There is little association between prehospital delay, persistent symptoms, and post-discharge healthcare utilization in patients evaluated for acute coronary syndrome

AIMS

Test for an association between prehospital delay for symptoms suggestive of acute coronary syndrome (ACS), persistent symptoms, and healthcare utilization (HCU) 30-days and 6-months post hospital discharge.

BACKGROUND

Delayed treatment for ACS increases patient morbidity and mortality. Prehospital delay is the largest factor in delayed treatment for ACS.

METHODS

Secondary analysis of data collected from a multi-center prospective study. Included were 722 patients presenting to the Emergency Department (ED) with symptoms that triggered a cardiac evaluation. Symptoms and HCU were measured using the 13-item ACS Symptom Checklist and the Froelicher's Health Services Utilization Questionnaire-Revised instrument. Logistic regression models were used to examine hypothesized associations.

RESULTS

For patients with ACS (n = 325), longer prehospital delay was associated with fewer MD/NP visits (OR, 0.986) at 30 days. Longer prehospital delay was associated with higher odds of calling 911 for any reason (OR, 1.015), and calling 911 for chest related symptoms (OR, 1.016) 6 months following discharge. For non-ACS patients (n = 397), longer prehospital delay was associated with higher odds of experiencing chest pressure (OR, 1.009) and chest discomfort (OR, 1.008) at 30 days. At 6 months, longer prehospital delay was associated with higher odds of upper back pain (OR, 1.013), palpitations (OR 1.014), indigestion (OR, 1.010), and calls to the MD/NP for chest symptoms (OR, 1.014).

CONCLUSIONS

There were few associations between prehospital delay and HCU for patients evaluated for ACS in the ED. Associations between prolonged delay and persistent symptoms may lead to increased HCU for those without ACS.

Unusual Fatigue and Failure to Utilize EMS Are Associated With Prolonged Prehospital Delay for Suspected Acute Coronary Syndrome

BACKGROUND

Rapid reperfusion reduces infarct size and mortality for acute coronary syndrome (ACS), but efficacy is time dependent. The aim of this study was to determine if transportation factors and clinical presentation predicted prehospital delay for suspected ACS, stratified by final diagnosis (ACS vs. no ACS).

METHODS

A heterogeneous sample of emergency department (ED) patients with symptoms suggestive of ACS was enrolled at 5 US sites. Accelerated failure time models were used to specify a direct relationship between delay time and variables to predict prehospital delay by final diagnosis.

RESULTS

Enrolled were 609 (62.5%) men and 366 (37.5%) women, predominantly white (69.1%), with a mean age of 60.32 (±14.07) years. Median delay time was 6.68 (confidence interval 1.91, 24.94) hours; only 26.2% had a prehospital delay of 2 hours or less. Patients presenting with unusual fatigue [time ratio (TR) = 1.71, P = 0.002; TR = 1.54, P = 0.003, respectively) or self-transporting to the ED experienced significantly longer prehospital delay (TR = 1.93, P < 0.001; TR = 1.71, P < 0.001, respectively). Predictors of shorter delay in patients with ACS were shoulder pain and lightheadedness (TR = 0.65, P = 0.013 and TR = 0.67, P = 0.022, respectively). Predictors of shorter delay for patients ruled out for ACS were chest pain and sweating (TR = 0.071, P = 0.025 and TR = 0.073, P = 0.032, respectively).

CONCLUSION

Patients self-transporting to the ED had prolonged prehospital delays. Encouraging the use of EMS is important for patients with possible ACS symptoms. Calling 911 can be positively framed to at-risk patients and the community as having advanced care come to them because EMS capabilities include 12-lead ECG acquisition and possibly high-sensitivity troponin assays.

Protein Cytokines, Cytokine Gene Polymorphisms, and Potential Acute Coronary Syndrome Symptoms

The purpose of this study was to determine whether relationships exist among protein cytokines, cytokine gene polymorphisms, and symptoms of potential acute coronary syndrome (ACS). Participants included 438 patients presenting to the emergency department (ED) whose symptoms triggered a cardiac evaluation (206 ruled in and 232 ruled out for ACS). Presence or absence of 13 symptoms was recorded upon arrival. Levels of tumor necrosis factor α (TNF-α), interleukin (IL)-6, and IL-18 were measured for all patients. A pilot analysis of 85 patients (ACS = 49; non-ACS = 36) genotyped eight single-nucleotide polymorphisms (SNPs; four TNF and four IL6 SNPs). Logistic regression models were tested to determine whether cytokines or SNPs predicted symptoms. Increased levels of TNF-α and IL-6 were associated with a decreased likelihood of chest discomfort for all patients. Increased levels of IL-6 were associated with a lower likelihood of chest discomfort and chest pressure for ACS patients, and an increased likelihood of shoulder and upper back pain for non-ACS patients. Elevated IL-18 was associated with an increased likelihood of sweating in patients with ACS. Of the four TNF SNPs, three were associated with shortness of breath, lightheadedness, unusual fatigue, and arm pain. In all, protein cytokines and TNF polymorphisms were associated with 11 of 13 symptoms assessed. Future studies are needed to determine the predictive ability of cytokines and related SNPs for a diagnosis of ACS or to determine whether biomarkers can identify patients with specific symptom clusters.

Trajectories of Depression and Anxiety in Latina Breast Cancer Survivors

OBJECTIVES

To identify subgroups of Latina breast cancer survivors with unique trajectories of depression and anxiety and examine predictors associated with these subgroups.

SAMPLE & SETTING

Secondary analysis of Latina breast cancer survivors (N = 293) from three psychosocial intervention studies.

METHODS & VARIABLES

Depression and anxiety were assessed at intake and at weeks 8 and 16. Group-based growth mixture modeling was used to identify subgroups who followed distinct trajectories of depression and anxiety. Multinomial logistic regression models were used to identify predictors of trajectory-based subgroup membership.

RESULTS

Three trajectories emerged for depression.

IMPLICATIONS FOR NURSING

Latina women treated for breast cancer are at an elevated risk for depression and anxiety and follow distinct trajectories of these symptoms. Psychosocial interventions are needed to manage these symptoms, particularly for subgroups in which depression and anxiety persist or worsen.

Abstract WP509: Stroke Survivors’ Perceptions of Well-Being and Recovery After a Tai Chi Exercise Intervention

Background: Tai Chi exercise is known to improve health and well-being among older adults. Most Tai Chi studies conducted among stroke survivors have focused on physical functioning, whereas inclusion of stroke survivors’ feelings and perceptions of Tai Chi is lacking. Understanding the benefits and difficulties of participating in Tai Chi exercise from stroke survivors’ perspectives is important for healthcare providers to investigate.

Objective: Using storytelling, we sought to identify stroke survivors’ feelings and perceptions of participating in a Tai Chi intervention during their post-stroke recovery.

Methods: This descriptive qualitative study examined stories from community-dwelling stroke survivors, collected as part of a larger randomized clinical trial. Participants (n=17) were on average 71 years old (range=54-87 years) mainly men (65%); and had the option of writing their own story or having someone write it for them. To examine these stories, an inductive content analysis approach was used with a priori theoretical codes (and sub-codes): 1.) Feelings (confidence, enjoy, hopeful, helpful, other), and 2.) Perceptions of Impact (physical abilities, mental/cognitive abilities, challenges, other). Lincoln and Guba’s criteria were followed to ensure trustworthiness of the data.

Results: When examining these stories, the majority of stroke survivors felt that participating in a Tai Chi intervention was helpful and enjoyable, and some felt improved confidence. Further, they perceived the impact of Tai Chi on their post-stroke recovery led to improved physical abilities, such as better balance and walking, along with fewer falls. Likewise, stroke survivors perceived that their mental and cognitive abilities improved due to learning a sequence of Tai Chi movements. There were no perceived challenges. Overall, they perceived the impact of Tai Chi helped them to be more independent, move forward, develop friendships and make connections in their communities again.

Conclusions: Using storytelling, healthcare providers can discuss the benefits of Tai Chi and then relate the feelings and perceptions of other stroke survivors’ experiences to encourage engagement in regular physical activity to aid in the post-stroke recovery process.

Acute Myocardial Infarction Experience Among Mexican American Women

INTRODUCTION

Health disparities in cardiovascular disease risk factors affect a burgeoning segment of the U.S. population-Mexican American (MA) women. MAs experience disparities in the prevalence of heart disease risk factors. However, there are no studies describing acute myocardial infarction (AMI) symptoms unique to this Hispanic subgroup. The aim of the study was to describe MA women's AMI symptom experience.

METHODS

A qualitative descriptive design guided the study. Data were collected in semistructured interviews with eight MA women who reported having an AMI within the past 18 months. Data were analyzed using qualitative content analysis.

RESULTS

The overall theme was "The nature of my AMI experience." This theme, composed of four categories, described their prodromal and AMI symptom experience: my perception of AMI, having a heart attack, AMI symptoms, and actions taken. No participants recognized prodromal or symptoms of AMI. Asphyxiatia (asphyxiating) and menos fuerza (less strength) were commonly described symptoms.

CONCLUSION

Participants attributed both prodromal and AMI symptoms to noncardiac causes, self-managed symptoms, and delay in seeking health care. Findings suggest that community engagement through culturally tailored family-focused heart health education for MA women and their family members may improve recognition of prodromal symptoms.

Using cognitive interviews to improve a Psychological-Social-Spiritual Healing instrument: Voices of aging African Americans with serious illness

AIM

The purpose of this study was to contribute to content validity, by providing input into the linguistic and pragmatic validities, of a 53 item Psychological-Social-Spiritual Healing instrument.

BACKGROUND

Discovery of cultural values and beliefs from African American elders' experiences of illness provides insight for development of more culturally sensitive instruments.

METHODS

Through an exploratory descriptive design, this study used cognitive interviewing methods to examine linguistic and pragmatic validity of the Psychological-Social-Spiritual Healing instrument, from the perspectives of aging seriously ill AAs. Participants were recruited from urban Jackson, MS from community settings from October 2014 to January 2015. With a purposefully chosen sample of seriously ill African Americans elders (N=15), and using the method of cognitive interviewing, responses related to cultural relevance, clarity and meaning of the 53 items of the instrument were collected. This in-depth query of items was accomplished through the use of both verbal probing and think aloud methods of cognitive interviewing.

RESULTS

Thirty-seven items were retained. Eight items were revised. Eight items were deleted.

CONCLUSIONS

From the expert input of seriously ill African American elders, a systematic decision-making process of item retention, revision or deletion led to the development of a more culturally sensitive Psychological-Social-Spiritual Healing instrument.

African American Elders' Serious Illness Experiences: Narratives of "God Did," "God Will," and "Life Is Better"

The foundation of culturally sensitive patient-centered palliative care is formed from one's social, spiritual, psychological, and physical experiences of serious illness. The purpose of this study was to describe categories and patterns of psychological, social, and spiritual healing from the perspectives of aging seriously ill African American (AA) elders. Using narrative analysis methodology, 13 open-ended interviews were collected. Three main patterns were "prior experiences," "I changed," and "across past, present experiences and future expectations." Themes were categorized within each pattern: been through it . . . made me strong, I thought about . . . others, went down little hills . . . got me down, I grew stronger, changed priorities, do things I never would have done, quit doing, God did and will take care of me, close-knit relationships, and life is better. "Faith" in God helped the aging seriously ill AA elders "overcome things," whether their current illness or other life difficulties.

Impact of comorbidities by age on symptom presentation for suspected acute coronary syndromes in the emergency department

BACKGROUND

It is estimated half of acute coronary syndrome (ACS) patients have one or more associated comorbid conditions.

AIMS

Aims were to: 1) examine the prevalence of comorbid conditions in patients presenting to the emergency department with symptoms suggestive of ACS; 2) determine if comorbid conditions influence ACS symptoms; and 3) determine if comorbid conditions predict the likelihood of receiving an ACS diagnosis.

METHODS

A total of 1064 patients admitted to five emergency departments were enrolled in this prospective study. Symptoms were measured on presentation to the emergency department. The Charlson Comorbidity Index (CCI) was used to evaluate group differences in comorbidity burden across demographic traits, risk factors, clinical presentation, and diagnosis.

RESULTS

The most prominent comorbid conditions were prior myocardial infarction, diabetes without target organ damage, and chronic lung disease. In younger ACS patients, higher CCI predicted less chest pain, chest discomfort, unusual fatigue and a lower number of symptoms. In older ACS patients, higher CCI predicted more chest discomfort, upper back pain, abrupt symptom onset, and greater symptom distress. For younger non-ACS patients, higher CCI predicted less chest pain and symptom distress. Higher CCI was associated with a greater likelihood of receiving an ACS diagnosis for younger but not older patients with suspected ACS.

CONCLUSIONS

Younger patients with ACS and higher number of comorbidities report less chest pain, putting them at higher risk for delayed diagnosis and treatment since chest pain is a hallmark symptom for ACS.

Symptom clusters in patients presenting to the emergency department with possible acute coronary syndrome differ by sex, age, and discharge diagnosis

OBJECTIVES

To identify classes of individuals presenting to the ED for suspected ACS who shared similar symptoms and clinical characteristics.

BACKGROUND

Describing symptom clusters in undiagnosed patients with suspected ACS is a novel and clinically relevant approach, reflecting real-world emergency department evaluation procedures.

METHODS

Symptoms were measured using a validated 13-item symptom checklist. Latent class analysis was used to describe symptom clusters.

RESULTS

The sample of 874 was 37% female with a mean age of 59.9 years. Four symptom classes were identified: Heavy Symptom Burden (Class 1), Chest Symptoms and Shortness of Breath (Class 2), Chest Symptoms Only (Class 3), and Weary (Class 4). Patients with ACS were more likely to cluster in Classes 2 and 3. Women and younger patients were more likely to group in Class 1.

CONCLUSIONS

Further research is needed to determine the value of symptom clusters in the ED triage and management of suspected ACS.

Implementing clinical research in the high acuity setting of the emergency department

INTRODUCTION

Clinical research in the emergency department provides supporting evidence needed for the development of practice guidelines, such as door-to-needle and door-to-balloon times for treatment of acute coronary syndromes, and is vital to improvements in patient outcomes. The purpose of this article is to describe barriers and lessons learned in launching a multisite clinical research study of symptoms of acute coronary syndromes in the emergency department.

METHODS

Participants included ED and research staff in 4 busy emergency departments in 3 states. At each step of the study launch, the principal investigator at the clinical site identified barriers that either were anticipated or experienced and discussed them with the site staff and study principal investigator to validate the issue as a barrier. Orientation sessions and ongoing communication between clinicians, research staff, and the research study team provided opportunity for adjustment of study protocols.

RESULTS

Barriers were lack of staff engagement in research, difficulty identifying eligible patients, perception of interference in clinical care, variability in research staff education and training, patient refusals, nurses' perceptions of lack of time, undifferentiated patients, and time-sensitive quality improvement indicators necessitating acceleration in care.

DISCUSSION

Important strategies to overcome barriers were developed, including identification and support of unit champions in emergency nursing and medicine; minor protocol modifications to improve enrollment goals; development of specific written expectations, roles, research protocols, and algorithms; and sharing successes among sites.

Determining Severe Respiratory Distress in Older Out-of-Hospital Patients

OBJECTIVES

This preliminary investigation represents the first step in developing a clinical decision rule (CDR) to assist out-of-hospital providers in caring for older patients in respiratory distress. The specific aims of the study were: 1) to identify up to ten candidate clinical indicators of severe respiratory distress in older out-of-hospital patients and 2) to determine the feasibility of obtaining data on these indicators from out-of-hospital treatment records, and of obtaining a measure of severe respiratory distress from the emergency department (ED) medical record.

METHODS

This mixed-methods study included a qualitative component to list possible clinical indicators of severe respiratory distress, and a Delphi survey N = six experts) to reduce the comprehensive list that resulted (aim 1). The feasibility of gathering clinical indicators and a measure of severe distress was evaluated using a retrospective chart review (N = 640) of out-of-hospital and ED medical records (aim 2).

RESULTS

Nine clinical indicators were identified: level of consciousness/mentation, inability to speak in full sentences, position of the patient on arrival, decreased oxygen saturation, accessory muscle use, dyspnea, increased respiratory effort, altered respiratory rate, and retractions. There were sufficient data available on all indicators except dyspnea and retractions; a measure of severe distress was readily obtained from the ED medical record.

CONCLUSION

Medical record data were available on seven out-of-hospital clinical indicators and an ED measure of severe distress. Further work needs to be done to refine the operational definitions of the indicators and to standardize the way they are documented in the out-of-hospital medical record.

Symptoms of acute coronary syndrome in women with diabetes: an integrative review of the literature

OBJECTIVE

To review studies comparing multiple acute coronary syndrome (ACS) symptoms in white and Latina women with and without diabetes.

METHODS

This empirical integrative review summarizes 8 studies and identifies the limitations of research to date.

RESULTS

There are conflicting results about acute coronary syndrome (ACS) symptoms in women with diabetes. Differences were found in associated ACS symptoms and symptom characteristics; however, some studies found no differences in frequency of chest pain by diabetic status. Diabetes is an independent predictor of "atypical" presentation of acute myocardial infarction in women, and research to date suggests that shortness of breath may be an important ACS symptom in women with diabetes.

CONCLUSIONS

There is a paucity of literature on ACS symptoms in women, particularly Latina women, with diabetes, and results are inconclusive. Future research should examine the full range of ACS symptoms in multiethnic samples of women with diabetes.

Rural Women Walking for Health

The purpose of this qualitative study is to describe rural women's barriers and motivators for participation in a walking program. Twenty rural women, ages 22 to 65, participated in a 12-week walking program. Data from field notes and focus groups were analyzed using qualitative content analysis. Data were inductively coded, codes were categorized into themes, and themes were classified as barriers or motivators to adopting a walking program. Three main barriers are identified: balancing family and self, chronic illness gets in the way of routine, and illness or injury breaks routine. Seven motivators are identified: being part of a group, group camaraderie, learning, pacesetter, seeing progress, energizing, and I am a walker. Women report that family responsibilities are a powerful and pervasive barrier. Motivators center on the importance of group interaction. This qualitative study increases our understanding of rural women's barriers and motivators to embarking on and sustaining a regular walking routine.

Heart-to-Heart: promoting walking in rural women through motivational interviewing and group support

BACKGROUND

Walking can significantly increase cardiorespiratory fitness and thereby reduce the incidence of heart disease in women. However, there is a paucity of research aimed at increasing walking in rural women, a high-risk group for heart disease and one for which exercise strategies may pose particular challenges.

PURPOSE

This study tested Heart-to-Heart (HTH), a 12-week walking program, designed to increase fitness through walking in rural women. Heart-to-Heart integrated individual-oriented strategies, including motivational interviewing, and group-based strategies, including team building.

METHODS

Forty-six rural women were randomized to either HTH or a comparison group. The primary outcome of cardiorespiratory fitness and secondary outcomes of self-efficacy and social support were measured preintervention and post-intervention. Group differences were analyzed with repeated-measures analysis of variance.

RESULTS

Women in HTH group had a greater improvement in cardiorespiratory fitness (P =.057) and in social support (P =.004) compared with women in the comparison group. Neither group of women experienced a change in exercise self-efficacy (P =.814).

CONCLUSIONS

HTH was effective in improving cardiorespiratory fitness in a sample of rural women. Further research is needed to refine HTH and determine the optimal approach in rural women to increase their walking.

State of the Heart: Building Science to Improve Women’s Cardiovascular Health

Cardiovascular disease is the No. 1 killer of women in the United States, and marked disparities in cardiovascular health exist between women and men and among groups of women. Coronary heart disease is underdiagnosed, undertreated, and underresearched in women. Women with suspected heart disease are less likely than men to receive indicated diagnostic tests and procedures; sex-based biases in treatment of myocardial infarction persist; and women continue to be underrepresented in cardiovascular research. An accumulating body of literature points to 3 major explanations: sex-based physiology, provider bias, and psychosocial influences. Women’s acute and prodromal signs and symptoms of myocardial infarction have been described, yet women have difficulty recognizing and acting on these indications. Primary and secondary prevention of heart disease in women is imperative; although the science is lacking in several areas, existing evidence on diet, hormone therapy, aspirin, physical activity and obesity, and diabetes can serve as the basis for interventions. Potentially, large impacts could be made on women’s morbidity and mortality if current scientific knowledge were implemented. The state of the science of women and heart disease is reviewed, with a focus on those areas with the greatest potential to address the needs of women’s cardiovascular status. Key gaps in the science and remaining questions are presented as a research agenda for the coming decade.

State of the heart: building science to improve women's cardiovascular health

Cardiovascular disease is the No. 1 killer of women in the United States, and marked disparities in cardiovascular health exist between women and men and among groups of women. Coronary heart disease is underdiagnosed, undertreated, and under-researched in women. Women with suspected heart disease are less likely than men to receive indicated diagnostic tests and procedures; sex-based biases in treatment of myocardial infarction persist; and women continue to be underrepresented in cardiovascular research. An accumulating body of literature points to 3 major explanations: sex-based physiology, provider bias, and psychosocial influences. Women's acute and prodromal signs and symptoms of myocardial infarction have been described, yet women have difficulty recognizing and acting on these indications. Primary and secondary prevention of heart disease in women is imperative; although the science is lacking in several areas, existing evidence on diet, hormone therapy, aspirin, physical activity and obesity, and diabetes can serve as the basis for interventions. Potentially, large impacts could be made on women's morbidity and mortality if current scientific knowledge were implemented. The state of the science of women and heart disease is reviewed, with a focus on those areas with the greatest potential to address the needs of women's cardiovascular status. Key gaps in the science and remaining questions are presented as a research agenda for the coming decade.

Understanding Treatment-Seeking Delay in Women with Acute Myocardial Infarction: Descriptions of Decision-Making Patterns

• Background Women delay seeking treatment for symptoms of acute myocardial infarction longer than men delay. Women’s delay time has not been thoroughly characterized.

• Objectives To qualitatively describe the period between the onset of symptoms of myocardial infarction and enactment of the decision to seek care (decision time) and to identify common patterns of cognitive, affective, and behavioral responses to the symptoms (decision trajectories).

• Methods In this qualitative study, 52 women were asked in semistructured interviews to describe the symptoms and related thoughts, decisions, and actions from the onset of symptoms of myocardial infarction to arrival at the hospital. Narrative analysis was used to examine the stories and to identify patterns of decision-making behavior.

• Results Six common patterns of behavior during the decision time were identified: knowing and going, knowing and letting someone take over, knowing and going on the patient’s own terms, knowing and waiting, managing an alternative hypothesis, and minimizing. The patterns were further grouped as knowing or managing. Women in the 2 groups (knowing and managing) differed primarily in their awareness and interpretations of the symptoms and in their patterns of behavior in seeking treatment.

• Conclusions Women’s delay in seeking treatment for symptoms of myocardial infarction can be categorized into distinct patterns. Clinicians can use knowledge of these patterns to detect responses and situations that can decrease decision time in future cardiac events and to educate women about how to respond to cardiac symptoms.

Understanding treatment-seeking delay in women with acute myocardial infarction: descriptions of decision-making patterns

BACKGROUND

Women delay seeking treatment for symptoms of acute myocardial infarction longer than men delay. Women's delay time has not been thoroughly characterized.

OBJECTIVES

To qualitatively describe the period between the onset of symptoms of myocardial infarction and enactment of the decision to seek care (decision time) and to identify common patterns of cognitive, affective, and behavioral responses to the symptoms (decision trajectories).

METHODS

In this qualitative study, 52 women were asked in semistructured interviews to describe the symptoms and related thoughts, decisions, and actions from the onset of symptoms of myocardial infarction to arrival at the hospital. Narrative analysis was used to examine the stories and to identify patterns of decision-making behavior.

RESULTS

Six common patterns of behavior during the decision time were identified: knowing and going, knowing and letting someone take over, knowing and going on the patient's own terms, knowing and waiting, managing an alternative hypothesis, and minimizing. The patterns were further grouped as knowing or managing. Women in the 2 groups (knowing and managing) differed primarily in their awareness and interpretations of the symptoms and in their patterns of behavior in seeking treatment.

CONCLUSIONS

Women's delay in seeking treatment for symptoms of myocardial infarction can be categorized into distinct patterns. Clinicians can use knowledge of these patterns to detect responses and situations that can decrease decision time in future cardiac events and to educate women about how to respond to cardiac symptoms.

Learning through connections with others: women's cardiac symptoms

Conducting group sessions in which women can share experiences, develop connections, and learn from each other may potentially be a powerful health educational tool. In a focus group conducted for evaluative feedback, the authors found that women began spontaneously sharing their experiences and feelings, receiving validation, and learning from each other almost from the start of the group session. The participants who were dissimilar in age, ethnicity/race, and socioeconomic status developed a strong connection based on the common experience of having had a heart attack. Although the participants had received patient education after their heart attack, they learned new information about cardiac symptoms and how to respond to them in the group session. This case example is a compelling reminder that women learn through connections. Therefore, a group approach to health education that acknowledges the salience of personal experiences, the experiences of others, the development of connections, and the exchange of information may provide a meaningful learning environment. Further research needs to be conducted to determine if conducting group appointments for women that fosters the development of connections and the exchange of information enriches the learning environment and enhances patient education.

Treatment-seeking delay among women with acute myocardial infarction: decision trajectories and their predictors

BACKGROUND

Women's delay in seeking treatment for acute myocardial infarction symptoms results in higher rates of mortality and morbidity for women.

OBJECTIVES

To describe decision trajectories used by women when experiencing symptoms of acute myocardial infarction, and to identify predictors of the decision trajectory used by women with acute myocardial infarction.

METHODS

A cross-sectional, descriptive design was used. The nonprobability sample included 52 women hospitalized for acute myocardial infarction. To elicit descriptions of decision making, focused, semistructured interviews were used in this mixed-methods study. Predictors of decision trajectories were measured with standardized instruments among the same women. Narrative analysis was used to examine the stories from the qualitative data and to identify decision trajectory types. Discriminant analysis was used to predict trajectory type membership.

RESULTS

The median delay time was 4.25 hours. Most of the women used one of two trajectory types: knowing (defined as those women who knew almost immediately that they would seek help, n = 25) and managing (those women who managed an alternative hypothesis or minimized their symptoms, n = 23). Discriminant analysis correctly classified 71% (chi [4] = 11.2; n = 48; p =.02) of the cases into trajectory types on the basis of four predictor variables: social support, personal control, heart disease threat, and neuroticism.

DISCUSSION

Women's behaviors during the period between onset of acute myocardial infarction symptoms and treatment seeking can be categorized into a small number of patterns termed decision trajectories. A profile of sociostructural and intrapersonal factors with potential for predicting behavior in relation to future coronary events was developed.

Sampling challenges in end-of-life research: case-finding for family informants

BACKGROUND

Research on end-of-life care is hampered by challenges in accessing appropriate subjects for data collection. Although families of decedents are rich sources of research data, they are underutilized, most likely due to the access difficulties they present to investigators.

OBJECTIVES

To describe case-finding strategies that can achieve a large and representative sample of family informants for research studies about end-of-life care.

METHODS

Case-finding strategies were developed and honed over the course o fthree epidemiological studies on end-of-life care. Family location information was culled from death certificates and a combination of public and commercial sources.

RESULTS

The researchers generated large random samples of study-eligible decedents and, using the case-finding strategies described, recruited family members of decedents as informants. By the third study, two-thirds of family members were located and interviewed within the narrow time frame of 2-5 months following the death of their loved one.

DISCUSSION

Epidemiological studies on end-of-life, using large random samples of decedents and their family members, are feasible when armed with an array of effective case finding strategies.

Women's risk of decision delay in acute myocardial infarction: implications for research and practice

Cardiovascular disease is the leading cause of death for women in the United States. Despite recent advances in treatment options for acute myocardial infarction (AMI), there has not been similar progress in decreasing the time between symptom onset and the decision to seek medical help (labeled "decision delay") and therefore availability of such treatments. Women delay longer than men before seeking help for symptoms of AMI, yet few studies have analyzed decision delay by gender. Factors studied to date do not adequately explain the differences in decision delay among women or between women and men with AMI. Additional research is needed to guide interventions to limit decision delay in women at risk for AMI. Until then, clinicians should use existing general guidelines to assist women at risk of AMI to avoid decision delay.

Family reports of barriers to optimal care of the dying

BACKGROUND

In response to intense national pressure to improve care of the dying, efforts have been made to determine problems or barriers to optimal care. However, prior research is limited by such factors as setting, focus, and sampling.

OBJECTIVES

The purpose of this study was to identify barriers to optimal care of a population-based representative sample of decedents across a full range of settings in which death occurred.

METHODS

Families were contacted 2 to 5 months after decedents' deaths by using data on their death certificates. Over a 14-month period, telephone interviews were conducted with 475 family informants who had been involved in caring for the patient in the last month of life. Interviews were standardized by use of a 58-item structured questionnaire.

RESULTS

Data show a high frequency of advance planning (68%) and a high level of respect by clinicians for patient-family preferences about end-of-life location and treatment decisions. Family satisfaction with care was generally high, even though pain was a problem in one third of the sample of decedents.

CONCLUSIONS

Barriers to optimal care of the dying remain, despite a generally positive overall profile; barriers include level of pain and management of pain, as well as some dissatisfaction with physician availability.

Family reports of pain in dying hospitalized patients: a structured telephone survey

OBJECTIVES

To see how often families in Oregon reported moderate to severe pain in dying patients in late 1998 compared with late 1997.

DESIGN

A systematic random sample of death certificates was used to identify family members of decedents who died in a hospital setting between October 1 and December 31, 1998. A structured telephone interview was used to obtain data.

PARTICIPANTS

Family members of 103 decedents (who died in hospitals 2 to 4 months before data collection) were identified with the use of death certificates.

RESULTS

In late 1998, 56 family members (54%) reported that their loved one experienced moderate to severe pain in the last week of life.

CONCLUSIONS

Family reports of moderate to severe pain in dying hospitalized Oregonians remain high. The influence of environmental factors on pain management may have implications for practice and policy nationwide.

Meaning of illness for women with coronary heart disease

OBJECTIVE

The goal of this study was to describe the meaning of an acute cardiac event and cardiac illness for women with coronary heart disease.

DESIGN

A longitudinal, descriptive design was used.

SETTING

The study was undertaken at a tertiary care hospital in the Pacific Northwest.

PATIENTS

The study considered a purposive sample of 6 women ranging in age from 47 to 67 years, who were hospitalized for coronary heart disease (3 for coronary bypass surgery and 3 for coronary angioplasty).

METHODS

We completed a series of 2 focused semistructured interviews, 1 while women were hospitalized for coronary heart disease and the second 3 months later. The qualitative method of grounded theory guided the collection and analysis of data.

RESULTS

The meaning of illness for women with coronary heart disease evolved over time in a process we termed seeking understanding. After the onset of symptoms, women described 3 responses: denial, acknowledging, and being scared. These did not occur in sequence, but as iterative processes. They described 4 additional themes after obtaining medical attention: naming, seriousness of illness, comparing self with others, and causality.

CONCLUSIONS

A substantive theory of seeking understanding was described in this study and contributes to our understanding of meaning and behavior of women with coronary heart disease. Future research with use of similar methods may lead to an understanding of women's decision-making process regarding their illness.

Oregon's low in-hospital death rates: what determines where people die and satisfaction with decisions on place of death?

Where Americans die is much more influenced by what part of the country they live in than by what their preferences are for location of death. Although most Americans report a preference for death at home, a majority still die in acute care hospitals. We describe the experiences of patients who died in Oregon (the state that currently has the lowest in-hospital death rate in the United States--31%) and the views of their families. We examine the factors influencing respect for dying patients' preferred location of death. Data from Oregon studies confirm that decisions to avoid hospital admission are far more common than discharge of the actively dying. Do-not-resuscitate orders were reported for 91% of nursing home residents in one study and living wills were reported for 67% of a random sample of adult Oregon decedents in a second study. In the second study, decisions not to start treatment were far more common than decisions to stop treatment (79% compared with 21%). Only 2.4% of families reported that "too little" treatment was given. Throughout the United States, use and availability of beds in acute care hospitals have been confirmed to be the principal determining factors in location of death. Within that constraint, however, the availability of other resources and services both facilitates the process of arranging for patients to die outside the hospital and improves satisfaction with the quality of terminal care.