No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
A Qualitative Meta-Analysis of Heart Failure Self-Care Practices Among Individuals With Multiple Comorbid Conditions
Abstract
Most heart failure (HF) patients have other comorbid conditions. HF self-care requires medication and diet adherence, daily weight monitoring, and a thoughtful response to symptoms when they occur. Self-care is complicated when other chronic conditions have additional self-care requirements. The purpose of this study is to explore how comorbidity influences HF self-care.
Using qualitative descriptive meta-analysis techniques, transcripts from 3 mixed methods studies (n = 99) were reexamined to yield themes about perceptions about HF and self-care and to explore the influence on HF self-care. The Charlson Comorbidity Index identified comorbid conditions.
The sample was 74% Caucasian, 66% male (mean age of 59.6 years ± 15 years). Fifty-three percent of the sample was New York Heart Association Class III. All had at least 1 other chronic condition. Narrative accounts revealed that adherence to diet, symptom monitoring, and differentiating symptoms from multiple conditions were the most challenging self-care skills. Emerging themes included 1) attitudes drive self-care prioritization and 2) fragmented self-care instruction leads to poor self-care integration and self-care skill deficits.
Individuals with multiple chronic conditions are vulnerable to poor self-care. Research testing coaching interventions that integrate self-care requirements and focus on developing skill in self-care across multiple chronic conditions is needed.
... Diabetes is a common comorbid illness, and individuals with both HF and diabetes commonly report conflicting instructions about what foods they can eat. 30 In 1 study, persons with both HF and diabetes took more daily medications than patients with only HF. 31 Yet, in another study of adults with both HF and diabetes, the presence of diabetes did not influence HF self-care. 32 Sleep disorders such as obstructive sleep apnea are also common in HF, and a recent systematic review found that poor sleep was associated with poor HF self-care. ...
... 39 Comorbid conditions make HF self-care difficult because symptoms may overlap, causing conflict regarding which set of self-care skills to use. 30 Previous studies have shown that patients with more comorbidities have poorer HF self-care 40 and self-care is better when patients are free from comorbid conditions. 41 In a metasummary of qualitative studies, comorbidity was identified as a barrier to effective HF self-care. ...
... 42 Self-care maintenance may be complicated by poor care coordination among multiple providers; fragmented care may lead to inconsistent instructions on medications and diet. 30 As a result, patients make their self-care decisions based on self-efficacy, baseline knowledge, attitudes, and finances rather than provider instructions. 43 Patients with comorbid conditions may also have functional limitations (eg, arthritis, residual effects of stroke, chronic obstructive pulmonary disease, diabetic neuropathy) that influence their ability to engage in self-care maintenance behaviors such as standing for meal preparation or exercise. ...
Many studies of heart failure (HF) self-care have been conducted since the last update of the situation-specific theory of HF self-care.
Objective:
The aim of this study was to describe the manner in which characteristics of the problem, person, and environment interact to influence decisions about self-care made by adults with chronic HF.
Methods:
This study is a theoretical update. Literature on the influence of the problem, person, and environment on HF self-care is summarized.
Results:
Consistent with naturalistic decision making, the interaction of the problem, person, and environment creates a situation in which a self-care decision is needed. Problem factors influencing decisions about HF self-care include specific conditions such as cognitive impairment, diabetes mellitus, sleep disorders, depression, and symptoms. Comorbid conditions make HF self-care difficult for a variety of reasons. Person factors influencing HF self-care include age, knowledge, skill, health literacy, attitudes, perceived control, values, social norms, cultural beliefs, habits, motivation, activation, self-efficacy, and coping. Environmental factors include weather, crime, violence, access to the Internet, the built environment, social support, and public policy.
Conclusions:
A robust body of knowledge has accumulated on the person-related factors influencing HF self-care. More research on the contribution of problem-related factors to HF self-care is needed because very few people have only HF and no other chronic conditions. The research on environment-related factors is particularly sparse. Seven new propositions are included in this update. We strongly encourage investigators to consider the interactions of problem, person, and environmental factors affecting self-care decisions in future studies.
... 6 Self-management of MCC is complicated by polypharmacy, treatment burden, and the need to coordinate care among multiple providers. [7][8][9][10] Self-regulation, defined as the process of regulating behavior and emotions to cope with and adapt to a situation, is an essential strategy for self-management of MCC. 11 One approach to describing self-regulation is the widely used Common-Sense Self-Regulation Model (CSM). ...
... In addition, two participants withheld arthritis-pain symptoms from their healthcare providers to prevent an increase in their medication count and ascribed their arthritis symptoms to normal wear and tear of aging. This finding aligns with current literature on arthritis and chronic disease self-management and indicates an important challenge for individuals with MCC; 10,53 It may be essential to discuss treatment preferences with patients (such as concerns about polypharmacy), so they feel safe to disclose information pertinent to their care. 54 Research initiatives are needed to explore patients' priorities and how they decide what to disclose to their healthcare providers. ...
Objectives
Many older adults with multiple chronic conditions (MCC) frequently experience hospitalizations, functional limitations, and poor quality of life. Outcomes may be improved by promoting self-regulation, which may individuals respond to health threats and manage their health conditions. The aim of this study was to describe self-regulatory coping among older adults with MCC.
Methods
A qualitative descriptive study using semi-structured interviews and content analysis and guided by the Common-Sense Self-Regulation Model. Seventeen community-dwelling older adults with two or more chronic conditions participated in our study.
Results
Three themes were developed from the analysis: (1) “I don’t think about it unless something happens": coping in the absence of a health event, (2) "doing what I am supposed to do”: coping during a health event, and (3) “How do I know if what I did works?”: appraisal of coping success.
Discussion
Self-regulatory coping was influenced by individual beliefs and experiences ( illness representations), context, self-efficacy and availability of support and resources to cope with MCC. These findings suggest implications for clinical practice and future self-regulation interventions for older adults with MCC.
... When a diabetologist or a GP was present, communication among doctors was not mentioned as a barrier, and no participant was bothered by certain contradictions among the different practitioners, which probably also related to a low level of literacy in its critical dimension. Indeed, other studies reported a significant discomfort related to contradictory medical discourses in populations with high literacy levels [57,58]. ...
... A study in Ghana investigated the resilience factors HIV-infected patients that enabled them to engage and remain engaged in their care [57], reporting three factors, one of which was the appropriate level of trust in their health professionals. This doctor-patient relationship seems to be transposable from one pathology to another, which has implications in terms of the care pathway. ...
Although diabetes is common among people living with HIV/AIDS (PLWHA), few data exists on how migrants from Sub-Saharan Africa (SSA) experience living with these two coexisting conditions in France. The objective of this study was to analyze perception of polypathology among PLWHA from SSA with type 2 diabetes and identify barriers and facilitators to their self-management. A qualitative study was conducted using semi-structured interviews from November 2019 to April 2020 with participants selected from a cohort of PLWHA and diabetes at Avicenne University Hospital. A total of 12 semi-structured interviews were conducted and analyzed using thematic analysis with inductive approach. Stigma remained a major issue in self-managing HIV, and some participants did not consider themselves as having a polypathology, as HIV has always been considered as a distinct condition. In general, emotion-based resources (e.g spirituality, trust in the medical discourse) and social support were mobilized more than problem-solving resources (e.g perception of medication as life-saving). Participants used the same main resource in self-management of HIV and diabetes, and resources used differed from participant to participant. This study highlighted challenges in self-management of diabetes and HIV in this population and complexity related to the socioeconomic and cultural specificities. Self-management could be more successful if patients and carers move in the same direction, having identified the individual coping resources to reach objectives.
... Reasons for excluding the 407 references are reported in the Prisma flow diagram (Figure 1). 18 Manuscript types included 46 observational studies, 2, 7, 14, 21-63 27 qualitative studies, 4, 64-89 12 literature reviews, 16,17,[90][91][92][93][94][95][96][97][98][99] eight mixed-methods studies, 3, 13, 100-105 six manuscripts without a reported study design, [106][107][108][109][110][111] two pilot studies, 112, 113 two theories, 1, 8 one quasi-experimental study, 114 one conceptual framework 10 and one case study. 115 Some of the 106 references related to more than one of the research questions. ...
... 87 Patients are often uncertain in situations when symptoms require interpretation 30 when clinical status deteriorates warranting medical attention. 34,72,80,90 Moreover, discrimination of HF symptoms from symptoms related to other comorbidities remains a challenge 66,79,[92][93][94]102 and many patients inaccurately attribute their symptoms to something other than HF 23 Response to body observation and body analysis varies. Some responses are more active in nature and may include resting, relaxing or changing their daily routine. ...
Background
Symptom perception in heart failure has been identified as crucial for effective self-care that is a modifiable factor related to decreased hospital readmission and improved survival.
Aims
To review systematically the heart failure symptom perception literature and synthesise knowledge on definition, description, factors and instruments.
Methods
We conducted a scoping review including studies reporting patient-reported symptom perception in adults with heart failure. Structured searches were conducted in Medline, PubMed, Embase, CINAHL, PsychINFO, Web of Science, Cochrane, JBI and grey literature. Two authors independently reviewed references for eligibility. Data were charted in tables and results narratively summarised.
Results
The search yielded 3057 references, of which 106 were included. The definition of heart failure symptom perception comprised body listening, monitoring signs, recognising, interpreting and labelling symptoms, and furthermore awareness of and assigning meaning to the change. Symptom monitoring, recognition and interpretation were identified as challenging. Symptom perception facilitators include prior heart failure hospitalisation, heart failure self-care maintenance, symptom perception confidence, illness uncertainty and social support. Barriers include knowledge deficits, symptom clusters and lack of tools/materials. Factors with inconsistent impact on symptom perception include age, sex, education, experiences of living with heart failure, comorbidities, cognitive impairment, depression and symptom progression. One instrument measuring all dimensions of heart failure symptom perception was identified.
Conclusion
Heart failure symptom perception definition and description have been elucidated. Several factors facilitating or hampering symptom perception are known. Further research is needed to determine a risk profile for poor symptom perception – which can then be taken into consideration when supporting heart failure self-care.
... Selfcare is defined as "a naturalistic decision-making process involving the choice of behaviors that maintain physiologic stability (maintenance) and the response to symptoms when they occur (management)" (Riegel & Dickson, 2008, p.1). Self-care maintenance is the regular activities that a patient needs to apply to preserve clinical stability like adhering to medications, monitoring symptoms of HF, and adhering to a low-sodium diet. Self-care management is the behaviors that are crucial for patients with HF when symptoms happen such as identifying the symptom as being caused by HF, performing appropriate treatment, and assessing if the treatment sufficiently resolved the symptoms (Dickson et al., 2011). Perceived social support and self-care behaviors among patients with HF Perceived social support offered through family and friends may help enhance patients' SCBs (Beckie et al., 2017;Chamberlain, 2017). ...
Perceived social support is known to affect self-care. No previous studies have been conducted to determine the association between perceived social support and self-care among patients with heart failure in Jordan. This study aimed to identify the predictors of self-care behaviors among patients with heart in Jordan. A cross-sectional correlational design was used. A convenience sample of 254 patients with heart failure was invited to participate. The Personal Resource Questionnaire (PRQ)-2000 and the Self-Care Heart Failure Index (SCHFI) were used to measure perceived social support and self-care among patients with heart failure in Jordan. The mean perceived social support score was low at 59 (SD = 15). The mean social support score was also low at 59 (SD = 25). The maintenance subscale score ranged from 10–86.66 and achieved the highest mean (57.77), followed by the management subscale (mean = 56.29, range10-90), while the confidence subscale mean was the lowest (mean = 50.80, range 5.56–88.96). All self-care subscales mean scores were below the target level (≥ 70) for self-care. Lower perceived social support, lower income, older age, smaller duration of disease, less persons living at home, worse cardiac functional status, and the presence of hypertension or diabetes were the significant predictors of low self-care. The culture and the health care system may clarify some results. Providing patients with sufficient social support enhances self-care. More consideration should be provided to the elderly and patients with low income, worse functional status, short duration of disease, hypertension, and diabetes to enhance self-care.
... The predominance of heart failure in India due to coronary heart disease, hypertension, obesity, diabetes and rheumatic heart disease to run from 1.3 to 4.6 million [3]. In a huge national sample of Medicare recipients, 86% of HF patients had two or more non-cardiac co-morbidities and more than 25% had six or more [4]. ...
... Проблематика коморбидных ассоциаций при ССЗ является одной из наиболее актуальных задач, которая стоит перед современной кардиологией и темы хронических неинфекционных заболеваний в целом. За последние годы накоплено огромное количество информации о том, что пациенты с нескольким хроническими патологиями имеют сниженную продолжительность и качество жизни, а также повышенные затраты домашних хозяйств на лечение [1]. Среди наиболее распространенных коморбидных ассоциаций стоит выделить взаимосвязь ССЗ с сахарным диабетом 2-го типа (СД), хронической болезнью почек ХБП, анемией, заболеваниями легких. ...
... Several factors contribute to adequacy of self-care. Depression [4], sleep disturbances [5], impaired cognition, multiple comorbid conditions [6], and low level of awareness of illness decline all limit self-care [7]. The involvement of the partner, i.e., the informal caregiver who assists the patient with daily self-care, is crucial. ...
Self-care behaviors are essential for the effective treatment of heart failure (HF), and poor self-care may lead to adverse clinical events in patients with HF. A growing body of literature addresses the need to analyze the characteristics of both patient and caregiver since they are in mutual, long-term interaction, and their reactions to events are dependent on each other. One of the most common approaches for analyzing data on HF self-care dyads is the Actor–Partner Interdependence Model (APIM). The purpose of this study was to conduct a scoping review to answer the following question: what did we learn from HF dyadic studies based on the APIM approach? Medline, Academic Search Ultimate, and CINAHL Complete databases were searched, using the terms “dyad,” “dyadic,” and “heart failure,” for studies published between 2009 and April 2021. Fifteen studies were reviewed from a pool of 106 papers. Studies using the APIM approach revealed interrelated patient and caregiver characteristics that influence self-care and explain many complex dyadic behaviors. Our analysis provided evidence that (1) APIM is a useful analytical approach; (2) a family-oriented approach can improve the functioning of a patient with HF; and (3) social support from caregivers significantly enhances patients’ adaptation to illness.
... In the context of chronic illness, self-care is aimed at maintaining stable health and managing illnesses (Riegel et al., 2012). Self-care has been shown to improve patient health outcomes, reduce symptoms, decrease hospital admissions and improve survival and health-related quality of life (Dickson et al., 2011;Lee et al., 2018;Ruppar et al., 2019;Sedlar et al., 2017). Although self-care is essential for patients with MCCs, it is difficult to perform because disease symptoms may overlap, medical regimes are complex, and patient's confidence in their ability to perform self-care is low because of comorbidities (Vellone et al., 2015). ...
Aims:
Explore the self-care experiences of patients with multiple chronic conditions (MCCs) and caregivers' contributions to patient self-care during COVID-19 pandemic.
Design:
A descriptive qualitative design was used. The COREQ checklist was used for study reporting.
Methods:
Individual semi-structured interviews were used to collect data from patients with MCCs and caregivers selected from the dataset of an ongoing longitudinal study. Data analysis was performed through deductive thematic analysis. The middle-range theory of self-care of chronic illness, which entails the three dimensions of self-care maintenance, monitoring and management, was used as a theoretical framework to guide data collection and analysis.
Results:
A total of 16 patients and 25 caregivers were interviewed from May to June 2020. The participants were mainly women, with a mean age for patients of 76.25 years and caregivers of 45.76 years; the caregivers were mainly the patients' children (72%). During the pandemic, some patients reported remaining unchanged in their self-care maintenance, monitoring and management behaviours, others intensified their behaviours, and others decreased them. Caregivers played an important role in protecting patients from the risk of contagion COVID-19 and in ensuring patients' self-care of chronic diseases through direct and indirect interventions.
Conclusions:
Critical events can modify the self-care experiences of chronically ill patients and caregivers' contributions, leading to maintenance, increase or decrease of self-care and contributions to self-care behaviours.
Impact:
Patients with MCCs and their caregivers can react in different ways in their performances of self-care and contribution to patients' self-care behaviours when ordinary daily life is disrupted; therefore, nurses should assess such performances during critical events to identify the individuals at risk of reduced self-care and promote the most suitable healthcare services (e.g. eHealth) to implement individualised interventions.
... Self-care is the cornerstone of HF management. Self-care comprises of adherence to behaviors, such as maintaining a low sodium diet and medication regimen, as well as symptom monitoring (self-care maintenance) to maintain physiological stability and response to symptoms when they occur (self-care management) [37]. ...
Supportive care may have significant input into the treatment of patients with
heart failure (HF). Support, understanding and being treated as a whole and
unique person are vital for patients with HF. In order to develop a
person-centred program, it is important to know patients’ needs from their
perspectives. The aim of the current review and meta-synthesis was to explore the
needs of patients with HF from their perspective. A qualitative review was
conducted using the keywords: (“needs” OR “need”) AND (“heart failure”) AND
(“qualitative”) in four databases. Pre-defined inclusion and exclusion criteria
were set. The ‘Consolidated criteria for reporting qualitative studies’ item
checklist was used to assess the research methodologies of the included studies.
A “thematic synthesis” methodological approach was used: (1) Line by line
coding of the findings from primary studies. (2) The resulting codes were
organized into related areas thus building descriptive themes. (3) Analytical
themes were developed. Eleven articles were included in the present review. The
results from the meta-synthesis extracted five different categories covering
patents’ needs: Self-management, palliative care, supportive care, social support
and continuing person-centred care. The need for continuing empowerment and
support to meet those needs was also identified, revealing the core theme: ‘Wind
beneath my wings’. The meta-synthesis quotations highlighted the necessity for
dynamic and interactive continuing person-centred care focusing on the ongoing
patients’ needs through the HF trajectory. Giving more emphasis to the human
dimension and holistic approach of patients with HF, along with cardiology
medicine development might be a key factor in improving clinical outcomes and
health related quality of life.
... Inconsistencies in carrying out self-care maintenance behaviours has been demonstrated in previous studies, indicating that it represents a multifaceted dimension of illness and consequently of self-care [12,14]. People with a more severe chronic illness usually perform more self-care behaviours [14,15,31], suggesting that those with the most severe health conditions and higher disease-related symptoms, as is the case in complete injuries, had an increased need to focus on self-care. Given the differences between SCI and other chronic illnesses with a progressive trajectory, it is likely that more self-maintenance behaviours are performed by SCI survivors with greater independence and ability to participate, in order to prevent the occurrence of SCs. ...
Validation cross-sectional study.
To develop and assess the psychometric properties of two instruments based on the middle-range theory of self-care in chronic illness: the Self-Care in Spinal Cord Injuries Inventory (SC-SCII) and the Self-Care Self-Efficacy Scale in Spinal Cord Injuries (SCSES-SCI).
Multicenter study in five spinal units across Italy and Ireland.
Instrument development was based on self-care behaviours identified in the scientific literature. Behaviours were grouped into four dimensions during a consensus conference: self-care maintenance, self-care monitoring, self-care management and self-care self-efficacy. Sixty-seven items were subsequently generated based on these dimensions. A multidisciplinary group of 40 experts evaluated content validity. Dimensionality of the final items was tested by confirmatory factor analyses (CFA) with a sample of 318 participants. Internal consistency and test–retest reliability were evaluated for each dimension. Construct validity was assessed using correlations between items and scoring differences amongst participants with more severe conditions and secondary complications.
Content validity of the SC-SCII and SCSES-SCI was satisfactory for thirty-five of the previously generated items, which were further refined. CFA showed comparative fit indexes ranging from 0.94 to 0.97 and root mean square errors of approximation from 0.03 to 0.07. Internal consistency ranged from 0.71 to 0.85, and intraclass correlation coefficients were higher than 0.70. Correlations among dimensions were moderate, and the theoretical hypotheses formulated when designing the instruments were largely confirmed.
The SC-SCII and the SCSES-SCI represent valid and reliable theoretically-grounded instruments to assess self-care in people with spinal cord injury.
... Prior work has shown that patient self-care (e.g., weight monitoring, medication adherence, healthy lifestyle behaviors, and comorbidity management) and other care-related factors (e.g., patient education and connection with care) are important in the prognosis of HF patients. [32][33][34] In conclusion, lower rates of HF mortality were observed in KPSC compared to the US. Given the aging of the US population and increasing prevalence of HF, it will be important to examine individual and carerelated factors driving susceptibility to HF mortality. ...
Background
In recent years, decreases in mortality rates attributable to cardiovascular diseases have slowed but mortality attributable to heart failure (HF) has increased.
Methods
Between 2001–2017, trends in age-adjusted mortality with HF as an underlying cause for Kaiser Permanente Southern California (KPSC) members were derived through linkage with state death files and compared with trends among California residents and the US. Average annual percent change (AAPC) and 95% confidence intervals (CI) were calculated using Joinpoint regression. Analyses were repeated examining HF as a contributing cause of death.
Results
In KPSC, the age-adjusted HF mortality rates were comparable to California but lower than the US, increasing from 23.9 per 100,000 person-years (PY) in 2001 to 44.7 per 100,000 PY in 2017, representing an AAPC of 1.3% (95% CI 0.0%, 2.6%). HF mortality also increased in California from 33.9 to 46.5 per 100,000 PY (AAPC 1.5%, 95% CI 0.3%, 2.7%), while remaining unchanged in the US at 57.9 per 100,000 PY in 2001 and 2017 (AAPC 0.0%, 95% CI − 0.5%, 0.5%). Trends among KPSC members ≥ 65 years old were similar to the overall population, while trends among members 45–64 years old were flat between 2001–2017. Small changes in mortality with HF as a contributing cause were observed in KPSC members between 2001 and 2017, which differed from California and the US.
Conclusion
Lower rates of HF mortality were observed in KPSC compared to the US. Given the aging of the US population and increasing prevalence of HF, it will be important to examine individual and care-related factors driving susceptibility to HF mortality.
... Self-care has been defined as the process of maintaining health and managing illness [4]. Systematic reviews [2,3] and meta-analyses [5,6] have shown that self-care improves symptoms, hospitalisations, healthcare costs, survival rates and health-related quality of life. However, self-care is challenging for many patients with HF, and adherence to important self-care behaviours is often insufficient [7,8]. ...
Background
The European Heart Failure Self-Care Behaviour Scale (EHFScBS) is used worldwide to measure heart failure (HF) patient self-care, but a caregiver version does not exist.
Objective
To develop and test the European HF Self-Care Behaviour Scale for Caregivers (EHFScBS-C) in a population of informal caregivers of HF patients.
Methods
The EHFScBS-C was derived from the EHFScBS to measure the extent to which caregivers contribute to HF patient self-care. The EHFScBS-C was developed in English and then translated into Italian, Spanish and Dutch, after which it was back-translated. EHFScBS-C data were collected from 193 H F caregivers enrolled in Italy, Spain and the Netherlands.
Results
Exploratory factor analysis revealed two factors with supportive fit indices (CFI = 0.990; RMSEA = 0.048): caregivers’ contributions to HF self-care related to medical issues, and caregivers’ contributions related to lifestyle. Internal consistency reliability was supported as well. Construct validity was demonstrated with significant correlations with the Caregiver Preparedness Scale.
Conclusion and Practice Implications
The EHFScBS-C has adequate validity and reliability for its use in clinical practice and research to measure the extent to which caregivers contribute to HF patient self-care. The EHFScBS-C can be used in combination with the EHFScBS to conduct dyadic studies.
... Studies have shown that 50-80% of heart failure patients do not perform self-care behaviours, such as diet control, daily weighing, regular exercise, symptom monitoring and active resource seeking, and that 12% do not take medication as prescribed ( Gallagher, 2010 ;Jaarsma et al., 20 0 0 ). The most challenging self-care skills are adherence to a low-salt diet, symptom monitoring, and the differentiation of symptoms of multiple conditions ( Dickson et al., 2011 ). Poor self-care behaviour in patients with heart failure is associated with younger age, male gender or single marital status, lower socioeconomic status, higher disease severity and symptom distress, more comorbidities, poorer disease knowledge, lower social support and depression ( Britz and Dunn, 2010 ;Liu et al., 2014 ;Tung et al., 2012 ;van der Wal et al., 2007 ). ...
Background:
Self-care behaviour is important for patients with heart failure to prevent disease progression. More than half of patients have poor self-care behaviour. Self-regulation theory emphasizes that patients need to initiate monitoring of their symptoms, identify their own problems, and perform appropriate self-care behaviour. However, studies focused on interventions based on self-regulation theory for patients with heart failure are limited.
Objectives:
To investigate the effects of a self-regulation programme on self-care behaviour in patients with heart failure.
Design:
A randomized controlled trial.
Participants and setting:
Eighty-two patients with heart failure were recruited from a cardiovascular outpatient department at a teaching hospital in northern Taiwan.
Methods:
Participants were randomly assigned to the intervention (n = 41) or control group (n = 41). The intervention group participated in a 4-week self-regulation programme, including one 20-to-30-min, face-to-face individual self-regulation education session and 15- to 20-min telephone follow-up counselling sessions twice per week for four weeks. The control group received only routine outpatient care. Self-care behaviour was measured by the Self-Care of Heart Failure Index at baseline, 4 weeks and 8 weeks after patients were enroled.
Results:
The intervention group reported improvements in self-care behaviours, including self-maintenance and self-confidence subscale scores, after four weeks of the self-regulation programme. In contrast, the control group showed no significant differences. Compared with the control group, the intervention group exhibited significantly greater improvements in self-care maintenance (B = 3.74, p = 0.01), self-care management (B = 6.33, p = 0.004), and self-care confidence (B = 5.15, p = 0.003) at four weeks but showed significantly greater improvements only in self-care management (B = 6.97, p = 0.03) and self-care confidence (B = 6.24, p = 0.001) at 8 weeks.
Conclusions:
This study confirmed that a self-regulation programme could effectively improve self-care behaviour in patients with heart failure. Further studies with multicentre randomized controlled trials and larger populations of heart failure patients are necessary to evaluate the effect of this self-regulation programme in various regions and countries.
Tweetable abstract:
A home-based self-regulation programme could effectively improve self-care behaviour in patients with heart failure.
... У пациентов с РА отмечается высокий риск преждевременной смертности в результате развития различных осложнений, в том числе и сердечно-сосудистых [5,6]. Одной из наиболее актуальных коморбидных ассоциаций при РА является хроническая сердечная недостаточность (ХСН), являющаяся исходом многих ССЗ [7,8]. ...
Objective. To evaluate the relationship between the manifestations of the immune-inflammatory process with dyslipidemia and morphofunctional parameters of the myocardial state in patients with chronic heart failure (CHF) with a preserved left ventricular ejection fraction (CHF-SFV) against the background of seropositive rheumatoid arthritis (RA).
Subjects and methods . The study involved 57 women with CHF-SFV, formed as a result of coronary heart disease and/or hypertension. All patients had functional class I and II according to NYHA. All patients were divided into comparable groups: the first group included 31 patients with a combination of CHF and seropositive RA of radiological stage I-III, the second group included 26 patients without RA. Patients with RA had a low and moderate degree of activity according to DAS28. The Diagnosis of CHF was verified by ESC (European Society of Cardiology) criteria, the diagnosis of RA – by EULAR/ACR criteria (2010). The therapy was in line with current clinical recommendations. Methotrexate was used as a basic anti-inflammatory drug in patients with RA. The average dosage was 12,9±2,5 mg/week. In the study groups, a comparative analysis of the main laboratory and instrumental indicators used in the diagnosis and monitoring of CHF, as well as the relationship of manifestations of the immunoinflammatory process with dyslipidemia and indicators of diastolic myocardial dysfunction was performed.
Results . The level of total cholesterol in the CHF group without RA averaged 4,4±0,9 mmol/l and 5,2±2,2 mmol/l in the CHF and RA group (p=0,09); triglycerides – 1,9±0,7 and 1,5±0,9 mmol/l (p=0,3); low-density lipoproteins (LDL – C)-2,6±0,8 and 3,1±1,1 mmol/l (p=0,04); high – density lipoproteins (HDL-C) – HDL) – 1,3±0,2 and 1,3±0,1 mmol/l, respectively (p=0,7). In the group of CHF on the background of RA, a direct relationship between the intake of methotrexate (the average dose was 12,9±2,5 mg/week) and the level of HDL-C: R=0,3; R2=0,1; F=0,9; (p=0,01). In the group of CHF and RA, there was a statistically significant relationship between the ratio of transmittal flow parameters with the level of DAS28 and RF: R=0,5; R2=0,3; F=2,6 (p=0,04).
Conclusion . Against the background of the immuno-inflammatory process caused by RA, a significant increase in the level of LDL was detected, which can negatively affect the course of dyslipidemia in patients with CHF-SFV. There was an increase in the concentration of HDL on the background of treatment with methotrexate in the group of CHF-SFV and RA. A direct correlation of the ratio of parameters of the transmittal flow with the RF and DAS28 levels was found. This relationship may affect the progression of left ventricular diastolic dysfunction in the group of CHF and RA, but prospective studies are needed to clarify its role.
... Результаты зарубежных исследований свидетельствуют о том, что при наличии сопутствующей патологии у больных с ХСН существенно ухудшается общий прогноз, увеличивается число, а также длительность госпитализаций [1]. Показано, что с увеличением коморбидности у больных с ХСН происходит достоверный рост смертности от всех причин [2]. ...
... АЦЦП -антитела к цитруллинированному циклическому пептиду, ВАШ -визуально-аналоговая шкала боли, ЛЖ -левый желудочек, РА -ревматоидный артрит, РФ -ревматоидный фактор, СКФ -скорость клубочковой фильтрации, СОЭ -скорость оседания эритроцитов, СРБ -С-реактивный белок, ССЗ -сердечно-сосудистые заболевания, ФВ ЛЖ -фракция выброса левого желудочка, ХС ЛНП -холестерин липопротеинов низкой плотности, ХСН -хроническая сердечная недостаточность, E/A -соотношение максимальных скоростей в фазы раннего и позднего диастолического наполнения (параметров трансмитрального потока), DAS28 -индекс активности РА. Введение Коморбидные ассоциации при сердечно-сосудистых заболеваниях (ССЗ), в частности при хронической сердечной недостаточности (ХСН) на сегодняшний день являются одной из активно обсуждаемых и исследуемых тематик [1]. Наиболее изученными являются ассоциации ХСН с хронической болезнью почек, сахарным диабетом 2 типа, анемией, фибрилляцией предсердий [2][3][4][5]. ...
Aim . To study the relationship of the systemic inflammation with the morphological and functional myocardial parameters in patients with heart failure (HF) due to hypertension and coronary artery disease in combination with rheumatoid arthritis (RA).
Material and methods . The study included 57 women with NYHA class I-II HF. Patients were divided into two comparable groups: group 1 (n=31) — patients with HF and seropositive RA (Steinbrocker X-ray stage I-III); group 2 (n=26) — HF patients without RA.
Results . A comparative analysis of morphological and functional parameters did not reveal significant differences: left ventricular ejection fraction in groups 1 and 2 were 51,06±5,6% and 51,6±6,4%, respectively (p=0,7); the ratio of peak velocity blood flow in early diastole to peak velocity flow in late diastole (E/A) was 0,9±0,1 and 0,8±0,1, respectively (p=0,7). For other echocardiographic parameters, differences were also not detected (p>0,05). Nevertheless, significant regression model was created between the RA activity score (DAS28), rheumatoid factor, and E/A was created: R=0,5; R2 =0,3; F=2,6; p=0,04.
Conclusion . As a result of the study, significant direct moderate correlation of the RA activity score (DAS28) with E/A ratio was revealed in the group of patients with HF and RA. The data obtained may indicate an unfavorable prognosis of HF with an increase in RA activity.
... Los ajustes en la dieta, el consumo de líquidos, la actividad física, el control del peso y el manejo del estrés pueden ser difíciles de tratar si el paciente escucha recomendaciones distintas realizadas por los profesionales que lo atienden. En un pequeño metaanálisis cualitativo, los pacientes con diabetes mellitus tipo 2 e insuficiencia cardiaca reportaron falta de conocimiento, habilidad y eficacia para integrar las múltiples recomendaciones de autocuidado, lo que los llevó a priorizar unos sobre otros (por ejemplo, monitorizaban sus niveles de glucosa diariamente pero no su peso corporal) 46 . En un registro norteamericano que incluyó 1.901 pacientes diabéticos se encontró que tener insuficiencia cardiaca severa se asociaba con menor priorización de la diabetes y menores puntajes en las escalas de autocuidado 47 . ...
Resumen
Introducción
los pacientes con diabetes mellitus tipo 2 tienen una prevalencia de insuficiencia cardiaca cuatro veces más alta que la población general.
Objetivo
revisar la evidencia de los diferentes tratamientos antidiabéticos en los pacientes con diabetes mellitus tipo 2 e insuficiencia cardiaca, las consideraciones necesarias cuando hay compromiso de la función renal y los posibles mecanismos que explican los resultados benéficos de estas terapias.
Conclusión
la evidencia actual ha demostrado que algunos de los medicamentos antidiabéticos tienen la capacidad de reducir la tasa de hospitalizaciones por insuficiencia cardiaca, en especial los inhibidores de SGLT2.
... The ratio of the awareness about lifestyle modifications and adherence to lifestyle modifications most common condition in the group of comorbidity are CKD (41%), anemia (29%) and diabetes (29%) [13][14]. We obtained similar results in our study. ...
Background
Influence of comorbidity on adherence to lifestyle therapy in patients with chronic heart failure (CHF) have not been studied yet.The aimThe aim of this study was to investigate awareness and adherence to lifestyle therapy in patient with CHF and comorbidity.Мethods203 patients with CHF (130 males and 73 females, mean age was 61,8±9,6 years) were studied. CHF was defined according to ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2016. Charlson comorbidity index was calculated. Awareness of lifestyle modifications was determined using a questionnaire developed in our clinic and used in previous scientific studies. Quality of life, psychological state, relation to disease were estimated. Follow-Up period was 1 year.ResultsThe awareness about lifestyle modifications in patients with CHF ranged from 38.9% (daily control of body weight) to 87.2% (reduced intake of dietary sodium). Adherence to lifestyle therapy was from 7.9% (daily weight control) to 37.9% (reduced intake of dietary sodium). Charlson comorbidity index corrected by age was 5.0±2.1 scores. Patients with high comorbidity (Charlson comorbidity index > 6 scores) had decreased of quality of life. There were not differences in adherence to lifestyle therapy in patients with CHF, depending on the level of comorbidity. Nonadherence patients were characterized by sensitive type of relation to disease, emotional lability (p< 0,05).СonclusionNonadherence to lifestyle therapy in patients with CHF is associated with desadaptive type of relation to disease, which is more common in patients with high comorbidity.
... inability to afford medicines), condition-related factors (e.g. multimorbidity and polypharmacy), 22,23 and poor health literacy. 24 In a qualitative data analysis, 90% of 112 adults with heart failure described intermittent non-adherence. ...
Background
Adherence to evidence-based therapy is essential for optimal management of heart failure. Yet, medication adherence is poor in heart failure patients. The Ascertaining Barriers to Compliance Project decomposed the medication adherence process into initiation, implementation, and discontinuation stages, but electronic monitoring-based adherence analyses usually do not consider this process.
Aims
The aim of this study was to describe individual-patient patterns of medication adherence from electronic monitoring data among adults with chronic heart failure, adherence types, and risk factors for increased all-cause hospitalization including measures of poor adherence such as discontinuation.
Methods
Data from two prospective studies of adherence measured with electronic monitoring for heart failure patients were combined and restricted to monitoring of angiotensin-converting enzyme inhibitors and beta-blockers over an initial three-month period. Hospitalizations were recorded for this period as well as for a three-month follow-up period. Analyses were conducted using adaptive modeling methods to identify individual-patient adherence patterns, adherence types, and risk factors for an increased hospitalization rate.
Results
Using electronic monitoring data for 254 heart failure patients, four adherence types were identified: highly consistent, consistent but variable, moderately consistent, and poorly consistent. Sixteen individually significant risk factors for increased hospitalization rates were identified and used to generate a multiple risk factors model. Medication discontinuation was the most important individual risk factor and most important in the multiple risk factors model.
Conclusion
Discontinuation of angiotensin-converting enzyme inhibitors or beta-blockers increases hospitalization rates for heart failure patients. Interventions that effectively address this problem are urgently needed.
... Greater self-care maintenance, selfcare monitoring, and self-care management behaviors were found in people with a more severe impact of the disease on their daily lives. These results are consistent with prior studies conducted in diabetes (Ausili et al., 2017) and heart failure (Dickson, Buck, & Riegel, 2011), showing that people with more compromised health status and more severe disease symptoms are most likely to perform self-care. Consistent with the middle-range theory of self-care of chronic illness, the three self-care scales are found as correlated, illustrating that they are related manifestations of the same general construct (Riegel et al., 2012). ...
This study developed two instruments, the Self-Care in Chronic Obstructive Pulmonary Disease (COPD) Inventory (SC-COPDI) and the COPD-Self-Care Self-Efficacy Scale (SCES), and tested their psychometric properties on a convenience sample of 498 patients from Northern, Central, and Southern Italy. First, the domains and the items of the SC-SCOPDI were generated based on the middle-range theory of self-care of chronic illness, comprising the dimensions of self-care maintenance, self-care monitoring, and self-care management, and the SCES-COPD was developed accordingly. Second, we assessed the content validity of each scale. Third, we conducted a multicenter cross-sectional study to test their structural validity, convergent and discriminative validity, internal consistency, and test–retest reliability. The theoretical dimensions of the two instruments were confirmed through confirmatory factor analysis. Convergent validity was demonstrated by the correlation among the three self-care scales and the Self-Efficacy Scale, and discriminative validity by higher self-care scale scores in individuals with greater COPD severity and poorer health status. The global reliability index ranged from .78 to .92 for all scales. The intraclass correlation coefficients were higher than .70. Further studies are needed to confirm the psychometric properties of the two instruments in different COPD populations and countries to extend their use in clinical practice.
... 247 In a small, qualitative meta-analysis, patients with DM and HF reported lack of knowledge, skill, and efficacy in integrating multiple self-care behaviors, which led them to prioritize some over others (eg, glucose monitoring, but not daily weights). 248,249 In a large, national survey of predominantly older adults, severe HF was associated with lower DM prioritization and self-care scores. 250 These challenges to self-care across multiple conditions may be attributed to lack of integration of information received from multiple providers. ...
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
... 247 In a small, qualitative metaanalysis, patients with DM and HF reported lack of knowledge, skill, and efficacy in integrating multiple self-care behaviors, which led them to prioritize some over others (eg, glucose monitoring, but not daily weights). 248,249 In a large, national survey of predominantly older adults, severe HF was associated with lower DM prioritization and selfcare scores. 250 These challenges to self-care across multiple conditions may be attributed to lack of integration of information received from multiple providers. ...
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
... Self-care is the cornerstone of HF management. Self-care comprises of adherence to behaviors, such as maintaining a low sodium diet and medication regimen, as well as symptom monitoring (self-care maintenance) to maintain physiological stability and response to symptoms when they occur (self-care management) [37]. ...
... Следует отметить, что исследуемая группа пациентов с АС характеризовалась пожилым возрастом и высоким уровнем коморбидности, которая, как известно, оказывает негативное влияние на клинический исход заболеваний, социальную адаптацию и качество жизни [17]. При значении индекса коморбидности более 5 баллов естественное течение заболевания сопровождается выживаемостью менее 70% [11]. ...
Aim. To study long-term results and predictors of adverse outcomes of transcatheter aortic valve implantation in patients with high surgical risk with severe aortic stenosis. Material and methods. The prospective single-center study included 140 patients with hemodynamically relevant aortic stenosis who underwent transcatheter aortic valve implantation. We assessed hemodynamic and clinical status, quality of life before and after 1 year of the intervention. Results. In the long-term follow-up after transcatheter aortic valve implantation, an improvement in the quality of life was noted in both the physical and psychoemotional aspects of health. We did not registered cases of prosthesis dysfunction, repeated surgical interventions one-year survival was 92%. Predictors of adverse outcomes of aortic valve transcatheter implantation were the comorbidity index (odds ratio (OR) 2,8 (1,6-4,9), p<0,001) and, especially, the comorbidity index over 5 points (OR 9,3 (2,9-19,4), p<0,001). Initially low level of quality of life, both in the physical aspect (OR 0,93 (0,86-0,99), p=0,013) and in the psycho-emotional aspect of health (OR 0,94 (0,89-0,99), p=0,027). Conclusion. Aortic valve transcatheter implantation showed high efficiency in improving the quality of life and reducing mortality in patients with severe aortic stenosis and high surgical risk. Initially low level of quality of life and comorbidity index adversely affect on long-term results.
... In a qualitative meta-analysis, transcripts from 3 mixed methods studies were reexamined to generate themes on perceptions about HF and self-care and to explore the influence on HF self-care (Dickson, Buck, & Riegel, 2011). The sample of 599 patients with HF (66% male, 59.6 ± 15 mean age in years, 74% Caucasians, 53% NYHA class III) all had at least 1 other chronic condition. ...
Background: Self-care is recognized as a common means for improving outcomes of
... Следует отметить, что исследуемая группа пациентов с АС характеризовалась пожилым возрастом и высоким уровнем коморбидности, которая, как известно, оказывает негативное влияние на клинический исход заболеваний, социальную адаптацию и качество жизни [17]. При значении индекса коморбидности более 5 баллов естественное течение заболевания сопровождается выживаемостью менее 70% [11]. ...
... Between 25% 15 and 50% 16 of older adults have multiple chronic conditions, and they generally do not think of their chronic conditions discretely but rather as a function of the symptoms that they must manage. 17 Therefore, the studies mentioned here are salient and should have been discussed. ...
... В настоящее время уделяется все больше внимания сочетанию нескольких заболеваний (коморбидности) [7]. Накоплена информация, указывающая на прямую связь между коморбидностью и повышенным риском смертности у пациентов с хроническими заболеваниями [8]. ...
This review presents relevant information about development and course of chronic heart failure (CHF) associated with rheumatoid arthritis (RA). One of the most discussed issues is the effect of systemic inflammatory process on prognosis of CHF. The review focused on current evidence for significance of this comorbidity in CHF. The diagnostic role of current immune markers, such as ga-lectin 3, pentraxin 3, growth differentiation factor 15, and osteopontin was described. The review discussed the significance of anti-inflammatory therapy for prognosis of CHF in the presence of systemic diseases. Possible beneficial effects of the basis therapy for RA on CHF outcomes were assessed. The authors noted a positive prognostic significance of methotrexate for the risk of decompen-sated CHF. © 2018 Limited Liability Company KlinMed Consulting. All Rights Reserved.
... This burden contributes to the poor prognosis in people experiencing advanced HF. 37 In a similar manner to other authors, we observed that patients with HF usually rely on informal caregivers, which implies not only relatives but also friends and neighbors. [38][39][40] Regarding housing, authors of a Spanish study showed that patients with HF living in poor conditions such as in a building without an elevator, hot water, a heater, an individual bedroom, an automatic washing machine, and a telephone had a worse clinical situation and were more vulnerable. 41 Although we detected some structural housing barriers in 1 of 3 patients, less than 3% lacked an elevator or a telephone or lived in very poor conditions. ...
Background:
Heart failure (HF) is a chronic condition that usually leads to death a few years after diagnosis. Although several clinical factors have been found to be related to increased mortality, less is known about the impact of social context, especially at the end stage of the disease. Knowing about social context is important to properly classify risk and provide holistic management for patients with advanced HF.
Objective:
The aim of this study was to determine the impact of social context on mortality in patients with advanced HF.
Methods:
A retrospective cohort study was conducted using data from clinical records on community-dwelling patients with HF and with New York Heart Association IV functional class living in Catalonia in northeastern Spain. Clinical data, patient dependency for basic activities of daily living, and social assessments were collected between 2010 and 2013. The primary outcome was all-cause mortality.
Results:
Data from 1148 New York Heart Association class IV patients were analyzed. Mean (SD) age was 82 (9.0) years, and 61.7% were women. The mean (SD) follow-up was 18.2 (11.9) months. Mortality occurred in 592 patients. Social risk was identified in 63.6% of the patients, and 9.3% acknowledged having social problems. In the adjusted multivariate model, being male (hazard ratio (HR), 1.82; 95% confidence interval [CI], 1.16-2.83), having high dependency on others for basic activities of daily living (HR, 2.16; 95% CI, 1.21-3.85), and presenting with a social problem (HR, 2.46; 95% CI, 1.22-4.97) were related to an increased risk of mortality.
Conclusions:
An unfavorable social profile is an independent risk factor for mortality in patients with advanced HF.
... The severity of the chronic illness, the patient's cognitive status and the presence of other comorbidities were found to be additional patient-related factors predicting self-care. In fact, in general, self-care is worse in patients with a more severe illness , worse cognitive status , and more comorbidities (Buck et al., 2015;Dickson, Buck, & Riegel, 2011;Putcha, Drummond, Wise, & Hansel, 2015). Predictors of caregiver-related self-care are sociodemographic characteristics and caregiver burden. ...
Aim
To describe a research protocol for a study designed to examine self‐care in patient and caregiver dyads in coping with multiple chronic conditions, to evaluate the influence of dyad self‐care on 1) patient mortality, quality of life, hospital admissions and the unplanned access of care; and 2) the positive aspects of caregiving.
The specific conceptual framework that we developed for this study considers the predictors of self‐care (at the patient, caregiver and dyadic levels), the process of self‐care and the outcomes of self‐care in patient and caregiver dyads with multiple chronic conditions. These elements in patient and caregiver dyads have not been well studied to date.
Design
This is a multi‐centre longitudinal study with data collection at 0, 6 and 12 months.
Methods
We will use generic and specific tools to assess the predictors of self‐care, the process of self‐care and the outcomes of self‐care in the dyads. The data will be analysed with descriptive and inferential statistics and multilevel modelling to control for the interdependent nature of dyadic data. The study was approved by an ethics committee and was funded by a grant from the Centre of Excellence for Nursing Scholarship Rome, in November 2015.
Discussion
This study seeks to determine the predictors and outcomes of self‐care in patient and caregiver dyads within the context of multiple chronic conditions.
Impact
The results of this study will inform clinical practice and research by identifying variables that are modifiable and therefore amenable to interventions.
This article is protected by copyright. All rights reserved.
... Secondly, qualitative metaanalysis refers to a research study design that is distinctly different from scoping reviews. Authors have previously used the term, "qualitative meta-analysis" to describe syntheses of qualitative studies within a field (Timulak, 2009;Dickson et al., 2011;Rahimi et al., 2009;Hall, 2009;Brown et al., 2012). Such designs tend to adopt ethnographic and grounded-theory approaches to analysis. ...
... In Europe it increases with age from 1.4/1000 person-years in subjects aged 55-59 years up to 47.4/1000 person-years in those aged 90 years or older [2]. The ageadjusted prevalence of AHF in the United States averages 36 cases per 100,000 of the population and accounts for 10,000 deaths annually [3]. ...
... Higher self-care monitoring was associated with more diabetes complications. People feeling severely ill or having a more compromised health status are more likely to perform better self-care [42]. Previous studies found similar results studying blood glucose monitoring in diabetes [38]. ...
Background:Self-care is essential for patients with diabetes mellitus. Both clinicians and researchers must be ableto assess the quality of that self-care. Available tools have various limitations and none are theoretically based. Theaims of this study were to develop and to test the psychometric properties of a new instrument based on themiddle range-theory of self-care of chronic illness: the Self-Care of Diabetes Inventory (SCODI).Methods:Forty SCODI items (5 point Likert type scale) were developed based on clinical recommendations andgrouped into 4 dimensions: self-care maintenance, self-care monitoring, self-care management and self-careconfidence based on the theory. Content validity was assessed by a multidisciplinary panel of experts. A multi-centre cross-sectional study was conducted in a consecutive sample of 200 type 1 and type 2 diabetes patients.Dimensionality was evaluated by exploratory factor analyses. Multidimensional model based reliability wasestimated for each scale. Multiple regression models estimating associations between SCODI scores and glycatedhaemoglobin (HbA1c), body mass index, and diabetes complications, were used for construct validity.Results:Content validity ratio was 100%. A multidimensional structure emerged for the 4 scales. Multidimensionalmodel-based reliabilities were between 0.81 (maintenance) and 0.89 (confidence). Significant associations were foundbetween self-care maintenance and HbA1c (p= 0.02) and between self-care monitoring and diabetes complications(p= 0.04). Self-care management was associated with BMI (p= 0.004) and diabetes complications (p=0.03).Self-careconfidence was a significant predictor of self-care maintenance, monitoring and management (allp< 0.0001).Conclusion:The SCODI is a valid and reliable theoretically-grounded tool to measure self-care in type 1 and type 2 DM patients.
Full paper can be found at: http://rdcu.be/wNmF
Introduction: Telephone follow-up is known for sharing information, providing health education, diagnosing complications quickly, managing symptoms, and providing quality aftercare services. The aim of this study was to investigate the effect of patient education and telephone follow-up on self-care and self-efficacy as well as readmission rate of heart patients with COVID-19. Material and Methods: In this interventional study, 64 heart patients with COVID-19 admitted to a training center in northern Iran during the period from June 1 to September 22, in 2020 were intervened. Data collection tools included demographic and clinical questionnaires, Scherer self-care and self-efficacy questionnaires. After completing the questionnaires and teaching self-care about corona disease and heart disease to patients during six sessions over the phone (10-20 minutes), the researcher again completed the self-care and self-efficacy questionnaires on the fourteenth day. For data analysis, paired t-test and independent t-test were used using SPSS software version 21. Results: The mean age of participants was 59.53±15.32. The results showed that the mean score of self- care after the intervention had a significant increase (P<0.001), so that the mean score of self- care before the intervention was 54 and after the intervention was 60.14, the mean score of self-efficacies after the intervention increased which is not statistically significant. Conclusion: Education and follow-up of heart patients with COVID-19 is associated with increased self-care in patients every day. Therefore, follow-up programs, especially telephone follow-up, are recommended to improve the health status of patients.
To explore the association between frailty and self-care in older adults with congestive heart failure and analyze their influencing factors. The cross-sectional study was conducted at the department of cardiology of a hospital in China from March 2018 to November 2018. A total of 165 participants were recruited. Frailty and self-care were measured by the Tilburg Frailty Indicator, and the Self-care of Heart Failure Index (V6). The physical, psychological, and social frailty exerted a significant negative association with self-care. Exercise, income, comorbidities, and times of congestive heart failure-related hospitalizations were independent risk factors for frailty; surgical treatment, comorbidities, and income were independent risk factors for self-care. These findings help to fill the need for new approaches to identify the high risk of frailty individuals in the acute care setting for targeted intervention and tailored transitions in care to promote optimal patient quality care and biopsychosocial well-being.
Objective:
The objective of the review is to synthesize the qualitative research literature on the experiences of adults living with multimorbidity.
Introduction:
Persons living with two or more chronic health conditions, known as multimorbidity, is a global health problem in countries of all income levels. Multimorbidity presents an ever-increasing resource and financial burden for health care systems and similarly challenges those living with multiple health conditions because of the complexity of their health and treatment requirements. Overall, persons with multimorbid conditions experience a high risk of mortality and a lower quality of life. Understanding the adult experience of multimorbidity is important for creating and implementing health care that meets the needs of individuals living with the burden of multiple chronic health conditions.
Inclusion criteria:
The systematic review will include published peer-reviewed and unpublished English-language studies from 2000 to 2020 that provide qualitative evidence of adults' (18+ years of age) experiences of living with multimorbidity.
Methods:
CINAHL with full text, Cochrane, MEDLINE, Embase, PsycINFO, Consumer Health Database, Scopus, and ScienceDirect journals and books will be searched. Reference lists of included studies will also be cross-checked with search outcomes to identify additional studies. Sources of gray literature will also be searched for unpublished studies. The critical appraisal of selected studies and the extraction of data will be independently undertaken by two reviewers using JBI methods. The findings will be pooled using meta-aggregation to produce comprehensive synthesized findings. A ConQual Summary of Findings will also be presented.
Systematic review registration number:
PROSPERO (CRD42020152038).
Background:
Management of heart failure (HF) involves complex self-care recommendations. Many patients have difficulty adhering to these recommendations, and mechanisms that support behavior change are poorly understood.
Objective:
The objective of this study was to explore the perceptions and motivations of individuals with HF who became adherent to HF treatment recommendations after being non-adherent.
Methods:
This was a qualitative descriptive study. Participants were recruited from cardiology clinics and completed a semi-structured interview on their experiences and motivations for self-care behavior change. Data was analyzed using thematic analysis. The sample size (n = 8) was sufficient to achieve saturation.
Results:
Five themes were identified: experiencing mortality, optimism and hope, making connections between behavior and health, self-efficacy, and the role of the clinician. The temporal chronological sequence of these themes across participants varied.
Conclusions:
This study adds to our current understanding of HF self-care by suggesting mechanisms that may enhance existing self-care interventions, and demonstrating the important role of the clinician.
High-acuity, progressive care, and critical care nurses often provide care for patients with heart failure during an exacerbation of acute disease or at the end of life. Identifying and managing heart failure symptoms is complex and requires early recognition and early intervention. Because symptoms of heart failure are not disease specific, patients may not respond to them appropriately, resulting in treatment delays. This article reviews the complexities and issues surrounding the patient's ability to recognize heart failure symptoms and the critical care nurse's role in facilitating early intervention. It outlines the many barriers to symptom recognition and response, including multimorbidities, age, symptom intensity, symptom escalation, and health literacy. The influence of self-care on heart failure management is also described. The critical care nurse plays a crucial role in teaching heart failure patients to identify and respond appropriately to their symptoms, thus promoting early intervention.
Professionals, such as nurses, that provide care may experience a negative impact on both their personal and professional lives due to grief. Grief is the emotional response of a person who has invested emotionally in someone or something and then loses that person or thing. Variations in intensity and duration of grief may occur as oncology nurses care for patients for extended periods of time, sometimes from diagnosis to death. The experience of this extended relationship makes oncology nurses particularly susceptible. This study seeks to examine oncology nurses’ grief through a qualitative meta-analysis. The many terms associated with the concept of nurses’ grief were analyzed with the goal of obtaining a more comprehensive understanding of these terms as well as presentation of what was found to be the most suitable concept and a supporting definition.
Background
Cardiovascular disease and sustained high blood glucose (prediabetes) are established concurrent diagnoses. People with these concomitant conditions carry out self-care which is overt (e.g. daily weighing or taking a specific diet), plus there are also concealed facets of self-care (e.g. accessing information about diet or medications). Also of note is the need to 'work' to achieve a self-determined level of self-care. The 'work' put into self-care is currently under-reported when people discuss their progress with health professionals.
Objective
Our research aimed to demonstrate that aspects of self-care are typically concealed. A further objective is to reveal the extent of 'work' dedicated to self-care.
Design
Interviews were conducted with 23 participants to reveal their experiences of long-term conditions, cardiovascular disease and prediabetes. Interpretive description underpinned the development of a thematic representation of the data.
Setting and participants
Recruitment was from a tertiary hospital coronary care unit in New Zealand. Included participants were those with an acute coronary event, also found to have a high blood glucose. Those people known to have diabetes prior to admission were not included.
Method
Participants were interviewed once, for approximately 60 minutes, nine months after discharge home. The data is analysed using thematic analysis, organising an interpretation into themes.
Results
Self-care requires 'work', the work itself was frequently understated by participants, they trivialised their important role in their self-care. Participants often required prompting to discuss the responsibilities, choices and behaviours they participated in to support self-care to improve their health and well-being. Participant data showed how the 'work' of self-care aligned to three work themes: solo self-care, teamwork, and constant companion self-care.
Conclusion
Nurses can improve the outcomes for people with long-term conditions by acknowledging and incorporating the often concealed 'work' of self-care when assessing, planning and implementing health care in any clinical setting. A important recommendation for nurses is to support people-as-patients, by encouraging self-determination and working with the preferences patients have for self-care, in order to enhance their quality of life while living with ill-health.
Objective:
To understand patients' experiences with condition interactions and develop a taxonomy to inform care for patients with multiple chronic conditions.
Methods:
We conducted qualitative and quantitative analysis of free-text data from patient surveys in which respondents were asked to indicate their most bothersome chronic condition and describe how their other conditions affect their self-care for that condition. Using standard content analysis, we developed a taxonomy comprising how patients perceive interactions among their conditions, and examined cross-cutting themes that reflect qualities of these interactions.
Results:
Among 383 eligible survey respondents, the mean (SD) number of chronic conditions was 4 (2); common conditions included hypertension (60%), chronic pain (49%), arthritis (41%), depression (32%), diabetes (29%), and post-traumatic stress disorder (26%). Patients' perceived condition interactions took four broad forms: 1) unidirectional interactions among conditions and/or treatments, 2) cyclical or multidimensional interactions, 3) uncertain or indistinct interactions, and 4) no perceived interaction. Cross-cutting themes included beliefs about causal relationships between conditions, identification of interactions as negative vs. positive, and interactions between physical and mental health.
Conclusion:
This study presents a novel taxonomy of condition interactions from the patient perspective.
Practice implications:
Understanding perceived condition interactions may support patient self-management and shared decision-making efforts.
Background:
Heart Failure (HF) guidelines recommend HF self-care education. An optimal method of educating HF patients does not currently exist.
Objectives:
To evaluate the effectiveness of supplementing usual HF education with video education and evaluate patients' satisfaction with video education.
Methods:
A mixed methods design was used. A convenience sample of 70 patients was recruited from an academic medical center. Participants completed the Atlanta Heart Failure Knowledge Test and the Self-care of Heart Failure Index before and after receiving video education, to measure HF knowledge, self-efficacy, and self-care respectively. Video usage and satisfaction with video education data were collected. All-cause 30-day readmissions data were compared to a historical group.
Results:
HF knowledge and self-care maintenance scores increased significantly. Self-efficacy, self-care management and all-cause 30-day readmissions did not significantly improve. Most HF patients were highly satisfied.
Conclusion:
Supplementing usual HF education with VE was associated with improved HF knowledge and self-care maintenance.
O estudo apresentado neste livro inscreve-se no domínio do autocuidado, mais concretamente “na promoção da autonomia da pessoa dependente para o autocuidado”, emerge de um percurso de investigação-ação (IA) e foi desenvolvido numa Unidade de Convalescença da Rede Nacional de Cuidados Continuados Integrados.
Os Cuidados Continuados Integrados estão centrados na recuperação global da pessoa, promovendo a sua autonomia e melhorando a sua funcionalidade, no âmbito da situação de dependência em que se encontra, e os critérios usuais de referenciação para estas unidades contemplam a dependência para o autocuidado em pessoas com necessidades de reabilitação funcional e de treino das atividades básicas de vida. Promover a autonomia destas pessoas, estimulando-a para uma mudança significativa do seu modo de vida e para uma aprendizagem com recurso a estratégias adaptativas, é algo que pode ser facilitado pelos enfermeiros.
O ciclo de IA empreendido gerou mudanças no modelo de cuidados em prática, tendo apelado para a utilização de estratégias promotoras da participação e do comprometimento interno dos enfermeiros com vista à viabilização da mudança. Foi possível partir “do que os enfermeiros fazem e como fazem”, para uma estratégia de reflexão “sobre a ação e na ação” e gerar evidência. Os resultados permitiram estruturar um conjunto de pressupostos que estão na génese de um modelo de orientação da conceção de cuidados, centrado na promoção da autonomia da pessoa dependente, tendo por base o seu potencial de recuperação.
O estudo teve a orientação do Professor Doutor Paulino Artur Ferreira de Sousa.
Background:
Congestion is a common cause of symptoms in heart failure (HF). Yet, intrathoracic impedance, an objective marker of cardiopulmonary congestion, has not been examined in relation to HF symptoms.
Objective:
To determine whether device-detected cardiopulmonary congestion is a predictor of physical and psychological symptoms and health-related quality of life (HRQOL) in adults with HF over 3 months.
Methods:
Multivariate generalized linear modeling was used to quantify the association of cardiopulmonary congestion (Optivol® Index exceeding 60 Ω threshold) with HRQOL (12-item Kansas City Cardiomyopathy Questionnaire) and both physical symptoms (Functional Assessment of Chronic Illness Therapy-Fatigue Scale; HF Somatic Perception Scale Dyspnea and Early & Subtle Symptoms subscales) and affective symptoms (9-item Patient Health Questionnaire; 6-item Patient-Reported Outcomes Measurement Information System Anxiety Scale).
Results:
The mean age of the sample (n = 49) was 62years old, 39% were women, and 63% had NYHA class III/IV HF. Participants who experienced threshold crossings in the previous 90days reported on average, 130% higher dyspnea (p = 0.017; confidence interval (CI) 10.2%, 437%), 40% higher early & subtle symptoms (p = 0.029; CI 3.4%, 89.7%), 106% higher depressive symptoms (p = 0.003; CI 19.1%, 257%) and 40% higher anxiety (p = 0.028; CI 3.7%, 89.1%). Threshold crossings in the previous 90days were also significantly associated with a clinically meaningful decrease in HRQOL (β = -16.16 ± 6.32; p = 0.01).
Conclusions:
Intrathoracic impedance measured with the Optivol Index can provide additional information regarding the patient experience of hallmark physical and psychological HF symptoms and HRQOL over 3months.
Background:
Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF.
Methods:
We enrolled 36 HF out-patients into a longitudinal sequential explanatory mixed methods study. We used objectively measured thoracic fluid accumulation and daily reports of signs and symptoms to evaluate accuracy of detected changes in fluid retention. Patterns of symptom interpretation and response were explored in telephone interviews conducted every 2 weeks for 3-months.
Results:
In this sample, 44% had a mismatch between objective and subjective fluid retention; younger persons were more likely to have mismatch. In interviews, two patterns were identified: those able to interpret and respond appropriately to symptoms were higher in decision-making skill and the quality of social support received.
Conclusion:
Many HF patients were poor at interpreting and managing their symptoms. These results suggest a subgroup of patients to target for intervention.
The importance of outpatient monitoring and self-care has become increasingly evident over the past decade. Large amounts of research and resources have been allocated to facilitating more appropriate, timely, and comprehensive care of adults living with heart failure. Furthermore, education of patients regarding the importance of self-care continues to be a major area of interest. The optimal care of heart failure patients in the present era is very complex, which requires a multidisciplinary approach that leverages multiple modalities. There are past and ongoing learning from adults with heart failure that can be applied to pediatric patients. However, novel approaches to infants, children, adolescents, and their families will need to be developed that take into account the unique needs of the pediatric heart failure population. This is an exciting time in the outpatient care of children and adults given the almost daily development of new technologies that can facilitate bidirectional communication between patients/families and providers providing both subjective and objective data that can enhance care delivery well beyond our current practice.
Background:
Heart failure (HF) is a common condition requiring self-care to maintain physical stability, prevent hospitalization, and improve quality of life. Symptom perception, a domain of HF self-care newly added to the situation-specific theory of HF self-care, is defined as a comprehensive process of monitoring and recognizing physical sensations and interpreting and labeling the meaning of the sensations.
Objective:
The purpose of this integrative review was to describe the research conducted on HF symptom perception to further understanding of this new concept.
Method:
A literature search was conducted using 8 databases. The search term of HF was combined with symptom, plus symptom perception subconcepts of monitoring, somatic awareness, detection, recognition, interpretation, and appraisal. Only peer-reviewed original articles published in English with full-text availability were included. No historical limits were imposed. Study subjects were adults. Twenty-one studies met the inclusion criteria. Each study was categorized into either symptom monitoring or symptom recognition and interpretation.
Results:
Although daily weighing and HF-related symptom-monitoring behaviors were insufficient in HF patients, use of a symptom diary improved HF self-care, symptom distress and functional class, and decreased mortality, hospital stay, and medical costs. Most HF patients had trouble recognizing an exacerbation of symptoms. Aging, comorbid conditions, and gradual symptom progression made it difficult to recognize and correctly interpret a symptom exacerbation. Living with others, higher education, higher uncertainty, shorter symptom duration, worse functional class, and an increased number of previous hospitalizations were positively associated with symptom recognition.
Conclusions:
Existing research fails to capture all of the elements in the theoretical definition of symptom perception.
Measurement of comorbidity affects all variable axes that are considered in health care research: confounding, modifying, independent, and dependent variable. Comorbidity measurement particularly affects research involving older adults because they bear the disproportionate share of the comorbidity burden.
We examine how well researchers can expect to segregate study participants into those who are healthier and those who are less healthy, given the variable axis for which they are measuring comorbidity, the comorbidity measure they select, and the analytic method they choose. We also examine the impact of poor measurement of comorbidity.
Available comorbidity measures make use of medical records, self-report, physician assessments, and administrative databases. Analyses using these scales introduce uncertainties that can be framed as measurement error or misclassification problems, and can be addressed by extant analytic methods. Newer analytic methods make efficient use of multiple sources of comorbidity information.
Consideration of the comorbidity measure, its role in the analysis, and analogous measurement error problems will yield an analytic solution and an appreciation for the likely direction and magnitude of the biases introduced.
This exploratory study investigated the personal self-management perspectives of a sample of heavily comorbid primary care adults with at least four chronic health conditions. The study was specifically designed to explore the perceived health care needs of adults with numerous comorbid conditions by focusing on their self-management practices and relationships with primary care providers.
Midwest academic-based family medicine primary care clinic lacking any formal patient education, case management, or phone follow-up services.
A total of 18 heavily comorbid focus group participants described the complexities of their self-management practices and frequently frustrating office visit interactions with primary care providers.
: Four core themes and nine subthemes were identified concerning participants' ongoing self-management practices when attempting to navigate health care delivery systems and interact with providers. Future case management practice and research implications are discussed.
Case managers have an opportunity to fill the gaps in care for patients with multiple comorbid conditions. The case manager has the potential to address several of the issues identified by the patients in this study by helping comorbid patients develop self-management skills and tailoring supportive primary care interventions to meet individual patient needs.
The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three.
We sought to understand how the number, type, and severity of comorbidities influence diabetes patients' self-management and treatment priorities.
Cross-sectional observation study.
A total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.
We constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).
40% of respondents had at least 1 microvascular comorbidity, 79% at least 1 macrovascular comorbidity, and 61% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.
The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients' self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
The purposes of this study were to describe heart failure patient perceptions regarding instructions received for following a low-sodium diet and the benefits, barriers, and ease and frequency of following the diet. A total of 246 patients with heart failure referred from academic medical centers in the United States and Australia participated in the study. A subset of 145 patients provided 24-hour urine samples for sodium excretion assessment. While most (80%) patients reported receiving recommendations to follow a low-sodium diet, their recall of specific instructions was poor. Although the majority (75%) reported following a low-sodium diet most or all of the time, 24-hour urine sodium excretion indicated that only 25% of patients were adherent. Patients who reported being more adherent, however, had lower urine sodium excretion levels. Attitudes regarding difficulty in and perceived benefits of following the diet were not related to sodium excretion. Data on attitudes and barriers provided guidance for strategies to improve adherence.
Aging is associated with losses in hearing and vision. The objective of this study was to assess whether aging also is associated with less ability to detect and interpret afferent physiological information.
A cross-sectional mixed methods study was conducted with 29 persons with a confirmed diagnosis of chronic heart failure of at least 6 months duration. The sample was divided at the median to compare younger (<73 years) versus older (> or = 73 years) patients in the ability to detect and interpret their heart failure symptoms.
Shortness of breath was stimulated using a 6-minute walk test (6MWT) and used to assess the ability of heart failure patients to detect shortness of breath using the Borg measure of perceived exertion compared with gold standard ratings of each person's shortness of breath by trained registered nurse research assistants (inter-rater congruence 0.91). Accuracy of ratings by older patients was compared with those of younger patients. In-depth interviews were used to assess symptom interpretation ability.
Integrated quantitative and qualitative data confirmed that older patients had more difficulty in detecting and interpreting shortness of breath than younger patients. Older patients were twice as likely as younger to report a different level of shortness of breath than that noted by the registered nurse research assistants immediately after the 6MWT.
These results support our theory of an age-related decline in the ability to attend to internal physical symptoms. This decline may be a cause of poor early symptom detection.
The results of this study suggest that there is a need to develop interventions that focus on the symptom experience to help patients-particularly older ones-in somatic awareness and symptom interpretation. It may be useful to explore patients' statements about how they feel: "Compared to what? How do you feel today compared to yesterday?"
Each year, the American Heart Association, in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 2000, the Statistical Update has been cited more than 6500 times in the literature (including citations of all annual versions). In 2008 alone, the various Statistical Updates were cited approximately 1300 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year's edition, the Statistics Committee, which produces the document for the American Heart Association, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant papers from the literature over the past year. In future years, the Committee plans for the Statistical Update to be a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the American Heart Association's 2020 Impact Goals. In addition, future Statistical Updates will begin to incorporate the vast amounts of data becoming available from large population-based efforts to study the genetics of cardiovascular disease (CVD). Below are a few highlights from this year's Update.
Self-care is advocated as a method of improving outcomes from heart failure (HF), the final common pathway for several prevalent illnesses, including hypertension and coronary artery disease. HF is widespread in aging populations across the world.1 The burden of HF is manifested in poor quality of life (QOL)2,3 and early mortality.4 In addition, there are >3 million ambulatory care and emergency department visits5 and well over 1 million hospitalizations for HF in the United States annually,6 which contributes to the exorbitant costs associated with HF. Much of this healthcare utilization is thought to be preventable if patients engage in consistent self-care.7,8
This scientific statement seeks to highlight concepts and evidence important to the understanding and promotion of self-care in persons with HF. Specifically, the document describes what is known about (1) the self-care behaviors required of HF patients, (2) factors that make self-care challenging for patients, (3) interventions that promote self-care, and (4) the effect of self-care on HF outcomes. The review ends with evidence-based recommendations for clinicians and direction for future research.
Self-care is defined as a naturalistic decision-making process that patients use in the choice of behaviors that maintain physiological stability (symptom monitoring and treatment adherence) and the response to symptoms when they occur.9 The term naturalistic decision making is used to describe how people make decisions in real-world settings. Naturalistic decision makers focus on process rather than outcomes, make decisions based on the situation, let the context influence their decision-making processes, and base practical decisions on the information available at the moment.10
In HF, self-care maintenance requires following the advice of providers to take medications, eat a low-sodium diet, exercise, engage in preventive behaviors, and actively monitor themselves for signs and symptoms. Self-care management refers to decision making in …
The effectiveness of many heart failure (HF) treatments has been demonstrated, and national guidelines have been widely disseminated, yet HF care remains suboptimal. Numerous studies have examined barriers to HF care, but to date, there has been limited synthesis of these findings.
Sixty articles reporting data on barriers to HF care published between 1998 and 2007 met the criteria for inclusion in this review. Barriers to care were reported at the patient, provider, and system levels. Patient barriers were reported in 45 studies and were categorized in the main themes of knowledge, adherence, communication, functional limitations, comorbidities, psychosocial, and socioeconomic factors. Provider barriers were examined in 23 studies and included knowledge, diagnostic challenges, pharmacological concerns, communication issues, and personal factors. Barriers at the healthcare system level were reported in 13 studies and pertained to problems with organizational structure, communication, and lack of resources. Several barriers were interrelated and could not be exclusively categorized to a single level of care, with overlap also occurring within the main barrier themes.
Barriers to HF care were common and pervasive throughout the continuum of care. To effectively improve the quality of care and outcomes among HF patients, obstacles to HF care must be addressed at multiple levels.
Comparisons of heart failure (HF) patients with an unselected healthy sample in terms of quality of life (QoL) and depressive symptoms might prove misleading. We compared QoL and depressive symptoms of a HF population with an age- and gender-matched sample of community dwelling elderly.
Data were collected from 781 HF patients (36% female; age 72 +/- 9; New York Heart Association II-IV) and 781 age- and gender-matched community-dwelling elderly. Participants completed the Medical Outcome Study 36-item General Health Survey, the Cantril's Ladder of life, and the Center for Epidemiological Studies-Depression scale (CES-D). Analysis of variance techniques with Welch F test and chi-square tests were used to describe differences in QoL and depressive symptoms between different groups. For both men and women with HF, QoL was reduced and depressive symptoms were elevated when compared with their elderly counterparts (CES-D >or=16: 39% vs. 21%, P < .001). HF patients had more chronic conditions-specifically diabetes and asthma/chronic obstructive pulmonary disease. Impaired QoL and depressive symptoms were most prevalent among HF patients with comorbidities. Prevalence was also higher in HF patients in the absence of these conditions.
HF has a large impact on QoL and depressive symptoms, especially in women with HF. Differences persist, even in the absence of common comorbidities. Results demonstrate the need for studies of representative HF patients with direct comparisons to age- and gender-matched controls.
Diabetes mellitus (DM) and chronic kidney disease (CKD) are common in patients with chronic heart failure (HF) and are associated with poor outcomes. However, the impact of multimorbidity due to DM and CKD on outcomes, relative to co-morbidity due to DM alone, has not been well studied in these patients. Of the 7,788 patients with chronic HF in the Digitalis Investigation Group trial, 2,218 had DM. We categorized these patients into those with DM alone (DM-only n = 1,123) and those with both DM and CKD (DM-CKD n = 1,095). Propensity scores for DM-CKD, calculated for each of the 2,218 patients, were used to match 699 pairs of patients with DM-only or DM-CKD. Matched Cox regression models were used to estimate associations between DM-CKD and outcomes. All-cause mortality occurred in 44% (rate 1,648/10,000 person-years) of patients with DM-CKD and 39% (rate 1,349/10,000 person-years of follow-up) of patients with DM-only (hazard ratio when DM-CKD was compared with DM-only 1.34, 95% confidence interval [CI] 1.11 to 1.62, p = 0.003). All-cause hospitalization occurred in 76% (rate 5,799/10,000 person-years) and 73% (rate 4,909/10,000 person-years) of patients with DM-CKD and DM-only, respectively (hazard ratio 1.16, 95% CI 0.99 to 1.36, p = 0.064). Respective hazard ratios for other outcomes were cardiovascular mortality 1.33 (95% CI 1.07 to 1.66, p = 0.010), HF mortality 1.41 (95% CI 1.02 to 1.96, p = 0.040), cardiovascular hospitalization 1.17 (95% CI 0.99 to 1.39, p = 0.064), and HF hospitalization 1.26 (95% CI 1.03 to 1.55, p = 0.026). In conclusion, compared with co-morbidity due to DM alone, the presence of multimorbidity due to DM and CKD was associated with increased mortality and morbidity in patients with chronic HF.
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
This study attempts to develop a comprehensive set of comorbidity measures for use with large administrative inpatient datasets.
The study involved clinical and empirical review of comorbidity measures, development of a framework that attempts to segregate comorbidities from other aspects of the patient's condition, development of a comorbidity algorithm, and testing on heterogeneous and homogeneous patient groups. Data were drawn from all adult, nonmaternal inpatients from 438 acute care hospitals in California in 1992 (n = 1,779,167). Outcome measures were those commonly available in administrative data: length of stay, hospital charges, and in-hospital death.
A comprehensive set of 30 comorbidity measures was developed. The comorbidities were associated with substantial increases in length of stay, hospital charges, and mortality both for heterogeneous and homogeneous disease groups. Several comorbidities are described that are important predictors of outcomes, yet commonly are not measured. These include mental disorders, drug and alcohol abuse, obesity, coagulopathy, weight loss, and fluid and electrolyte disorders.
The comorbidities had independent effects on outcomes and probably should not be simplified as an index because they affect outcomes differently among different patient groups. The present method addresses some of the limitations of previous measures. It is based on a comprehensive approach to identifying comorbidities and separates them from the primary reason for hospitalization, resulting in an expanded set of comorbidities that easily is applied without further refinement to administrative data for a wide range of diseases.
The model for management of patients with heart failure may be a key determinant of morbidity and quality of life. Development of a better management strategy for these patients requires determination of the reasons for decompensation that leads to hospitalization.
To ascertain and rank the principal reasons for hospitalization of patients who have heart failure.
Retrospective audit of all 1992 admissions (N = 1031; 691 patients) coded for heart failure at a Veterans Affairs medical center and a tertiary care university medical center.
The diagnosis of heart failure was verified by preset criteria in 72% of the patients. Of the 496 patients with documented heart failure, worsening heart failure was a main reason for admission in 390 (79%). Despite different socioeconomic backgrounds, excessive sodium retention was the leading factor (55%) associated with decompensation in patients at both institutions. Other factors precipitated admission much less often.
Many hospitalizations for heart failure might be avoided by case management directed at lessening sodium overload. Increased use of medications known to be effective in persons with heart failure (angiotensin-converting enzyme inhibitors, digoxin, and adequate diuretic therapy) might reduce the likelihood of decompensation. Implementation of behavioral interventions to assist patients with self-monitoring signs of sodium retention and to improve compliance with medications and dietary sodium restrictions are strategies for further reducing the risk of decompensation.
Disease management programs are often advocated for the care of patients with chronic disease. This systematic review was conducted to determine whether these programs improve outcomes for patients with heart failure.
Randomized clinical trials of disease management programs in patients with heart failure were identified by searching Medline 1966 to 1999, Embase 1980 to 1998, Cinahl 1982 to 1999, Sigle 1980 to 1998, the Cochrane Controlled Trial Registry, the Cochrane Effective Practice and Organization of Care Study Registry, and the bibliographies of published studies. We also contacted experts in the field. Studies were selected and data extracted independently by two investigators, and summary risk ratios (RR) and 95% confidence intervals (CI) were calculated using both the random and fixed effects models.
A total of 11 trials (involving 2,067 patients with heart failure) were identified. Disease management programs were cost saving in 7 of the 8 trials that reported cost data and also appeared to have beneficial effects on prescribing practices. Hospitalizations (RR = 0.87, 95% CI: 0.79 to 0.96) but not all-cause mortality (RR = 0.94, 95% CI: 0.75 to 1.19) were reduced by the programs. However, there were considerable differences in the effects of various interventions on hospitalization rates; specialized follow-up by a multidisciplinary team led to a substantial reduction in the risk of hospitalization (RR = 0.77, 95% CI 0.68 to 0.86, n = 1366), whereas trials employing telephone contact with improved coordination of primary care services failed to find any benefit (RR = 1.15, 95% CI 0.96 to 1.37, n = 646).
Disease management programs for the care of patients with heart failure that involve specialized follow-up by a multidisciplinary team reduce hospitalizations and appear to be cost saving. Data on mortality are inconclusive. Further studies are needed to establish the incremental benefits of the different elements of these programs.
Self-care is difficult for patients with heart failure (HF) because early symptoms are subtle and the treatment regimen is complex. The primary purpose of this study was to describe HF self-care abilities and the difficulties that patients have in achieving success in self-care. A secondary purpose was to compare self-care abilities in patients experienced with HF with those patients who are newly diagnosed.
Descriptive, cross-sectional, comparative surveys were conducted to assess demographic and clinical factors that may interfere with self-care and lifestyle changes made to accommodate the diagnosis of HF. Symptoms the patients had and self-care responses to those symptoms were assessed by using the Self-Management of Heart Failure questionnaire.
The 139 patients were primarily elderly, male, retired, unmarried, and earning less than $20,000 annually. Hearing and eyesight were impaired and most patients were functionally compromised. Most of the group had multiple HF symptoms during the past year, yet their knowledge of the importance of signs and symptoms was poor and many misperceptions were evident. Recognition of changes in signs and symptoms was difficult for most patients, but easier for those more experienced with HF. Experienced patients were more likely to use appropriate self-care remedies than newly diagnosed patients. Few patients were comfortable evaluating the effectiveness of their self-care actions and most had low self-confidence in their ability to perform self-care.
With the low level of self-care ability and the number of difficulties these patients face, it is not surprising that rehospitalization rates remain high. Specific recommendations for the teaching and delivery of care are provided.
The management of chronic heart failure in elderly patients is often complicated by the presence of multiple comorbid conditions, polypharmacy, psychosocial and financial concerns, and difficulties with adherence to complex medication and dietary regimens. In addition, few patients over 80 years of age have been enrolled in clinical trials, so that the efficacy of current heart failure therapies remains uncertain in this age group. Taken together, these factors contribute to the persistently high hospitalization and mortality rates as well as the poor quality of life associated with chronic heart failure in the elderly.
In this article, nonpharmacologic aspects of care and the pharmacotherapy of systolic heart failure in elderly patients are reviewed. Optimal management requires a systematic approach comprising 5 key elements: coordination of care across disciplines, patient and caregiver education, enhancement of self-management skills, effective followup, and the judicious use of medications. However, it must be recognized that even with “best practice” interventions, the prognosis for established heart failure remains poor. Future research must therefore be directed at developing more effective strategies for the prevention of heart failure in our aging population.
Self-care of heart failure (HF) is difficult to master, but the reasons why remain unclear. The purpose of this study was to explore how HF influences patients' lives, assess how they perform self-care, and determine how their life situation facilitates or impedes HF self-care. Qualitative data were obtained from 26 individuals with chronic HF. Data were gathered using structured interviews and analyzed using content analysis. Physical limitations, debilitating symptoms, difficulties coping with treatment, lack of knowledge, distressed emotions, multiple comorbidities, and personal struggles were common. Self-care involved the recognition of symptoms, but atypical symptoms such as faintness were rarely attributed to HF. Patients discussed their successes and failures in following dietary, exercise, and medication recommendations. Some adaptation strategies were practical and some involved internal resources. Many patients accepted support from others, but some withdrew. With the number of barriers these patients face, it is not surprising that self-care of HF is typically poor and that readmission rates continue to be high. Recommendations are provided for a stepped approach to patient education and counseling that uses these findings in practice.
The authors undertook a qualitative meta-analysis of their own studies to examine the context of health care and health care relationships. They "translated" selected concepts and metaphors from each study through those of the other studies, yielding new interpretations. In this article, they present their methods, discuss possible applications of this approach, and examine some issues that remain unresolved in the area of qualitative meta-analysis. They offer this approach, which produced broader perspectives than the individual studies afforded, as a promising way of synthesizing qualitative findings, providing a foundation for praxis, and influencing practice toward health and social justice.
We studied the impact of noncardiac comorbidity on potentially preventable hospitalizations and mortality in elderly patients with chronic heart failure (CHF).
Chronic HF disproportionately affects older individuals, who typically have extensive comorbidity. However, little is known about how noncardiac comorbidity complicates care in these patients.
This was a cross-sectional study of 122,630 individuals age >/=65 years with CHF identified through a 5% random sample of all U.S. Medicare beneficiaries. We assessed the relationship of the 20 most common noncardiac comorbidities to one-year potentially preventable hospitalizations and total mortality. Preventable hospitalizations were determined by admissions for ambulatory care sensitive conditions using predefined criteria.
Sixty-five percent of the sample had at least one hospitalization, of which 50% were potentially preventable. Exacerbations of CHF accounted for 55% of potentially preventable hospitalizations. Nearly 40% of patients with CHF had >/=5 noncardiac comorbidities, and this group accounted for 81% of the total inpatient hospital days experienced by all CHF patients. The risk of hospitalization and potentially preventable hospitalization strongly increased with the number of chronic conditions (both p < 0.0001). After controlling for demographic factors and other diagnoses, comorbidities that were associated consistently with notably higher risks for CHF-preventable and all-cause preventable hospitalizations, and mortality, included chronic obstructive pulmonary disease/bronchiectasis, renal failure, diabetes, depression, and other lower respiratory diseases (all p < 0.01).
Noncardiac comorbidities are highly prevalent in older patients with CHF and strongly associate with adverse clinical outcomes. Cardiologists and other providers routinely caring for older patients with CHF may improve outcomes in this high-risk population by better recognizing non-CHF conditions, which may complicate traditional CHF management strategies.
rivate and public policymakers and health insurance plans increasingly are examining and introducing disease management programs to help treat chronic illnesses such as cardiovascular disease and stroke. The term disease manage- ment programs typically refers to multidisciplinary efforts to improve the quality and cost-effectiveness of care for select patients with chronic illness. This trend highlights the impor- tance of assessing the clinical and public policy implications of this phenomenon from the perspectives of patients' best interests and quality of care. To address the complex issues surrounding disease man- agement, the American Heart Association (AHA) assembled a multidisciplinary Advisory Working Group on Disease Management in 2002 to offer ongoing guidance in this evolving area. The Advisory Working Group developed a working definition of disease management and established core principles for the application of disease management to cardiovascular disease and stroke, which are the subject of this report. A. Quality of Care The AHA is committed to improving the quality of care that is available to patients suffering from or at risk for cardio- vascular disease and stroke through research, public educa- tion, advocacy, and the development and application of disease-specific, scientifically based standards and
Self-care is believed to improve outcomes in heart failure (HF) patients. However, research testing this assumption is hampered by difficulties in measuring self-care. The purpose of this study was to evaluate the psychometric properties of a revised instrument measuring self-care in persons with HF, the Self-Care of Heart Failure Index (SCHFI). The SCHFI is a self-report measure comprised of 15 items rated on a 4-point response scale and divided into 3 subscales.
Psychometric testing was done using data from 760 HF patients (age 70.36 +/- 12.3 years, 51% male) from 7 sites in the United States. Reliability of the SCHFI (alpha.76) was adequate. Reliability of the Self-Care Maintenance subscale was lower than desired (alpha.56) but the reliability of the other subscales was adequate: Self-Care Management (alpha.70) and Self-Care Self-Confidence (alpha.82). Construct validity was supported with satisfactory model fit on confirmatory factor analysis (NFI=.69, CFI.73). Construct validity was supported further with significant total and subscale (all P <.05) differences between patients experienced with HF and those newly diagnosed, consistent with the underlying theory.
Low reliability of the Self-Care Maintenance subscale was expected because the items reflect behaviors known to vary in individuals. The reliability and validity of the SCHFI are sufficient to support its use in clinical research.
Heart failure (HF) is the leading cause of hospitalization in older adults; it is also an important cause of death and chronic disability. HF in the elderly differs in many respects from HF occurring during middle age; in particular, the diagnosis and treatment of HF in the elderly are often complicated by the presence of multiple cardiac and noncardiac comorbid conditions, many of which have important implications for the care of the older HF patient. This article reviews the effects of common noncardiac comorbidities on the management of HF in older adults and discusses the impact of noncardiac comorbid conditions on clinical outcomes in the geriatric HF patient.
A low sodium diet is a cornerstone of nonpharmacologic therapy for heart failure patients. Although nonadherence is common, little is known about why heart failure patients fail to adhere to this diet.
The purpose of this study was to explore the experience of heart failure patients in following a low sodium diet.
We conducted a qualitative descriptive study with a convenience sample of 20 participants. Interviews were conducted and analyzed for themes. The data reflected three primary themes about nonadherence to the low sodium diet: lack of knowledge, interference with socialization, and lack of food selections. Participants expressed a need for details about low sodium food selection, food preparation, and rationale for the diet. Lack of knowledge also was manifested as diet confusion for participants who required additional dietary restrictions. Interference with socialization was manifested by patients' experiences with family conflict when family members ate high-sodium foods and difficulty eating out. The theme of lack of low sodium food selections was reflected by comments about limited food choices, and lack of palatability.
Researchers and clinicians need to consider patients' perceptions as they generate and evaluate interventions to increase adherence to a low sodium diet.
To evaluate in patients with heart failure (HF) due to systolic dysfunction the occurrence of polypharmacy, alternative medicine, immunization against influenza, and patients' knowledge about their medication.
Sixty-five patients, 49 men, mean age 60.5+/-12.0 years answered a confidential questionnaire during 2002. Polypharmacy was frequent, 48 (74%) were taking six or more pills per day and 18 (28%) 11 or more. Fifteen patients (23%) used over-the-counter analgesics. Eight patients (12%) used alternative medicine [five women (31%) vs. three men (6%), P=0.02]. Forty-four patients (68%) received immunization against influenza (18 patients <65 years (54%) vs. 25 patients > or =65 years (79%), P=0.03). Half the patients knew that beta-blockers and vasodilators decreased blood pressure, 31 patients receiving diuretics (88%) knew that this drugs help to eliminate liquids, 12 patients (38%) recognized this effect with low dose spironolactone and 23% or less with other drugs. Only 12 patients (42%) treated with acenocoumarol and 13 of those treated with aspirin (32%) recognized the action of these drugs.
Patients with HF and systolic dysfunction have a poor knowledge about the medication they receive. Polypharmacy, over-the-counter, homeopathic and alternative medicine use is frequent whereas the rate of immunization against influenza is low.
Disease management has shown great promise as a means of reorganizing chronic care and optimizing patient outcomes. Nevertheless, disease management programs are widely heterogeneous and lack a shared definition of disease management, which limits our ability to compare and evaluate different programs. To address this problem, the American Heart Association's Disease Management Taxonomy Writing Group developed a system of classification that can be used both to categorize and compare disease management programs and to inform efforts to identify specific factors associated with effectiveness.
The AHA Writing Group began with a conceptual model of disease management and its components and subsequently validated this model over a wide range of disease management programs. A systematic MEDLINE search was performed on the terms heart failure, diabetes, and depression, together with disease management, case management, and care management. The search encompassed articles published in English between 1987 and 2005. We then selected studies that incorporated (1) interventions designed to improve outcomes and/or reduce medical resource utilization in patients with heart failure, diabetes, or depression and (2) clearly defined protocols with at least 2 prespecified components traditionally associated with disease management. We analyzed the study protocols and used qualitative research methods to develop a disease management taxonomy with our conceptual model as the organizing framework.
The final taxonomy includes the following 8 domains: (1) Patient population is characterized by risk status, demographic profile, and level of comorbidity. (2) Intervention recipient describes the primary targets of disease management intervention and includes patients and caregivers, physicians and allied healthcare providers, and healthcare delivery systems. (3) Intervention content delineates individual components, such as patient education, medication management, peer support, or some form of postacute care, that are included in disease management. (4) Delivery personnel describes the network of healthcare providers involved in the delivery of disease management interventions, including nurses, case managers, physicians, pharmacists, case workers, dietitians, physical therapists, psychologists, and information systems specialists. (5) Method of communication identifies a broad range of disease management delivery systems that may include in-person visitation, audiovisual information packets, and some form of electronic or telecommunication technology. (6) Intensity and complexity distinguish between the frequency and duration of exposure, as well as the mix of program components, with respect to the target for disease management. (7) Environment defines the context in which disease management interventions are typically delivered and includes inpatient or hospital-affiliated outpatient programs, community or home-based programs, or some combination of these factors. (8) Clinical outcomes include traditional, frequently assessed primary and secondary outcomes, as well as patient-centered measures, such as adherence to medication, self-management, and caregiver burden.
This statement presents a taxonomy for disease management that describes critical program attributes and allows for comparisons across interventions. Routine application of the taxonomy may facilitate better comparisons of structure, process, and outcome measures across a range of disease management programs and should promote uniformity in the design and conduct of studies that seek to validate disease management strategies.
Self-care is vital for successful heart failure (HF) management. Mastering self-care is challenging; few patients develop sufficient expertise to avoid repeated hospitalization.
To describe and understand how expertise in HF self-care develops.
Extreme case sampling was used to identify 29 chronic HF patients predominately poor or particularly good in self-care. Using a mixed-methods (qualitative and quantitative) design, participants were interviewed about HF self-care, surveyed to measure factors anticipated to influence self-care, and tested for cognitive functioning. Audiotaped interviews were analyzed using content analysis. Qualitative and quantitative data were combined to produce a multidimensional typology of patients poor, good, or expert in HF self-care.
Only 10.3% of the sample was expert in HF self-care. Patients poor in HF self-care had worse cognition, more sleepiness, higher depression, and poorer family functioning. The primary factors distinguishing those good versus expert in self-care were sleepiness and family engagement. Experts had less daytime sleepiness and more support from engaged loved ones who fostered self-care skill development.
Engaged supporters can help persons with chronic HF to overcome seemingly insurmountable barriers to self-care. Research is needed to understand the effects of excessive daytime sleepiness on HF self-care.
Heart failure (HF) self-care is extremely challenging and few people master it. Self-care was defined as an active, cognitive process in which persons engage for the purpose of maintaining their health (maintenance) and managing symptoms (management).
To examine the contribution of attitudes, self-efficacy, and cognition to HF self-care management.
In this mixed methods study, 41 individuals (63.4% male, 68.3% Caucasian, mean age 49.17 (10.51) years, 58.5% NYHA III, median ejection fraction 30%) were interviewed and completed instruments on HF self-care, cognition, and physical functioning. Content analysis of narrative data revealed themes of self-care management practices, attitudes and self-efficacy towards self-care. Non-parametric tests assessed differences based on the types identified in the content analysis.
A self-care typology was constructed from the data: experts, novices and inconsistent. There were statistically significant differences (p=0.001) in self-care practices among types and variance in attitudes, self-efficacy, and cognition. Experts had experience and skill in self-care, which novices lacked, and positive attitudes and self-efficacy that aligned with their behaviors. Most patients (71%) were classified as inconsistent, a self-care type associated with impaired cognition, poor physical functioning, negative attitudes, and poor self-efficacy.
This typology provides insight into how expertise in self-care develops and the reasons why it is not always sustained.
Little is known about the burden of illness associated with advanced congestive heart failure (CHF). Understanding the needs of this population requires further information about symptoms and other factors related to quality of life. We studied a convenience sample of 103 community-dwelling patients with New York Heart Association Class III/IV CHF. The primary outcome, quality of life, was measured with the Multidimensional Index of Life Quality. Potential correlates of quality of life included overall symptom burden (Memorial Symptom Assessment Scale, MSAS), including global symptom distress (MSAS Global Distress Index, GDI); psychological state (Mental Health Inventory-5); functional status (Sickness Impact Profile); spirituality (Functional Assessment of Chronic Illness Therapy-Spirituality Scale); and co-morbid conditions (Charlson Comorbidity Index). Patients had a mean age of 67.1 years (SD=12.1); were mostly white (72.8%), male (71.8%), and married (51.5%); and had a mean ejection fraction of 22.3% (SD=6.8). The most prevalent symptoms were lack of energy (66%), dry mouth (62%), shortness of breath (56%), and drowsiness (52%). Pain was reported by about one-third of patients. For each of these symptoms, high symptom-related distress was reported by 14.1%-54.1%. Quality of life was moderately compromised (Multidimensional Index of Life Quality composite, median=56, possible range 12-84). Impairment in quality of life was strongly associated with global symptom distress (MSAS GDI; r=0.74, P<0.001); burden of comorbid conditions (r = -0.32, P=0.002), female sex (r=-0.22, P=0.03), functional impairment, particularly psychological impairment (r=-0.55, P<0.001), and poorer psychological well-being (r=0.68, P<0.001). In multivariate analyses, impairment in quality of life was significantly related to high symptom distress, poorer psychological well-being, and poor functional mobility (R2=0.67; P=0.002 for all). Distressful symptoms related to impaired quality of life included lack of energy (P=0.04), irritability (P=0.03), and drowsiness (P=0.02). Community-dwelling patients with advanced CHF experience numerous symptoms, significant symptom distress, and a compromised quality of life. Overall quality of life was strongly associated with symptom distress, psychological well-being and functional status. A focus on ameliorating prevalent physical symptoms and psychological distress, along with supportive measures that promote functional mobility, may lead to an improvement in the overall quality of life in this patient population.
The purposes of this study were to describe heart failure patient perceptions regarding instructions received for following a low-sodium diet and the benefits, barriers, and ease and frequency of following the diet. A total of 246 patients with heart failure referred from academic medical centers in the United States and Australia participated in the study. A subset of 145 patients provided 24-hour urine samples for sodium excretion assessment. While most (80%) patients reported receiving recommendations to follow a low-sodium diet, their recall of specific instructions was poor. Although the majority (75%) reported following a low-sodium diet most or all of the time, 24-hour urine sodium excretion indicated that only 25% of patients were adherent. Patients who reported being more adherent, however, had lower urine sodium excretion levels. Attitudes regarding difficulty in and perceived benefits of following the diet were not related to sodium excretion. Data on attitudes and barriers provided guidance for strategies to improve adherence.
Heart failure, a common syndrome in developed countries worldwide, is associated with poor quality of life, frequent rehospitalizations, and early death. Self-care is essential to improving outcomes in this patient population. The purpose of this article is to describe a situation-specific theory of heart failure self-care in which self-care is defined as a naturalistic decision-making process involving the choice of behaviors that maintain physiologic stability (maintenance) and the response to symptoms when they occur (management). Self-care maintenance is further defined to encompass routine symptom monitoring and treatment adherence. Self-care management is characterized as a process initiated by symptom recognition and evaluation, which stimulates the use of self-care treatments and treatment evaluation. Confidence in self-care is thought to moderate and/or mediate the effect of self-care on various outcomes. Four propositions were derived from the self-care of heart failure conceptual model: (1) symptom recognition is the key to successful self-care management; (2) self-care is better in patients with more knowledge, skill, experience, and compatible values; (3) confidence moderates the relationship between self-care and outcomes; and (4) confidence mediates the relationship between self-care and outcomes. These propositions were tested and supported using data obtained in previous research. Support of these propositions provides early evidence for this situation-specific theory of heart failure self-care.