanied by a parent. In multivariable analyses, 18.0-24.99 years vs. 25.0-39.99 years at visit (OR = 3.43, p = 0.022) and central nervous system (CNS) tumor diagnosis (OR = 6.09 vs. leukemia/lymphoma diagnosis, p = 0.010) were significantly associated with parental accompaniment. Accompaniment was not associated with number and severity of medical late effects, neurocognitive impairment, or emotional distress. Accompaniment was not associated with completed surveillance tests or a clinic follow-up within 2 years.

CONCLUSION

Forty-six percent of survivors were accompanied by a parent, and accompaniment was not associated with survivor health status. Accompaniment was not associated with adherence to recommended surveillance tests or clinic follow-up.

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

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

Online resources for family caregivers of cognitively competent patients: A review of user-driven reputable health website content on caregiver communication with health professionals

OBJECTIVE

Most patients want their family involved in consultations and decisions, however some family caregivers report feeling overwhelmed and unsure of their role. As caregivers are increasingly looking to medical websites for guidance, this study aimed to review reputable web-resources available to inform family caregivers on how to be involved in medical consultations and decisions.

METHODS

Google searches were performed using lay search strings, to imitate how a cancer caregiver may locate information. Relevant webpages were included if they were directed at caregivers and from a reputable health organisation. Qualitative content analyses were performed on the included webpages.

RESULTS

22 webpages were included and 8 were directed at caregivers of cancer patients. Six key categories of information were identified: preparing for consultations, helping during consultations, advocating for the patient, decision-making, communicating in hospital settings, and communicating with family and friends.

CONCLUSION

A range of online resources were found to guide family caregivers, particularly cancer caregivers, on involvement in consultations. However, few provided information to caregivers on complex situations such as treatment decision-making, advocating for patient's needs, and communicating in a hospital setting.

PRACTICE IMPLICATIONS

Clinicians can actively refer family caregivers to online resources that support caregiver communication in medical settings.

Partner involvement in treatment-related decision making in triadic clinical consultations - A systematic review of qualitative and quantitative studies

OBJECTIVE

Explore how partners are involved in treatment-related decision-making within triadic clinical encounters.

METHODS

Studies were identified via database searches and reference lists. One author assessed eligibility of studies, which were verified by an additional co-author. Data were extracted by one author and cross-checked for accuracy by a second. Quality of articles was assessed using Qualsyst. Retrieved studies were categorised by one author, and agreed through discussion.

RESULTS

From 2442 records, 14 studies were included and categorised as: (1) Descriptions of partner role and behaviour; (2) Role intentions of partners; (3) Relationship between partner and patient behaviour; (4) HCP-Partner interactions.

CONCLUSION

Partners are often involved in triadic clinical consultations that have implications for treatment-related decision making. Most studies offered general descriptions but lacked detailed investigation of communicative processes in triads and how these may operate with partners vs. other companions.

PRACTICE IMPLICATIONS

Existing studies lack detailed investigation through direct observation of the processes of partner involvement. Research in other areas of clinical communication suggests that future interventions could be informed by attention to the following areas: partner behaviour vs. other companion types in triads; relationships between partner involvement and decision-making processes; partner involvement in triads vs. other groups (e.g. quadratic).

Caregiver Well-being and the Quality of Cancer Care

OBJECTIVES

To conceptualize the pathways and assess current evidence for the relationship between caregiver well-being and the quality of the cancer patient's care.

DATA SOURCES

Qualitative, quantitative, and theoretical literature and official reports.

CONCLUSION

Caregiver well-being has both direct and indirect effects on the quality of cancer care, including care received from the health care team, from the caregiver themselves, and in relation to patients' own self-management.

IMPLICATIONS FOR NURSING PRACTICE

Supporting caregivers has tangible consequences with regard to the quality of cancer care on multiple levels, with direct implications for patient outcomes. Nurses have a key role in providing psychosocial care to patients and their caregivers, and in supporting system-level change.

Illness trajectory in heart failure: narratives of family caregivers

OBJECTIVE

To explore the meaning of being a family caregiver for a relative with advanced heart failure (HF) in their own home, and to gain an understanding of how dignity is upheld in family caregiving contexts.

METHOD

We used a phenomenological-hermeneutical method inspired by the Ricoeurian philosophy. Portuguese caregivers for relatives with advanced HF participated in two reflective interviews over a four-month period.

RESULTS

The ten family caregivers enrolled in this study included two daughters and eight spouses with a mean age of 70 years. We identified two main themes: (1) Struggle between inner force and sense of duty; (2) Struggle between feelings of burden and security.

FINAL CONSIDERATIONS

People with HF have debilitating symptoms associated with psychological stress, which can burden both them and their family caregivers. Findings support that family caregivers require participation in the planning and execution of their relative's health care.

Chronic Conditions, Medically Supportive Care Partners, And Functional Disability Among Cognitively Impaired Adults

BACKGROUND AND OBJECTIVES

To assess whether medically supportive care partners modify the associations of symptomatic chronic conditions with the number of functional disabilities in a cohort of multimorbid older adults with cognitive impairment.

RESEARCH DESIGN AND METHODS

The research design is a prospective study of a nationally representative cohort of Medicare beneficiaries. National Health and Aging Trends Study (NHATS) data were linked with Medicare claims for years 2011-2015. Participants were aged 65 or older and had cognitive impairment with at least 2 chronic conditions (N = 1,003). Annual in-person interviews obtained sociodemographic information at baseline and time-varying variables for caregiving, hospitalization, and 6 activities of daily living (ADL); these variables were merged with Center for Medicare and Medicaid Services data to ascertain 16 time-varying chronic conditions. A care partner was defined as a person who sat with their care recipient during doctor visits in the past year and/or who helped them with prescribed medications in the last month. Chronic condition associations and their potential effect modifications by care partner status were assessed using weighted generalized estimating equations accounting for the complex survey design of the longitudinal analytical sample.

RESULTS

Chronic kidney disease, depression, and heart failure were associated with an increased number of functional disabilities. Among these, only the association of chronic kidney disease with the number of functional disabilities (interaction p value = .001) was weakened by the presence of a care partner.

DISCUSSION AND IMPLICATIONS

The presence of care partners showed limited modification of the associations of symptomatic chronic conditions with functional disability.

Patient competence in relation with medical and psychosocial characteristics in cardiology context: A cross-sectional study

BACKGROUND

Growth of cardiovascular disease (CVD), variation in provision of medical services, rising costs, and increasing information availability through the media are making patients more actively involved in decision-making process of their treatment. The aim of this study was to better understand the components of patient competence in the context of coronary artery disease (CAD) and to further evaluate their relations with medical, demographic, and psychosocial characteristics.

METHODS

In this cross-sectional study, 148 patients with at least one year diagnosis of acute coronary syndrome (ACS) were enrolled in the study from April to June 2014. Data on demographic characteristics, depression, anxiety, quality of life (QOL), social support, and drug adherence were collected from participants. Pearson correlation, one way analysis of variance (ANOVA), and multiple linear regression tests were performed for analyzing data.

RESULTS

The mean age of patients was 53.63 ± 5.15. Of the participants, 58 (39.5%) and 61 cases (41.5%) were found to be depressed and anxious, respectively. Higher levels of self-regulation correlated with higher education years and social support, and also with lower depression and anxiety (P < 0.050). Stress management and confronting the threat were linked to education years, depression, anxiety, QOL, and social support (P < 0.050).

CONCLUSION

The patients with CAD, in order to be involved in the proper treatment process and manage their emotions during this process, need to have the required competencies. Patient competence as a whole and its components have been related to medical, demographic, and psychosocial characteristics.

Enhanced Patient-Centered Educational Program for HF Self-care management in Sub-acute settings

Heart Failure (HF) is a complex condition that leads to inadequate blood circulation causing shortness of breath, fatigue, and weakness. It is one of the leading causes of death in the United States. Heart failure is associated with adverse outcomes such as high rates of hospitalization, readmission, mortality, and poor quality of life. However, despite the establishment of interventions to assist with the control of HF, numerous patients are still being readmitted to the hospital. The main purpose of this evidence-based practice (EBP) project was to implement and evaluate the effectiveness of patient centered educational program on self-care management among HF patients in sub-acute settings. The EBP was implemented in two sub-acute units at Alaris Health located at Cedar Grove. A total of 20 participants completed the pretest and 14 participants completed the post test. The Expanded Chronic Care Model of 2003 (ECCM) was utilized as the theoretical framework to coordinate the health determinants which is the "self-care management." This EBP project used a pretest and post-test using the tool Self-care of Heart Failure Index V6.2(SCHFI). The data was analyzed using the descriptive statistics using the mean and the difference between the pre- and post-test scores. Educational intervention was provided based on the survey scores. The intervention involved provision of educational program related to effective self-care management among HF patients, their families, and care providers. The results of the study demonstrated a statically significant increase in the mean score between the pre-and post-survey related to self-care maintenance, self-care management, and self-confidence. The results of the project suggested that patient-centered educational program can enhance self-care maintenance, management, and confidence among heart failure patients.

Who Decides: Me or We? Family Involvement in Medical Decision Making in Eastern and Western Countries

Background. Research suggests that desired family involvement (FI) in medical decision making may depend on cultural values. Unfortunately, the field lacks cross-cultural studies that test this assumption. As a result, providers may be guided by incomplete information or cultural biases rather than patient preferences. Methods. Researchers developed 6 culturally relevant disease scenarios varying from low to high medical seriousness. Quota samples of approximately 290 middle-aged urban residents in Australia, China, Malaysia, India, South Korea, Thailand, and the USA completed an online survey that examined desired levels of FI and identified individual difference predictors in each country. All reliability coefficients were acceptable. Regression models met standard assumptions. Results. The strongest finding across all 7 countries was that those who desired higher self-involvement (SI) in medical decision making also wanted lower FI. On the other hand, respondents who valued relational-interdependence tended to want their families involved – a key finding in 5 of 7 countries. In addition, in 4 of 7 countries, respondents who valued social hierarchy desired higher FI. Other antecedents were less consistent. Conclusion. These results suggest that it is important for health providers to avoid East–West cultural stereotypes. There are meaningful numbers of patients in all 7 countries who want to be individually involved and those individuals tend to prefer lower FI. On the other hand, more interdependent patients are likely to want families involved in many of the countries studied. Thus, individual differences within culture appear to be important in predicting whether a patient desires FI. For this reason, avoiding culture-based assumptions about desired FI during medical decision making is central to providing more effective patient centered care.

Examining the context and helpfulness of family companion contributions to older adults' primary care visits

OBJECTIVE

Older adults commonly involve family (broadly defined) in their care. We examined communication behaviors of family companions during older adults' primary care visits, including whether these behaviors vary with respect to how older adults manage their health, preferences for involving family in medical decision-making, and ratings of companion helpfulness.

METHODS

Analysis of audio-taped primary care visits of older patients who were accompanied by a family companion (n=30 dyads) and linked patient surveys.

RESULTS

Family companions predominantly facilitated doctor and patient information exchange. More than half of companion communication behaviors were directed at improving doctor understanding of the patient. Companions were more verbally active during visits of patients who delegated the management of their health to others than visits of patients who co-managed or self-managed their health. Companions were rated as more helpful by patients who preferred active involvement of family in medical decision-making.

CONCLUSION

Family companion participation and helpfulness in primary care communication varies by patients' preferences for involving family in medical decision-making and approach to manage their health.

PRACTICE IMPLICATIONS

Research to examine the effects of clarifying patient and family companion expectations for primary care visits could inform strategies to improve the patient-centeredness of medical communication.

Correlates of family involvement before and during medical visits among older adults with high-risk diabetes

AIMS

To examine the characteristics of patients with diabetes who regularly receive help from a supporter in preparing for and attending medical visits, and the association between this help and clinical risk factors for diabetes complications.

METHODS

We linked survey data about family involvement for patients in the Veterans Health Administration system with poorly controlled Type 2 diabetes (n = 588; mean 67 years; 97% male) with health record data on blood pressure, glycaemic control and prescription-fill gaps. We used multivariable regression to assess whether supporter presence and, among patients with supporters, supporter role (visit preparation, accompaniment to medical visit or no involvement) were associated with concurrent trends in clinical risk factors over 2 years, adjusting for sociodemographic and health characteristics.

RESULTS

Most patients (78%) had a main health supporter; of these, more had regular support for preparing for appointments (69%) than were regularly accompanied to them (45%). Patients with preparation help only were younger and more educated than accompanied patients. Support presence and type was not significantly associated with clinical risk factors.

CONCLUSIONS

Family help preparing for appointments was common among these patients with high-risk diabetes. In its current form, family support for medical visits may not affect clinical factors in the short term. Supporters helping patients engage in medical visits may need training and assistance to have an impact on the clinical trajectory of patients with diabetes.

A Narrative Review of Patient and Family Engagement: The "Foundation" of the Medical "Home"

BACKGROUND

Patient and family engagement (PFE) is vital to the spirit of the medical home. This article reflects the efforts of an expert consensus panel, the Patient and Family Engagement Workgroup, as part of the Society of General Internal Medicine's 2013 Research Conference.

OBJECTIVE

To review extant literature on PFE in pediatric and adult medicine and quality improvement, highlight emerging best practices and models, suggest questions for future research, and provide references to tools and resources to facilitate implementation of PFE strategies.

METHODS

We conducted a narrative review of relevant articles published from 2000 to 2015. Additional information was retrieved from personal contact with experts and recommended sources from workgroup members.

RESULTS

Despite the theoretical importance of PFE and policy recommendations that PFE occurs at all levels across the health care system, evidence of effectiveness is limited, particularly for quality improvement. There is some evidence that PFE is effective, mostly related to engagement in the care of individual patients, but the evidence is mixed and few studies have assessed the effect of PFE on health outcomes. Measurement issues and the lack of a single comprehensive conceptual model pose challenges to progress in this field. Recommendations for future research and a list of practical tools and resources to facilitate PFE are provided.

CONCLUSIONS

Although PFE appeals to patients, families, providers, and policy-makers, research is needed to assess outcomes beyond satisfaction, address implementation barriers, and support engagement in practice redesign and quality improvement. Partnering with patients and families has great potential to support high-quality health care and optimize outcomes.

Needs of caregivers in heart failure management: A qualitative study

OBJECTIVES

To identify the needs of caregivers supporting a person with heart failure and to inform the development of a caregiver resource to be used as part of a home-based self-management programme.

METHODS

A qualitative study informed by thematic analysis involving 26 caregivers in individual interviews or a focus group.

RESULTS

Three distinct aspects of caregiver support in heart failure management were identified. Firstly, caregivers identified needs about supporting management of heart failure including: coping with the variability of heart failure symptoms, what to do in an emergency, understanding and managing medicines, providing emotional support, promoting exercise and physical activity, providing personal care, living with a cardiac device and supporting depression management. Secondly, as they make the transition to becoming a caregiver, they need to develop skills to undertake difficult discussions about the role; communicate with health professionals; manage their own mental health, well-being and sleep; and manage home and work. Thirdly, caregivers require skills to engage social support, and voluntary and formal services while recognising that the long-term future is uncertain.

DISCUSSION

The identification of the needs of caregiver has been used to inform the development of a home-based heart failure intervention facilitated by a trained health care practitioner.

Exploring the Relationship of Patient and Informal Caregiver Characteristics with Heart Failure Self-Care Using the Actor-Partner Interdependence Model: Implications for Outpatient Palliative Care

BACKGROUND

The convergence of prevalence, cost, symptom experience, community setting, and informal caregiving in heart failure (HF) has profound implications for outpatient palliative care. The majority of HF patients depend on informal caregiver's assistance. Dyadic (patients and caregiver) characteristics can complicate this assistance. Yet relatively little is known concerning dyadic characteristics' impact on self-care. HF self-care involves routine, daily treatment adherence and symptom monitoring (self-care maintenance), and symptom response (self-care management).

OBJECTIVE

Describe the dyadic characteristics of mood and perception of the relationship in HF patients and caregivers, then explore the relationship of the characteristics with self-care.

DESIGN

Prospective, cross sectional study of hospitalized HF patients in mixed dyads (spousal/adult child/relative) analyzed using Actor-Partner Interdependence Model (APIM) techniques.

MEASUREMENTS

Mood was measured by the Brief Symptom Inventory and Patient Health Questionnaire, perception of the relationship by the Dyadic Adjustment Scale, and self-care by the Self-care in Heart Failure Index.

RESULTS

In 40 dyads the average patient was a 71 year old male (n = 30); caregiver was a 59 years old female (n = 26). Overall self-care scores were consistently low. Patient depression scores were significantly greater than caregivers (p = .0055). Greater caregiver anxiety were associated with lower caregiver maintenance scores (p < .0001) but greater caregiver depression were associated with lower patient maintenance scores (p < .0001). While patient and caregiver's perception of the relationship was associated with their self-care, more importantly, caregiver's perception of the relationship was associated with their confidence to engage in the patient's self-care (p = .003).

DISCUSSION/CONCLUSION

This study suggests that caregivers, often unacknowledged or unmeasured, impact patient's day to day HF self-care. Palliative care clinicians need to talk to dyads with a history of poor self-care about their relationship.

Family partner intervention influences self-care confidence and treatment self-regulation in patients with heart failure

BACKGROUND

Heart failure self-care requires confidence in one's ability and motivation to perform a recommended behavior. Most self-care occurs within a family context, yet little is known about the influence of family on heart failure self-care or motivating factors.

AIMS

To examine the association of family functioning and the self-care antecedents of confidence and motivation among heart failure participants and determine if a family partnership intervention would promote higher levels of perceived confidence and treatment self-regulation (motivation) at four and eight months compared to patient-family education or usual care groups.

METHODS

Heart failure patients (N=117) and a family member were randomized to a family partnership intervention, patient-family education or usual care groups. Measures of patient's perceived family functioning, confidence, motivation for medications and following a low-sodium diet were analyzed. Data were collected at baseline, four and eight months.

RESULTS

Family functioning was related to self-care confidence for diet (p=0.02) and autonomous motivation for adhering to their medications (p=0.05) and diet (p=0.2). The family partnership intervention group significantly improved confidence (p=0.05) and motivation (medications (p=0.004; diet p=0.012) at four months, whereas patient-family education group and usual care did not change.

CONCLUSION

Perceived confidence and motivation for self-care was enhanced by family partnership intervention, regardless of family functioning. Poor family functioning at baseline contributed to lower confidence. Family functioning should be assessed to guide tailored family-patient interventions for better outcomes.

Older adults receiving assistance with physician visits and prescribed medications and their family caregivers: prevalence, characteristics, and hours of care

OBJECTIVES

To profile older adults receiving assistance with physician visits and prescribed medications and the time demands associated with their care.

METHODS

Observational study of 7,197 community-dwelling adults ages 65+ responding to the 2011 National Health and Aging Trends Study.

RESULTS

More than one third of older adults receive assistance with either physician visits or prescribed medications (26.3%), or both (9.9%). The 3.3 million older adults who receive assistance with both physician visits and prescribed medications are a high-need subgroup: 3 in 5 have possible (16.5%) or probable (46.1%) dementia and three quarters (76.6%) receive help with mobility, self-care, or household activities. These 3.3 million older adults receive more than twice as many weekly hours of help with all activities (60.5 hr) as those receiving help with either physician visits or prescribed medications (26.5 hr), or neither (18.6 hr). Older adults receiving help with both physician visits and prescribed medications are assisted by 7.2 million helpers, most often adult children (46.6%), or spouses (23.6%). The 3.1 million helpers who assist with both physician visits and prescribed medications provide an average of 45.4 hr of help per week; nearly two thirds (64.3%) also assist with mobility or self-care.

DISCUSSION

Older adults receiving help with both physician visits and prescribed medications typically have high health and functioning needs that involve significant time demands for caregivers.