Measuring patient outcomes in chronic heart failure: psychometric properties of the Care-Related Quality of Life survey for Chronic Heart Failure (CaReQoL CHF)

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.

Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management

Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.

Perceptions and satisfaction of patients with chronic heart failure when using a remote monitoring web application named Satelia® Cardio

INTRODUCTION

The use of telehealth, such as remote patient monitoring (RPM), for chronic heart failure (CHF) impacts patient pathways. Patient-centricity in chronic disease management is valuable. Even though RPM is recommended in practice, the evaluation of patient satisfaction has been limited to date. The objective of this study was to assess the perceptions and satisfaction of patients with CHF when using RPM.

METHODS

A voluntary declarative survey was conducted with users of Satelia® Cardio, an RPM web application which was included in an experimental model program in France funded by the ETAPES program initiative sponsored by the French Ministry of Health. Monitoring was based on patient-reported outcomes (seven questions on symptoms, one question on weight) which were answered online (digitally literate patients) or by phone with a nurse (patients with poor digital literacy). The survey included questions on perceived usefulness, ease of use and impact on quality of life (QoL).

RESULTS

Overall, 87% of the 825 patients were satisfied with having their CHF digitally monitored. Patients found that the application was easy to use (94%), problem free (95%), provided well-timed notifications (98%), easily accessible (96.5%), understandable (89%), and did not require an unreasonable amount of time to answer questions (99%). Most patients felt that RPM helped physicians provide better care during their follow-ups (70%, mean score: 7.98/10) and 45% of the digitally literate patients indicated an improved QoL.

CONCLUSION

Poor digitally literate patients may need human-based or assisted RPM. Patients monitored daily for CHF through RPM expressed strong satisfaction and acceptance.

A Systematic Review of the Development and Implementation of Needs-Based Palliative Care Tools in Heart Failure and Chronic Respiratory Disease

Background

The impetus to develop and implement tools for non-malignant patient groups is reflected in the increasing number of instruments being developed for heart failure and chronic respiratory diseases. Evidence syntheses of psychometric quality and clinical utility of these tools is required to inform research and clinical practice.

Aims

This systematic review examined palliative care needs tools for people diagnosed with advanced heart failure or chronic respiratory diseases, to determine their: (1) psychometric quality; and (2) acceptability, feasibility and clinical utility when implemented in clinical practice.

Methods

Systematic searches of MEDLINE, CINAHL, Embase, Cochrane and PsycINFO from database inception until June 2021 were undertaken. Additionally, the reference lists of included studies were searched for relevant articles. Psychometric properties of identified measures were evaluated against pre-determined and standard criteria.

Results

Eighteen tools met inclusion criteria: 11 were developed to assess unmet patient palliative care needs. Of those, 6 were generic, 4 were developed for heart failure and 1 was developed for interstitial lung disease. Seven tools identified those who may benefit from palliative care and include general and disease-specific indicators. The psychometric qualities of the tools varied. None met all of the accepted criteria for psychometric rigor in heart failure or respiratory disease populations. There is limited implementation of needs assessment tools in practice.

Conclusion

Several tools were identified, however further validation studies in heart failure and respiratory disease populations are required. Rigorous evaluation to determine the impact of adopting a systematic needs-based approach for heart failure and lung disease on the physical and psychosocial outcomes of patients and carers, as well as the economic costs and benefits to the healthcare system, is required.

[Recommendations to develop Care Models for patients with Heart Failure (MAIC Project) from macromanagement]

BACKGROUND

The general objective of the study was to reflect on the key factors to advance in optimal models of care for Heart Failure (HF) and specifically, on the macromanagement elements most necessary for the development of comprehensive HF management models.

MATERIAL AND METHODS

An Advisory Committee, composed of 15 experts and a multidisciplinary group of 31 additional experts, was appointed, together forming a Delphi panel of 46 experts. Based on a systematic bibliographic review and the analysis of the care course of the patient with HF, an initial battery of key factors for the development of HF care models was identified by the Advisory Committee. This proposal was adjusted and prioritized by the Delphi panel applying Delphi Rand/UCLA methodology.

RESULTS

After two Delphi rounds, 75 key factors grouped into 7 challenges were defined. In the first of the challenges, related to the development of HF management models, 16 key factors were identified, 7 of which were valued as high priority and related to the establishment of common objectives, resources for the continuity of care and improving the measurement of health outcomes.

CONCLUSIONS

The definition of management elements at the macro level was considered a priority to advance in the development of optimal models of assistance to HF.

mHealth 6-minute walk test - accuracy for detecting clinically relevant differences in heart failure patients

Heart failure is a serious disease which increases mortality as well as hospital admission rates for affected patients. Disease management programs supported by telehealth solutions are cost-effective approaches for reducing all-cause mortality and heart failure hospitalizations. A 6-minute walk test (6MWT) app could help heart failure patients to self-monitor their functional capacity. We have developed such an application capable of tracking the geolocation, guiding users through a 6MWT and providing the walked distance after six minutes. Besides common global navigation satellite system (GNSS) filtering methods like a Kalman filter, we have investigated the impact of positioning the device (tablet) and GNSS reception on the accuracy of the test. In a field experiment, we gathered 166 6MWT recordings with the developed mobile application. Applying the Kalman filter reduced the overall relative error from 35.5 % to 3.7 %. Wearing the tablet on the body led to significantly better results than holding it in the hand (p < .001). The average accuracy of 2.2 % of body-worn measurements was below previously defined thresholds for reliable results. It thus allows to define a procedure on how to perform and integrate an accurate 6MWT in telehealth settings for clinical decision support in heart failure patients.

Patient-reported outcomes in symptom-driven remote arrhythmia monitoring: evaluation of the Dutch HartWacht-telemonitoring programme

Aims

There is limited quantitative evidence on the effect of symptom-driven telemonitoring for cardiac arrhythmias on patient-reported outcomes. We evaluated the effect of a symptom-driven remote arrhythmia monitoring programme on the patient-reported health-related quality of life (HRQoL), sense of safety, physical limitations, and self-management.

Methods and results

This was an observational retrospective longitudinal study of the symptom-driven HartWacht-telemonitoring programme using a remote single-lead electrocardiogram monitoring system. Real-world patient data from participants who were enrolled in the telemonitoring programme for (suspected) symptomatic atrial fibrillation (AF) between July 2017 and September 2019 were evaluated. Primary outcomes were the patient-reported generic HRQoL, disease-specific HRQoL, sense of safety, physical limitations, and self-management at date of enrolment, 3 months and 6 months of follow-up. Outcomes were compared to a historical control group consisting of AF patients receiving standard care. A total of 109 participants in the HartWacht programme [59 men (54%); mean age 61 ± 11 years; 72% diagnosed AF] were included in complete case analysis. There was no significant change in HRQoL and sense of safety during follow-up. A significant improvement in the perceived physical limitations was observed. The level of self-management declined significantly during follow-up. Comparisons to the historic control group (n = 83) showed no difference between the patient-reported disease-specific HRQoL, sense of safety and physical limitations at 6 months of follow-up.

Conclusion

Symptom-driven remote arrhythmia monitoring for AF does not seem to affect HRQoL and sense of safety, whereas the perceived physical limitations tend to improve. Patient-reported self-management declined during the first 6 months of participation.

Tools to help healthcare professionals recognize palliative care needs in patients with advanced heart failure: A systematic review

BACKGROUND

The delivery of palliative care interventions is not widely integrated in chronic heart failure care as the recognition of palliative care needs is perceived as difficult. Tools may facilitate healthcare professionals to identify patients with palliative care needs in advanced chronic heart failure.

AIM

To identify tools to help healthcare professionals recognize palliative care needs in patients with advanced chronic heart failure.

DESIGN

This systematic review was registered in the PROSPERO database (CRD42019131896). Evidence of tools' development, evaluation, feasibility, and implementation was sought and described.

DATA SOURCES

Electronic searches to identify references of tools published until June 2019 were conducted in MEDLINE, CINAHL, and EMBASE. Hand-searching of references and citations was undertaken. Based on the identified tools, a second electronic search until September 2019 was performed to check whether all evidence about these tools in the context of chronic heart failure was included.

RESULTS

Nineteen studies described a total of seven tools. The tools varied in purpose, intended user and properties. The tools have been validated to a limited extent in the context of chronic heart failure and palliative care. Different health care professionals applied the tools in various settings at different moments of the care process. Guidance and instruction about how to apply the tool revealed to be relevant but may be not enough for uptake. Spiritual care needs were perceived as difficult to assess.

CONCLUSION

Seven tools were identified which showed different and limited levels of validity in the context of palliative care and chronic heart failure.

A scoping review and mapping exercise comparing the content of patient-reported outcome measures (PROMs) across heart disease-specific scales

Background

Over the past decade, the importance of person-centered care has led to increased interest in patient-reported outcome measures (PROMs). In cardiovascular care, selecting an appropriate PROM for clinical use or research is challenging because multimorbidity is often common in patients. The aim was therefore to provide an overview of heart-disease specific PROMs and to compare the content of those outcomes using a bio-psycho-social framework of health.

Methods

A scoping review of heart disease-specific PROMs, including arrhythmia/atrial fibrillation, congenital heart disease, heart failure, ischemic heart disease, and valve diseases was conducted in PubMed (January 2018). All items contained in the disease-specific PROMs were mapped to WHO’s International Classification of Functioning, Disability and Health (ICF) according to standardized linking rules.

Results

A total of 34 PROMs (heart diseases in general n = 5; cardiac arrhythmia n = 6; heart failure n = 14; ischemic heart disease n = 9) and 147 ICF categories were identified. ICF categories covered Body functions (n = 61), Activities & Participation (n = 69), and Environmental factors (n = 17). Most items were about experienced problems of Body functions and less often about patients’ daily activities, and most PROMs were specifically developed for heart failure and no PROM were identified for valve disease or congenital heart disease.

Conclusions

Our results motivate and provide information to develop comprehensive PROMs that consider activity and participation by patients with various types of heart disease.

The psychometric validation of the Dutch version of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) after traumatic brain injury (TBI)

BACKGROUND

Traumatic brain injury (TBI) is one of the most common neurological conditions. It can have wide-ranging physical, cognitive and psychosocial effects. Most people recover within weeks to months after the injury, but a substantial proportion are at risk of developing lasting post-concussion symptoms. The Rivermead Post-Concussion Syndrome Questionnaire (RPQ) is a short validated 16-items self-report instrument to evaluate post-concussive symptoms. The aim of this study was to test psychometrics characteristics of the current Dutch translation of the RPQ.

METHODS

To determine the psychometric characteristics of the Dutch RPQ, 472 consecutive patients six months after they presented with a traumatic brain injury in seven medical centers in the Netherlands (N = 397), and in two in Belgium (Flanders) (N = 75) took part in the study which is part of the large prospective longitudinal observational CENTER-TBI-EU-study. Psychometric properties at six months post TBI, were assessed using exploratory and confirmatory factor analyses. Sensitivity was analyzed by comparing RPQ scores and self-reported recovery status of patients with mild vs. moderate and severe TBI.

FINDINGS

The Dutch version of RPQ proved good, showing excellent psychometric characteristics: high internal consistency (Cronbach's α .93), and good construct validity, being sensitive to self-reported recovery status at six months post TBI. Moreover, data showed a good fit to the three dimensional structure of separate cognitive, emotional and somatic factors (Chi2 = 119; df = 117; p = .4; CFI = .99; RMSEA = .006), reported earlier in the literature.

DISCUSSION

Psychometric characteristics of the Dutch version of RPQ proved excellent to good, and can the instrument therefore be applied for research purposes and in daily clinical practice.

First real-world experience with mobile health telemonitoring in adult patients with congenital heart disease

BACKGROUND

Arrhythmias and heart failure are common and invalidating sequelae in adult patients with congenital heart disease (CHD). Mobile health (m-Health) enables daily monitoring and a timely response that might prevent deterioration. We present an observational prospective registry to evaluate feasibility of an m‑Health telemonitoring program for managing arrhythmia, heart failure and blood pressure in symptomatic adults with CHD.

METHODS

Symptomatic adult patients with CHD are enrolled in an m‑Health telemonitoring program, which evaluates single-lead ECG, blood pressure and weight measurements. In case of symptoms extra measurements could be performed. Data are collected by mobile apps, matched with individualised thresholds. Patients are contacted if thresholds were exceeded or if arrhythmias were found, for treatment adjustments or reassurance. Data on emergency care utilisation, hospitalisation and patient-reported outcome measures are used to assess quality of life and self-management.

RESULTS

129 symptomatic CHD patients were invited to participate, 55 participated. Reasons for refusing consent included too time consuming to participate in research (30) and to monitor vital signs (14). At baseline 22 patients were in New York Heart Association class ≥ II heart failure, 43 patients had palpitations or documented arrhythmias, and 8 had hypertension. Mean follow-up was 3.0 months, one patient dropped out, and adherence was 97%.

CONCLUSION

The first results indicate that this program is feasible with high adherence.