Patient-Centered Adult Cardiovascular Care: A Scientific Statement From the American Heart Association

Patient-centered care is gaining widespread acceptance by the medical and lay communities and is increasingly recognized as a goal of high-quality health care delivery. Patient-centered care is based on ethical principles and aims at establishing a partnership between the health care team and patient, family member, or both in the care planning and decision-making process. Patient-centered care involves providing respectful care by tailoring management decisions to patients' beliefs, preferences, and values. A collaborative care approach can enhance patient engagement, foster shared decision-making that aligns with patient values and goals, promote more personalized and effective cardiovascular care, and potentially improve patient outcomes. The objective of this scientific statement is to inform health care professionals and stakeholders about the role and impact of patient-centered care in adult cardiovascular medicine. This scientific statement describes the background and rationale for patient-centered care in cardiovascular medicine, provides insight into patient-oriented medication management and patient-reported outcome measures, highlights opportunities and strategies to overcome challenges in patient-centered care, and outlines knowledge gaps and future directions.

The Association of Unmet Palliative Care Needs and Physical Frailty With Clinical Outcomes: A Prospective Study of Adults With Heart Failure

BACKGROUND

People with heart failure, particularly those who are physically frail, experience complex needs that can be addressed by palliative care (PC). However, we have a limited understanding of how the intersection of unmet PC needs and physical frailty contributes to health-related quality of life (HRQOL) and risk for hospitalization or mortality.

OBJECTIVE

In this study, we sought to examine the association of unmet PC needs and physical frailty with clinical outcomes (baseline HRQOL and hospitalizations or mortality at 6 months).

METHODS

We recruited a convenience sample of community-dwelling persons with heart failure from an urban hospital system who were older than 50 years and hospitalized in the last year. We measured physical frailty using the FRAIL scale (nonfrail, 0-2; frail, 3-5), PC needs using the Integrated Palliative Outcome Scale (range, 0-58; higher scores indicating higher needs), and HRQOL using the Kansas City Cardiomyopathy Questionnaire (range, 0-100; higher scores indicate higher HRQOL). We performed multivariable linear regression to test the relationships between physical frailty, PC needs, and HRQOL, and multivariable logistic regression for associations with all-cause 6-month hospitalization or mortality. We also performed an exploratory analysis of 4 PC needs/frailty groups (high PC needs/frail, high PC needs/nonfrail, low PC needs/frail, low PC needs/nonfrail) with outcomes.

RESULTS

In our overall sample (n = 298), mean (SD) age was 68 (9.8) years, 37% were women (n = 108), 28% identified as Black/African American (n = 84), and 65% had heart failure with preserved ejection fraction (n = 194). Mean PC needs score was 19.7, and frail participants (n = 130, 44%) had a significantly higher mean PC needs score than nonfrail participants (P < .001). Those with higher PC needs (Integrated Palliative Care Outcome Scale ≥ 20) had significantly worse HRQOL (P < .001) and increased odds of hospitalization or mortality (odds ratio, 2.5; P < .01) compared with those with lower PC needs, adjusting for covariates. Physically frail participants had significantly worse HRQOL (P < .001) and higher odds of hospitalization or mortality at 6 months (odds ratio, 2.6; P < .01) than nonfrail participants, adjusting for covariates. In an exploratory analysis, physically frail participants with high PC needs had the lowest HRQOL score, with an average score of 28.6 points lower (P < .001) and 4.6 times higher odds of hospitalization or mortality (95% confidence interval, 2.03-10.43; P < .001) than low-needs/nonfrail participants.

CONCLUSION

Higher unmet PC needs and physical frailty, separately and in combination, were associated with lower HRQOL and higher odds of hospitalization or mortality. Self-reported PC needs and physical frailty assessment in clinical settings may improve identification of patients at the highest risk for poor HRQOL and hospitalization or mortality amenable to PC intervention.

Relationship Status and Quality Are Associated With Perceived Benefits of Caregiving for People With Heart Failure

BACKGROUND

"Benefit finding" is a strengths-based strategy for coping with medical illness that may be particularly useful for caregivers of people with heart failure given the highly fluctuating disease course.

OBJECTIVE

The aim of this study was to investigate benefit finding's association with the caregiver-care recipient relationship, depression, and burden at baseline and longitudinally.

METHODS

This is a longitudinal observational study of caregivers' benefit finding, relationship quality, depression, and burden. Correlation and multiple regression analyses identify baseline associations and predictors of 12-month change in benefit finding.

RESULTS

At baseline (n = 100; median, 60 years [interquartile range, 46-69]; 81% female, 70% partner/spouse), increased benefit finding correlated with higher relationship quality (r = 0.53; 95% confidence interval [CI], 0.38-0.67), lower depression (r = -0.33; 95% CI, -0.49 to -0.14), and lower burden (r = -0.31; 95% CI, -0.47 to -0.11). Twelve-month change in benefit finding was predicted by change in relationship quality (ß = 7.12; 95% CI, 0.62-13.61) but not depression or burden.

CONCLUSIONS

Relationship quality and benefit finding changed together over time. Interventions strengthening the caregiver-care recipient bond may be especially impactful for heart failure caregivers.

Promising Impact of Telenovela Intervention for Caregivers of Hospice Patients: A Pilot Study

BACKGROUND

Hospice family caregivers (HFCGs) support the needs of their loved ones but are at risk of developing distress and anxiety. NOVELA is a four-chapter telenovela-style educational video to support topics related to hospice caregiving. Telehealth visits are scheduled in 4 weekly sessions consisting of a chapter and subsequent discussion with an interventionist. This feasibility pilot study tested NOVELA's effect to change HFCGs' outcomes, session and outcome measure completion (defined a priori as >70%).

METHODS

This is a single-group pretest-posttest study of HFCGs of care recipients with PPS score >20% from 3 hospices in the U.S. Mid-Atlantic region. At baseline and at final posttest, participants completed a web-based survey assessing 3 outcomes: anxiety, self-efficacy, and satisfaction with intervention. Descriptive, t-test, and chi-square statistics were computed.

RESULTS

Participants in our study (N = 59) were mainly collage educated, White, female, adult children of home-bound people with a non-cancer diagnosis. Outcomes changed in the expected direction (P > .05) with higher self-efficacy (Cohen's d = -.08 [95% CI -.4 to .2) and lower anxiety (Cohen's d = .2 [95% CI -.1 to .5]) scores from final to baseline, 86% of HFCGs were satisfied or very satisfied with NOVELA, session (33/59) and outcome measure (43/59) completion averaged 68%.

CONCLUSION

Encouraging trends in NOVELA's estimation of effect suggests that NOVELA may buffer stressful aspects of hospice caregiving. However, further refinement of NOVELA is needed. Supporting HFCGs through supportive educational interventions may reduce distress and anxiety with broad implications for quality improvement.

Caregivers' Contributions to Heart Failure Self-care: An Updated Systematic Review

BACKGROUND

A previous systematic review reporting the contributions of informal, unpaid caregivers to patient heart failure (HF) self-care requires updating to better inform research, practice, and policy.

OBJECTIVE

The aim of this study was to provide an updated review answering the questions: (1) What specific activities do informal caregivers of adults with HF take part in related to HF self-care? (2) Have the activities that informal caregivers of adults with HF take part in related to HF self-care changed over time? (3) What are the gaps in the science?

METHODS

This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, CINAHL, EMBASE, and Cochrane CENTRAL databases were searched. Eligible studies involved an informal, unpaid caregiver of an adult with HF as a study variable or participant. Caregiving activities were benchmarked using the theory of self-care in chronic illness.

RESULTS

Two thousand one hundred fifty-four research reports were identified, of which 64 met criteria. Caregivers' contributions occurred in self-care maintenance (91%), monitoring (54%), and management (46%). Activities performed directly on or to the patient were reported more frequently than activities performed for the patient. Change over time involved the 3 domains differentially. Gaps include ambiguous self-care activity descriptions, inadequate caregiving time quantification, and underrepresented self-care monitoring, supportive, and communication activities.

CONCLUSIONS

Newly identified caregiver-reported activities support updating the theory of self-care in chronic illness to include activities currently considered ancillary to HF self-care. Identified gaps highlight the need to define specific caregiving activities, determine task difficulty and burden, and identify caregiver self-care strategy and education needs. Exposing the hidden work of caregiving is essential to inform policy and practice.

Identification of Fatigue Subtypes and Their Correlates in Prevalent Heart Failure: A Secondary Analysis of the Atherosclerosis Risk in Communities Study

BACKGROUND

Among patients with heart failure (HF), fatigue is common and linked to quality of life and functional status. Fatigue is hypothesized to manifest as multiple types, with general and exertional components. Unique subtypes of fatigue in HF may require differential assessment and treatment to improve outcomes. We conducted this study to identify fatigue subtypes in persons with prevalent HF in the ARIC study (Atherosclerosis Risk in Communities) and describe the distribution of characteristics across subtypes.

METHODS

We performed a cross-sectional analysis of 1065 participants with prevalent HF at ARIC visit 5 (2011-2013). We measured exertional fatigue using the Modified Medical Research Council Breathlessness scale and general fatigue using the Patient Reported Outcomes Measurement Information System fatigue scale. We used latent class analysis to identify subtypes of fatigue. Number of classes was determined using model fit statistics, and classes were interpreted and assigned fatigue severity rating based on the conditional probability of endorsing survey items given class. We compared characteristics across classes using multinomial regression.

RESULTS

Overall, participants were 54% female and 38% Black with a mean age of 77. We identified 4 latent classes (fatigue subtypes): (1) high general/high exertional fatigue (18%), (2) high general/low exertional fatigue (27%), (3) moderate general/moderate exertional fatigue (20%), and (4) low/no general and exertional fatigue (35%). Female sex, Black race, lower education level, higher body mass index, increased depressive symptoms, and higher prevalence of diabetes were associated with higher levels of general and exertional fatigue.

CONCLUSIONS

We identified unique subtypes of fatigue in patients with HF who have not been previously described. Within subtype, general and exertional fatigue were mostly concordant in severity, and exertional fatigue only occurred in conjunction with general fatigue, not alone. Further understanding these fatigue types and their relationships to outcomes may enhance our understanding of the symptom experience and inform prognostication and secondary prevention efforts for persons with HF.

Feasibility of a Multi-Component Strengths-Building Intervention for Caregivers of Persons With Heart Failure

Caregivers of persons with heart failure (HF) navigate complex care plans, yet support strategies often focus solely on meeting the needs of patients. We conducted a randomized waitlist control trial (N = 38) to test the feasibility and gauge initial effect size of the Caregiver Support intervention on quality of life, caregiver burden, and self-efficacy among HF caregivers. The intervention includes up to five remote, nurse-facilitated sessions. Components address: holistic caregiver assessment, life purpose, action planning, resources, and future planning. Caregivers were 93.3% female, 60% White, and 63.3% spouses. Average age was 59.4. Participants who completed the intervention reported high satisfaction and acceptability of activities. Between-group effect sizes at 16 and 32 weeks suggest improvement in quality of life (mental health) (.88; 1.08), caregiver burden (.31; .37), and self-efficacy (.63; .74). Caregivers found Caregiver Support acceptable and feasible. Findings contribute evidence that this intervention can enhance caregiver outcomes. Clinicaltrials.gov Identifier NCT04090749.

"Caregiving is teamwork…" Information sharing in home care for older adults with disabilities living in the community

AIM

We examined information sharing between direct care workers, family caregivers, and clinicians involved in the care of older adults with disabilities.

METHODS

Semi-structured interviews with N = 11 representatives of home care agencies ("residential service agencies" in Maryland).

RESULTS

Work system and process characteristics relevant to information sharing included: (1) using electronic management systems and patient portals to communicate within agencies and with clinicians, (2) implementing tools to gather information about client goals, preferences, and routines, and (3) relying on family members for information about clients' needs. Participants did not report differences in dementia-related care coordination; however, dementia-related adaptations involved additional considerations for navigating relationships with family and standardizing processes to communicate with clinicians.

CONCLUSION

Findings highlight care demands experienced by direct care workers and support calls to better coordinate information sharing between interdisciplinary care teams.

Acceptability and Feasibility of a Pain and Depressive Symptoms Management Intervention in Middle-Aged and Older African American Women

Background and Objectives

The intersection of race, gender, and age puts older African American women at high risk of experiencing comorbid pain and depressive symptoms. The purpose of this study was to assess the feasibility and acceptability of a 12-week behavioral activation intervention to target self-selected goals related to pain and depressive symptoms in middle-aged and older African American women.

Research Design and Methods

This randomized waitlist control study included 34 self-identified African American women, 50 years of age or older, with moderate-to-severe chronic pain and depressive symptoms. The intervention consisted of 8 in-person or virtual 1-hour visits with a nurse. Follow-up acceptability assessments were conducted with 10 participants.

Results

The average age of the participants was 64.8 (standard deviation [SD] 10.5). They reported an average pain intensity score of 7.0 (SD 1.9) out of 10 and an average Patient Health Questionnaire-9 depressive symptoms score of 11.9 (SD 4.0) at baseline. Of the 34 participants who consented, 28 (82.4%) women started the intervention and 23 (82.1%) completed the intervention. Participants described the study as useful and beneficial. Participants recommended including a group component in future iterations. Effect sizes at 12 weeks were -0.95 for depressive symptoms indicating a substantial decrease in experienced depressive symptoms, but pain intensity was virtually unchanged (+0.09).

Discussion and Implications

The findings of this study demonstrate that the intervention is acceptable among middle-aged and older African American women and their personal goals were met. Including a group component and identifying effective ways to decrease attrition rates will be key in the next steps of development for this intervention. It is crucial to provide tailored, nonpharmacological approaches to pain, and depression symptom management in older adult populations who experience inequities in pain and mental health outcomes. This study emphasizes the importance of participant-driven goal-setting interventions.

Analysis of action planning, achievement and life purpose statements in an intervention to support caregivers of persons with heart failure

BACKGROUND

Caregivers of persons living with heart failure (HF) experience uncertainty related to heart failure trajectory and caregiving demands. Caregiver Support is a nurse-led intervention consisting of a well-being assessment, development of a life purpose statement, and action planning related to self-care and support for caregivers.

OBJECTIVES

The goal of this study was to describe the caregivers' action plans, action plan achievement and life purpose statements.

METHODS

We used inductive content analysis to code life purpose statements and action plans by 2 coders. Descriptive statistics were used to describe the average number of action plans set per caregiver, the average number of themes coded per action plan and life purpose statement, and the status of goal achievement (i.e., by thematic domain, subdomains). Goal achievement was defined categorically: Achieved, not achieved, and not assessed. The achievement rate was calculated as the proportion of achieved action plans out of the total number of assessed action plans.

RESULTS

The sample (n = 22) was predominantly women, spousal caregivers, and an average age of 62±14.2 years. Thirty-six percent of caregivers were Black and 41% reported financial strain. Action plans comprised five categories: personal health and well-being, social support, home environment, instrumental support and other. The most common topics of life purpose statements were faith and self-care/actualization. Of 85 action plans, 69 were assessed and 66.7% were achieved.

CONCLUSIONS

These findings highlight the diversity of values and needs of caregivers and provides insights for additional person-centered support.

SHARING Choices: Lessons Learned from a Primary-Care Focused Advance Care Planning Intervention

BACKGROUND

Few advance care planning (ACP) interventions have been scaled in primary care.

PROBLEM

Best practices for delivering ACP at scale in primary care do not exist and prior efforts have excluded older adults with Alzheimer's Disease and Related Dementias (ADRD).

INTERVENTION

SHARING Choices (NCT#04819191) is a multicomponent cluster-randomized pragmatic trial conducted at 55 primary care practices from two care delivery systems in the Mid-Atlantic region of the U.S. We describe the process of implementing SHARING Choices within 19 practices randomized to the intervention, summarize fidelity to planned implementation, and discuss lessons learned.

OUTCOMES

Embedding SHARING Choices involved engagement with organizational and clinic-level partners. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 1215 conversations occurred. Most conversations (94.8%) were less than 45 minutes duration. Just 13.1% of ACP conversations included family. Patients with ADRD comprised a small proportion of patients who engaged in ACP. Implementation adaptations included transitioning to remote modalities, aligning ACP outreach with the Medicare Annual Wellness Visit, accommodating primary care practice flexibility.

LESSONS LEARNED

Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with practice staff; adapting implementation processes to fit the unique needs of two health systems; and modifying efforts to meet health system goals and priorities.

TIMS: A Mixed Methods Evaluation of the Impact of a Novel Chaplain Facilitated Recorded Interview Placed in the Medical Chart for the Medical Staff in an ICU During the COVID-19 Pandemic

The purpose of this study is to examine how a novel intervention known as TIMS, "This is My Story," impacted clinicians caring for patients during the COVID-19 pandemic in the medical intensive care unit (MICU) at the Johns Hopkins Hospital. An eight-question survey was administered to MICU staff on their experience with TIMS files for pre- and post-listening reflections. Qualitative interviews were conducted with 17 staff members who prospectively agreed to participate. A total of 97 pre-listening and 88 post-listening questionnaires were completed. Responses indicated that the audio recording was appropriate to discover more about the patient beyond the immediately observable and useful (98%), "considerably" increased staff empathy for the patient (74%), and thought it would "some" or "considerably" improve subsequent interactions with the patient's loved ones (99%). The qualitative analysis revealed that medical staff found the audio format easy to use and helpful in humanizing patients in their clinical practice. The study demonstrates that TIMS audio files are an important addition to the electronic medical record, enabling clinicians to practice with greater awareness of the patient's context and increased empathy for patients and families.

The Context of Caregiving in Heart Failure: A Dyadic, Mixed Methods Analysis

BACKGROUND

Caregiving for persons with heart failure (HF) varies based on the individual, family, and home contexts of the dyad, yet the dyadic context of HF caregiving is poorly understood.

OBJECTIVE

The aim of this study was to explore dyadic perspectives on the context of caregiving for persons with HF.

METHODS

Family caregivers and persons with HF completed surveys and semistructured interviews. Investigators also photographed caregiving areas to complement home environment data. Descriptive qualitative analysis resulted in 7 contextual domains, and each domain was rated as strength, need, or neutral. We grouped dyads by number of challenging domains of context, categorizing dyads as high (≥3 domains), moderate (1-2 domains), or minimal (0 domains) needs. Quantitative instruments included the 36-item Short Form Health Survey, ENRICHD Social Support, HF Symptom Severity, and Zarit Burden Interview. We applied the average score of each quantitative measure to the groups derived from the qualitative analysis to integrate data in a joint display.

RESULTS

The most common strength was the dyadic relationship, and the most challenging domain was caregiving intensity. Every dyad had at least 2 domains of strengths. Of 12 dyads, high-needs dyads (n = 3) had the worst average score for 7 of 10 instruments including caregiver and patient factors. The moderate-needs dyads (n = 6) experienced the lowest caregiver social support and mental health, and the highest burden.

CONCLUSION

Strengths and needs were evident in all patient-caregiver dyads with important distinctions in levels of need based on assessment of multiple contextual domains. Comprehensive dyadic and home assessments may improve understanding of unmet needs and improve intervention tailoring.

Recruitment, Retention and Intervention Delivery Experiences With Hospice Family Caregivers

BACKGROUND

Recruitment and attrition are inherently challenging issues in hospice research. We sought to describe strategies of recruitment, retention, and delivery of NOVELA (short for telenovela), an intervention for hospice family caregivers (HFCG).

METHODS

Statistics were kept of every referral, consenting participant, visit session, and intervention activity. We used the Social Marketing Mix Framework to describe recruiting strategies employed and lessons learned.

RESULTS

Two hospices in the U.S. Mid-Atlantic region referred 47 HFCG and N = 20 agreed to participate, out of which 50% (N = 10) completed all 4 sessions with an average of 2.8 sessions per person, each lasting an average duration of 13.5 minutes (range 8.0-25.7). The main reason for missing a session was a patient's death (N = 8). Successful recruitment strategies employed in NOVELA included: (a) intensive start-up hospice engagement, (b) remote recruitment and delivery of NOVELA, and (c) scheduling flexibility to work around caregivers' other demands.

CONCLUSION

The recruitment and intervention delivery had successes and challenges resulting in the identification of multiple opportunities to strengthen our strategy and inform future studies with HFCGs.

Palliative Care Needs of Physically Frail Community-Dwelling Older Adults With Heart Failure

CONTEXT

Physical frailty is emerging as a potential "trigger" for palliative care (PC) consultation, but the PC needs of physically frail persons with heart failure (HF) in the outpatient setting have not been well described.

OBJECTIVES

This study describes the PC needs of community dwelling, physically frail persons with HF.

METHODS

We included persons with HF ≥50 years old who experienced ≥1 hospitalization in the prior year and excluded those with moderate/severe cognitive impairment, hospice patients, or non-English speaking persons. Measures included the FRAIL scale (0-5: 0 = robust, 1-2 = prefrail, 3-5 = frail) and the Integrated Palliative Outcome Scale (IPOS) (17 items, score 0-68; higher score = higher PC needs). Multiple linear regression tested the association between frailty group and palliative care needs.

RESULTS

Participants (N = 286) had a mean age of 68 (range 50-92) were majority male (63%) and White (68%) and averaged two hospitalizations annually. Most were physically frail (44%) or prefrail (41%). Mean PC needs (IPOS) score was 19.7 (range 0-58). On average, participants reported 5.86 (SD 4.28) PC needs affecting them moderately, severely, or overwhelmingly in the last week. Patient-perceived family/friend anxiety (58%) weakness/lack of energy (58%), and shortness of breath (47%) were the most prevalent needs. Frail participants had higher mean PC needs score (26) than prefrail (16, P < 0.001) or robust participants (11, P < 0.001). Frail participants experienced an average of 8.32 (SD 3.72) moderate/severe/overwhelming needs compared to prefrail (4.56, SD 3.77) and robust (2.39, SD 2.91) participants (P < 0.001). Frail participants reported higher prevalence of weakness/lack of energy (83%), shortness of breath (66%), and family/friend anxiety (69%) than prefrail (48%, 39%, 54%) or robust (13%, 14%, 35%) participants (P < 0.001).

CONCLUSION

Physically frail people with HF have higher unmet PC needs than those who are nonfrail. Implementing PC needs and frailty assessments may help identify vulnerable patients with unmet needs requiring further assessment and follow-up.

DEPRESSION AND PAIN PERSEVERANCE THROUGH EMPOWERED RECOVERY (DAPPER) PILOT PROGRAM: A CASE STUDY ON TECHNOLOGY

There is a paucity of work focusing on the engagement of older African American women with technology. The aim of the pilot study was to test the Depression and Pain Perseverance through Empowered Recovery (DAPPER) program in a sample of older African American women living with pain and low mood (N=19). The research team hypothesized that most of the women would prefer virtual visits, thus both in-person and virtual options were available for program delivery. So far, of 11 participants, five women have opted to do in-person visits. When asked why, one participant said that having the nurse come to her house was “rewarding, [especially] when you live alone.” Another participant commented that she did not have a computer in her home. These findings demonstrate that older adults exist on a spectrum of comfort with and access to technology.

WHEN AND WHERE: LESSONS LEARNED ABOUT TECHNOLOGY FROM AN INTERVENTION FOR CAREGIVERS OF PERSONS WITH HEART FAILURE

Use of technology in older adult populations is growing, therefore it is important to understand opportunities for healthcare initiatives that support older adults using technology. The aim of the pilot study was to test Caregiver Support, a self-care and social support intervention, for caregivers of persons living with heart failure (N=24). Originally, the protocol was designed with in-person visits. We expected this option to reduce participant burden: the caregiver would not have to travel, and the interventionist would gain more insight about the home context to aid with intervention delivery. However, due to the COVID-19 pandemic, it became necessary to conduct the visits virtually. All participants completed the 5-component intervention via virtual meeting and there were no dropouts related to technology use. When asked about the virtual modality, participants emphasized the flexibility of virtual meetings. In summary, the intervention visits conducted virtually were perceived as a caregiver-centered approach.

Methods and operational aspects of human-centred design into research processes for individuals with multiple chronic conditions: A survey study

AIM

To examine ways in which human-centred design was integrated into a nursing school's research processes involving individuals with multiple chronic conditions.

DESIGN

Cross-sectional survey study.

METHODS

Three surveys were sent out, with surveys 1 and 2 involving faculty who had worked closely with design strategists and survey 3 as a school-wide survey eliciting experience with human-centred design, respectively.

RESULTS

Survey respondents (n = 7 for surveys 1 and 2 and n = 36 for survey 3) had no or minimal experience with human-centred design. Faculty respondents indicated it helped engaging various stakeholders, particularly in intervention development. Key lessons learned included: (1) the importance of designer involvement from study conception, (2) distinguishing a design strategist's skillset from strictly visual design, (3) challenges during the ethical review processes, and (4) sustainability of resources. The dynamic approach of human-centred design has benefited our efforts to advance the science of caring for individuals with multiple chronic conditions.

Multi-level correlates of received social support among heart transplant recipients in the international BRIGHT Study: a secondary analysis

AIMS

Social support is critical in follow-up of patients after heart transplant (HTx) and positively influences well-being and clinical outcomes such as medication adherence. The purpose of this study was to (i) explore received social support variation (emotional and practical) in HTx recipients at country and centre level and (ii) to assess multi-level correlates.

METHODS AND RESULTS

Secondary data analysis of the multi-level cross-sectional BRIGHT study was conducted in 36 HTx centres in 11 countries. Received social support related to medication adherence was measured with emotional and practical sub-scales. The Conceptual Model of Social Networks and Health guided selection of patient, micro (interpersonal and psychosocial), meso (HTx centre) and macro-level (country health system) factors. Descriptive statistics, intraclass correlations, and sequential multiple ordinal mixed logistic regression analysis were used. A total of 1379 adult HTx recipients were included. Patient level correlates (female sex, living alone, and fewer depressive symptoms) and micro-level correlates (higher level of chronic disease management and trust in the healthcare team) were associated with better emotional social support. Similarly, patient level (living alone, younger age, and male sex), micro-level and meso-level (patient and clinician-rated higher level of chronic disease management) were associated with better practical social support. Social support varied at country and centre levels for emotional and practical dimensions.

CONCLUSIONS

Social support in HTx recipients varies by country, centre, and was associated with multi-level correlates. Qualitative and longitudinal studies are needed to understand influencing factors of social support for intervention development, improvement of social support, and clinical outcomes.

Providers' Perceptions of Neurology Care Delivered Through Telemedicine Technology

Background: The COVID-19 pandemic and subsequent acceleration of telemedicine usage allowed many neurologists to trial telemedicine for neurological care. The purpose of this study is to explore neurology providers' experiences with delivering telemedicine care during the COVID-19 pandemic. Methods: Semistructured video interviews were conducted with 27 neurology providers who practice at a single, urban academic center. Interviews were transcribed and analyzed for content and themes. Results: Five major themes were identified: virtual examination subspecialty differences, tips and tricks for the virtual examination, improved infrastructure needs, future technologies that could support the virtual examination, and preferences for the postpandemic telemedicine protocol. Subspecialists who described their visits as more focused on behavioral examination and obtaining patient history reported fewer limitations with delivering neurological care through telemedicine platforms. Conclusions: The implementation of a telemedicine system should reflect the needs of each neurology subspecialty. Funding is needed to improve logistical infrastructure for health providers' telemedicine visits, such as technical and administrative assistance, as well as creation and testing of technologies to support physical examination in the virtual environment.

"We're all we got is each other": Mixed-methods analysis of patient-caregiver dyads' management of heart failure

BACKGROUND

Individuals living with heart failure often require informal caregiving assistance for optimal self-care maintenance. The influence of caregiver burden and resilience on dyadic congruence is not well understood.

OBJECTIVE

To compare how dyadic congruence is influenced by level of burden and resilience expressed by caregivers of patients with heart failure.

METHODS

Mixed-methods analysis of individuals with heart failure and their caregivers, focusing on measures of caregiver burden (Zarit Burden Interview) and resilience (Brief Resilience Scale). Data were integrated using the Heart Failure Care Dyadic Typology.

RESULTS

Twelve dyads (n=24 participants) were classified as Type II (n=7) and Type III (n=5) dyads. Among Type II dyads, average caregiver burden was 19.43 (± 13.89) and resilience was 3.16 (± 1.04). For Type III dyads, average caregiver burden was 3.80 (± 4.27) and resilience 4.07 (± 1.36), respectively. Two key themes were derived: 1) caregivers' tendency to take the lead, and 2) the usefulness of cognitive reframing. Data integration elucidated that theme 1 was more common among Type II dyads and those with higher burden, and theme 2 was more prevalent among Type III dyads and those with higher resilience.

CONCLUSION

Findings highlight important variances in how dyads collectively manage heart failure. Future inquiry should involve tailored intervention development to bolster informal caregivers' quality of life and ability to better support patients throughout their heart failure trajectory.

"You think you got it down and then the moment comes": The certainty of uncertainty in end-of-life decision making

OBJECTIVES

Some observers have proposed that physicians may die differently compared with the average patient. Semi-structured interviews with family members of physicians who died offer an opportunity to better understand how patient preferences and wishes are perceived and acted on by family members at the end of life. The decision-making experiences of these family members for a loved one who was a physician may have implications for the lay person at end of life.

METHODS

The Johns Hopkins Precursors Study includes individuals who matriculated into the graduating classes of 1948 to 1964 of the Johns Hopkins University School of Medicine. From this cohort, we interviewed 26 family members of physicians who died. Interviews were coded and analyzed using a comparative, iterative process.

RESULTS

We found that family members of physicians who died described the uncertainty at end of life. This overarching theme was organized into the following: (a) the certainty of uncertainty; (b) the preparation for uncertainty; and (c) brokering of decisions in the face of uncertainty. Despite careful end-of-life preparation by well-informed physicians, family members were still left to broker decisions as they navigated the wishes of the physician and what the family and medical care team believed to be in the best interest of the physician.

SIGNIFICANCE OF RESULTS

Our findings suggest that our family members were not immune to uncertainty. The clinical momentum at the end of life may contribute to challenges faced by patients and family members when brokering decisions. Normalizing uncertainty in medical training and for families may aid in addressing the stress of uncertainty at end of life.

Hospice Family Caregiver Perceptions of Benefits and Challenges of a Telenovela Educational Intervention

Background: Telenovelas show significant promise as a mode of education that could potentially enhance hospice family caregivers' (HFCG) ability to manage distress or pain for themselves and the care recipient. Objectives: We sought to understand HFCGs' perceived benefits and challenges of NOVELA using the Levels of Kirkpatrick as a conceptual framework. Setting/Subjects: HFCGs from two hospices in the Mid-Atlantic region of the United States. Measurements: Semistructured interviews were conducted to understand perceptions of HFCGs on the benefits and challenges of the NOVELA intervention. Results: Participants (N = 20) in our study were mainly homebound, well educated, White female, and adult children of people with advanced cancer who reported mild anxiety and moderate self-efficacy at baseline. Three unique themes were identified: acceptability of NOVELA, usability and relevance of NOVELA, and the effect of NOVELA. According to our conceptual model, the intervention positively affects all three adult learning categories: reaction, learning, and behavior. Conclusion: Our findings suggest that HFCGs support the proposed NOVELA intervention and it appears to be an acceptable educational tool during hospice care (NCT04533594).

Strengths-building through life purpose, self-care goal setting and social support: Study protocol for Caregiver Support

Background

For caregivers of people with heart failure, addressing a range of care recipient needs at home can potentially be burdensome, but caregivers may also gain meaning from caregiving. The Caregiver Support Program, a multicomponent strengths-based intervention, is designed to improve outcomes of heart failure caregivers.

Objectives

1) Test the feasibility and gauge an initial effect size of the Caregiver Support Program to improve caregiver quality of life (primary outcome), and fatigue and burden (secondary outcomes) from baseline to 16 weeks, 2) test whether fatigue and caregiver burden are associated with objective measures of resilience (sweat inflammatory cytokines (Il-6 and IL-10) and self-reported resilience, 3) evaluate changes in heart rate variability, IL-6 and IL-10, pre- and post-intervention.

Methods

This is a single-blind, two group, waitlist control trial. Eligible caregivers are 1) ≥ 18 years, 2) English speaking, 3) live with the person with heart failure or visit them at least 3 days per week to provide care, 4) provide support for at least 1 instrumental activity of daily living (IADL), 5) live within a 1 h driving radius of the Johns Hopkins Hospital, and 6) the care-recipient has been hospitalized within the last 6 months. Trial participants are randomized into the immediate intervention (n = 24) or waitlist control group (n = 24). Data collection is at baseline, 16 weeks, and 32 weeks.

Conclusion

The Caregiver Support program has the potential to increase quality of life and decrease fatigue and caregiver burden for caregivers of people with heart failure and multiple co-morbidities.

Abstract 80: Subtypes Of Fatigue In Heart Failure In The Atherosclerosis Risk In Communities Study

Background: Heart failure (HF) affects ~6 million people in the US and is associated with marked morbidity and adverse clinical outcomes. Among HF patients, fatigue is common and distressing symptoms that significantly impacts patient quality of life and function. Current literature primarily examines fatigue as a single and generalized symptom. Fatigue is hypothesized, however, to manifest as multiple types, with both general and exertional components. Unique subtypes of fatigue in HF may require differential assessment and treatment to improve patient-reported and clinical outcomes.

Objective: To identify unique fatigue subtypes in persons with prevalent HF in the Atherosclerosis Risk in Communities (ARIC) study.

Methods: We performed a cross-sectional analysis of 1,114 participants at Visit 5 (2011-13) of the ARIC study with prevalent HF. We used the Modified Medical Research Council Breathlessness scale obtained at Visit 5 to assess exertional fatigue, and the PROMIS fatigue scale obtained at the 1 st semi-annual follow up after Visit 5 (2012-2014) to assess general fatigue. We used latent class analysis to identify unique subtypes of fatigue based on patterns of responses to each of the scales.

Results: Participants were 54% female and 38% Black with a mean age of 77 ± 5.5. We identified four latent classes of fatigue symptoms: 1) low/no fatigue, 2) high exertional & moderate general fatigue, 3) high general & low exertional fatigue, and 4) high general & exertional fatigue. The low/no fatigue class was the largest with an estimated 35.2% of the sample. The high exertional & moderate general class and the high general & low exertional class had similar estimated prevalences (23.5% and 23.8%, respectively). The high general & high exertional class was the smallest with an estimated 17.4% prevalence.

Conclusions: We identified unique subtypes of fatigue in HF patients that have not been previously described in the literature. Future studies should examine the relationship between these latent classes of fatigue type and important patient-reported and clinical HF outcomes. Understanding these fatigue types and their relationships to outcomes may enhance our understanding of the symptom experience and inform prognostication in patients with HF.

Mitigating End-of-Life Burden: Parallel Perspectives of Physician-Patients & Family Caregivers

CONTEXT

Patients and family caregivers perceive burden in care at the end of life differently even when the patient is a physican.

OBJECTIVES

We describe how older adult physicians as prospective patients (hereafter "physician-patients") and family caregivers of physician-patients view burden in care at the end of life.

METHODS

Interviews with physician-patients (n = 28) and family caregivers (n = 26) of physician-patients who had died were conducted as part of a shared decision-making study. Both groups expressed concerns with burden at the end of life. We coded and analyzed descriptions of burden using inductive and deductive approaches to coding sub-themes as in qualitative description. We then created a conceptual model depicting the relationships among the concepts, returning to the interviews to verify respective contexts.

RESULTS

Unilateral actions taken at different points in the illness trajectory by both groups suggested different concerns about burden occurring in parallel. While everyone anticipated burden associated with care at the end of life, physician-patients made legal and financial arrangements to minimize this burden. Nevertheless several family caregivers described the burden that they experienced. We propose a conceptual model to guide future research and care.

CONCLUSION

Physician-Patients ' clinical insights drive their attempts to alleviate burden on their families. However, family caregivers still experienced burden. Recognizing the parallel perspectives of burden may inform the type and timing of interventions to effectively minimize burden and provide compassionate care to both patients and families at the end of life.

Exploring the Experiences of Co-morbid Pain and Depression in Older African American Women and Their Preferred Management Strategies

The intersection of race, gender, and age places older African American women at an increased risk for untreated physical pain and depression that can significantly diminish their quality of life. The objectives of this study were to (1) explore older African American women's perceptions of pain and depressive symptoms and how these symptoms influence each other, and (2) explore effective pain and depression alleviation strategies used by the women. We conducted five focus groups with older African American women (N = 18). We used deductive coding to analyze focus group transcripts and qualitative description to summarize themes. We identified five major themes: (1) Spiritual Suffering from Linked Pain and Depression, (2) Lack of Understanding from Healthcare Providers, (3) Push Through and Live Through, (4) Medications Not Worth the Risk and, (5) Strategies for Pain and Depression. This study offers insight into the experiences of pain and depression in older African American women, and alleviation strategies they perceive as effective. These qualitative findings may be used to inform interventions for older African American women who experience pain and depressive symptoms.

Pain Among African American Family Caregivers: Association With Health Outcomes

There have been few investigations of the role that adolescent cognitive ability might play in predicting physical resilience across the life course, including decreased risk of early mortality. Our limited knowledge of how multiple cognitive ability domains shape trajectories of longevity is due, in part, to a lack of aging cohorts with early life cognitive assessments, and family data that allow for examination of shared family and genetic characteristics that may play a role in cognitive ability-health links. We capitalized on data from the 1960 Project Talent high school cohort (n>360,000, born 1942-1946) and mortality data (n=22,584; 5,497 deceased) collected as part of two recent follow-ups, the Project Talent Twin & Sibling Study and the Project Talent Aging Study, to examine these potential associations. In 1960, ability was assessed in multiple cognitive domains (e.g., general aptitude, quantitative, reasoning). Mortality status was ascertained through 2016. Binary logistic generalized estimating equations with race, age, sex, and adolescent family SES covariates, indicated that each 1 standard deviation higher ability in multiple cognitive domains in adolescence predicted lower odds of earlier mortality (ORs of 0.79 - 0.87). Co-sibling control models indicated a similar pattern, suggesting that benefits associated with higher cognitive performance do not simply reflect shared environmental and genetic background, but may represent a direct protective effect. These findings indicate that better performance in multiple cognitive domains in adolescence, above and beyond the influence of genetic and family environmental factors, may be or point to modifiable protective factors against risk of early mortality.