Are we teaching what patients need to know? Building skills in heart failure self-care

Closing the loop in person-centered care: patient experiences of a chronic kidney disease self-management intervention

PURPOSE

The provision of self-management support (SMS) for people with earlier stages (1-4) of chronic kidney disease (CKD) can improve patient outcomes and extend time to dialysis. However, attempts to deliver such support have often not taken patient preferences into account. After the development, implementation, and quantitative evaluation of the person-centered CKD-SMS intervention, the aim of this study was to investigate participant experiences and perceptions of the program, as well as to seek suggestions to improve future SMS attempts.

PATIENTS AND METHODS

Semi-structured, face-to-face interviews were conducted with almost all (63/66) participants in the CKD-SMS. Deductive categories were derived from previous research into self-management from the CKD patient's perspective, and this was supplemented by categories that emerged inductively during multiple readings of interview transcripts. Content analysis was used to analyze interview data.

RESULTS

Participants recognized self-management of CKD as complex and multifaceted. They felt that the CKD-SMS helped them develop skills to engage in necessary self-management tasks, as well as their knowledge about their condition and confidence to take an active role in their healthcare. These participants experience a healthcare environment that is characterized by complexity and inconsistency, and participation in the intervention helped them to navigate it. The benefit of participating in this research to contribute to the scientific literature was also recognized by participants. Overall, participants found the CKD-SMS useful in its current format, and made some suggestions for future interventions.

CONCLUSION

People with CKD must engage in self-management behavior within a complex health environment. Individualized SMS such as the CKD-SMS provides an opportunity to support patients to manage their health effectively.

Recommendations of Common Data Elements to Advance the Science of Self-Management of Chronic Conditions

PURPOSE

Common data elements (CDEs) are increasingly being used by researchers to promote data sharing across studies. The purposes of this article are to (a) describe the theoretical, conceptual, and definition issues in the development of a set of CDEs for research addressing self-management of chronic conditions; (b) propose an initial set of CDEs and their measures to advance the science of self-management; and (c) recommend implications for future research and dissemination.

DESIGN AND METHODS

Between July 2014 and December 2015 the directors of the National Institute of Nursing Research (NINR)-funded P20 and P30 centers of excellence and NINR staff met in a series of telephone calls and a face-to-face NINR-sponsored meeting to select a set of recommended CDEs to be used in self-management research. A list of potential CDEs was developed from examination of common constructs in current self-management frameworks, as well as identification of variables frequently used in studies conducted in the centers of excellence.

FINDINGS

The recommended CDEs include measures of three self-management processes: activation, self-regulation, and self-efficacy for managing chronic conditions, and one measure of a self-management outcome, global health.

CONCLUSIONS

The self-management of chronic conditions, which encompasses a considerable number of processes, behaviors, and outcomes across a broad range of chronic conditions, presents several challenges in the identification of a parsimonious set of CDEs. This initial list of recommended CDEs for use in self-management research is provisional in that it is expected that over time it will be refined. Comment and recommended revisions are sought from the research and practice communities.

CLINICAL RELEVANCE

The use of CDEs can facilitate generalizability of research findings across diverse population and interventions.

Improving Heart Failure Self-care Through a Community-Based Skill-Building Intervention: A Study Protocol

BACKGROUND

Self-care is the cornerstone of heart failure (HF) management. Numerous approaches to improving HF self-care, which involves adherence to the treatment plan, routine symptom monitoring, and the response to symptoms when they occur, have been developed with little impact on HF outcomes. On the basis of HF practice recommendations that patients receive education and counseling that emphasizes self-care and targets skill building of critical target behaviors, we are conducting a clinical trial designed to improve self-care among community-dwelling older adults using an innovative group-based, skill-building approach led by a trained health educator.

OBJECTIVE

This article describes the study design and research methods used to implement and evaluate the intervention.

METHODS

The study uses a staggered randomized controlled design to assess feasibility of providing an HF self-care intervention in a community group setting to improve HF self-care, knowledge, and health-related quality of life at 1 and 3 months. A community engagement approach is used to partner with the community throughout all phases of the project. Seventy-five older adults with HF are randomly assigned to the intervention consisting of six to eight 60-minute sessions held in community senior centers or to the wait-list control group. Focus groups are used to elicit feedback on the participants' experience in the program.

RESULTS

Preliminary study participation data (n=60; women, 48%; black, 27%; Hispanic, 32%; mean [SD] age, 70 [10] years) and focus group feedback suggest that the delivery approach is feasible and acceptable, and the participants are very satisfied with the program.

CONCLUSIONS

Implementation of a community-based HF self-care intervention delivered in partnership with established community-based centers is an innovative approach to intervention. If efficacy is demonstrated, this intervention has far-reaching implications for helping the growing population of HF patients in ethnically diverse communities.

Establishing a pragmatic framework to optimise health outcomes in heart failure and multimorbidity (ARISE-HF): A multidisciplinary position statement

Background

Multimorbidity in heart failure (HF), defined as HF of any aetiology and multiple concurrent conditions that require active management, represents an emerging problem within the ageing HF patient population worldwide.

Methods

To inform this position paper, we performed: 1) an initial review of the literature identifying the ten most common conditions, other than hypertension and ischaemic heart disease, complicating the management of HF (anaemia, arrhythmias, cognitive dysfunction, depression, diabetes, musculoskeletal disorders, renal dysfunction, respiratory disease, sleep disorders and thyroid disease) and then 2) a review of the published literature describing the association between HF with each of the ten conditions. From these data we describe a clinical framework, comprising five key steps, to potentially improve historically poor health outcomes in this patient population.

Results

We identified five key steps (ARISE-HF) that could potentially improve clinical outcomes if applied in a systematic manner: 1) Acknowledge multimorbidity as a clinical syndrome that is associated with poor health outcomes, 2) Routinely profile (using a standardised protocol — adapted to the local health care system) all patients hospitalised with HF to determine the extent of concurrent multimorbidity, 3) Identify individualised priorities and person-centred goals based on the extent and nature of multimorbidity, 4) Support individualised, home-based, multidisciplinary, case management to supplement standard HF management, and 5) Evaluate health outcomes well beyond acute hospitalisation and encompass all-cause events and a person-centred perspective in affected individuals.

Conclusions

We propose ARISE-HF as a framework for improving typically poor health outcomes in those affected by multimorbidity in HF.

Nurse-Led Multidisciplinary Heart Failure Group Clinic Appointments: Methods, Materials, and Outcomes Used in the Clinical Trial

BACKGROUND

The Self-management and Care of Heart Failure through Group Clinics Trial evaluated the effects of multidisciplinary group clinic appointments on self-care skills and rehospitalizations in high-risk heart failure (HF) patients.

OBJECTIVE

The purpose of this article is to (1) describe key Self-management and Care of Heart Failure through Group Clinics Trial group clinic interactive learning strategies, (2) describe resources and materials used in the group clinic appointment, and (3) present results supporting this patient-centered group intervention.

METHODS

This clinical trial included 198 HF patients (randomized to either group clinical appointments or to standard care). Data were collected from 72 group clinic appointments via patients' (1) group clinic session evaluations, (2) HF self-care behaviors skills, (3) HF-related discouragement and quality of life scores, and (4) HF-related reshopitalizations during the 12-month follow-up. Also, the costs of delivery of the group clinical appointments were tabulated.

RESULTS

Overall, patients rated group appointments as 4.8 of 5 on the "helpfulness" in managing HF score. The statistical model showed a 33% decrease in the rate of rehospitalizations (incidence rate ratio, 0.67) associated with the intervention over the 12-month follow-up period when compared with control patients (χ(2)1=3.9, P=.04). The total cost for implementing 5 group appointments was $243.58 per patient.

CONCLUSION

The intervention was associated with improvements in HF self-care knowledge and home care behavior skills and managing their for HF care. In turn, better self-care was associated with reductions in HF-related hospitalizations.

Heart failure family-based education: a systematic review

OBJECTIVE

To systematically review evidence for the efficacy of family-based education for heart failure (HF) patients and carers.

METHOD

A systematic review was conducted. Databases CINAHL, MEDLINE Complete, Cochrane, PubMed, Web of Science, EMBASE, PsycINFO, and Scopus were searched between 1 January 2005 and 1 May 2015. Randomised controlled trials included HF patient and carer dyads or carers alone. The primary outcome was HF knowledge. Secondary outcomes included self-care behaviour, dietary and treatment adherence, quality of life, depression, perceived control, hospital readmissions, and carer burden.

RESULT

Six trials reported in nine papers were included. Wide variation in the quality of the studies was found. Two studies only examined HF knowledge; a significant improvement among patients and carers was reported. Other significant findings were enhanced patient self-care, boosted dietary and treatment adherence, enriched patient quality of life, improved perceived control among patients but not carers, and reduced carer burden

CONCLUSION

Modest evidence was found for family-based education among HF patients and carers. Methodological shortcomings of trials signify the need for empirically sound future research.

PRACTICE IMPLICATION

Family-based HF education needs to include strategies that are tailored to the HF patient and carer, and sustainable in nature.

How effective is an in-hospital heart failure self-care program in a Japanese setting? Lessons from a randomized controlled pilot study

BACKGROUND

Although the effectiveness of heart failure (HF) disease management programs has been established in Western countries, to date there have been no such programs in Japan. These programs may have different effectiveness due to differences in health care organization and possible cultural differences with regard to self-care. Therefore, the purpose of this study was to evaluate the effectiveness of a pilot HF program in a Japanese setting.

METHODS

We developed an HF program focused on enhancing patient self-care before hospital discharge. Patients were randomized 1:1 to receive the new HF program or usual care. The primary outcome was self-care behavior as assessed by the European Heart Failure Self-Care Behavior Scale (EHFScBS). Secondary outcomes included HF knowledge and the 2-year rate of HF hospitalization and/or cardiac death.

RESULTS

A total of 32 patients were enrolled (mean age, 63 years; 31% female). There was no difference in the total score of the EHFScBS between the two groups. One specific behavior score regarding a low-salt diet significantly improved compared with baseline in the intervention group. HF knowledge in the intervention group tended to improve more over 6 months than in the control group (a group-by-time effect, F=2.47, P=0.098). During a 2-year follow-up, the HF program was related to better outcomes regarding HF hospitalization and/or cardiac death (14% vs 48%, log-rank test P=0.04). In Cox regression analysis after adjustment for age, sex, and logarithmic of B-type natriuretic peptide, the program was associated with a reduction in HF hospitalization and/or cardiac death (hazard ratio, 0.17; 95% confidence interval, 0.03-0.90; P=0.04).

CONCLUSION

The HF program was likely to increase patients' HF knowledge, change their behavior regarding a low-salt diet, and reduce HF hospitalization and/or cardiac events. Further improvement focused on the transition of knowledge to self-care behavior is necessary.

Self Managing Heart Failure in Remote Australia - Translating Concepts into Clinical Practice

Congestive heart failure (CHF) is an ambulatory health care condition characterized by episodes of decompensation and is usually without cure. It is a leading cause for morbidity and mortality and the lead cause for hospital admissions in older patients in the developed world. The long-term requirement for medical care and pharmaceuticals contributes to significant health care costs. CHF management follows a hierarchy from physician prescription to allied health, predominately nurse-led, delivery of care. Health services are easier to access in urban compared to rural settings. The differentials for more specialized services could be even greater. Remote Australia is thus faced with unique challenges in delivering CHF best practice. Chronic disease self-management programs (CDSMP) were designed to increase patient participation in their health and alleviate stress on health systems. There have been CDSMP successes with some diseases, although challenges still exist for CHF. These challenges are amplified in remote Australia due to geographic and demographic factors, increased burden of disease, and higher incidence of comorbidities. In this review we explore CDSMP for CHF and the challenges for our region.

Self-management support for people with chronic kidney disease: Patient perspectives

BACKGROUND

Self-management of chronic kidney disease (CKD) is crucial for health outcomes and people need to be effectively supported by healthcare professionals (HCPs). Some programmes designed to improve self-management have been implemented, but people with the disease are rarely consulted regarding what they desire from these programmes.

OBJECTIVES

To provide a synthesis of the literature on preferences for self-management support of people with CKD.

DESIGN

An integrative review.

METHODS

Four databases (MedLine, CINAHL, PsycARTICLES and PsycINFO) were searched using relevant search terms.

RESULTS

The search strategy identified 1,913 records, of which 12 studies met inclusion criteria. Ten themes were identified as important areas to be addressed by self-management interventions. In addition, patient suggestions for implementation of such interventions are discussed.

CONCLUSION

The principles of a person-centred approach ought to frame the support provided by HCPs when supporting those with CKD to better self-manage.

Predictors of delay in heart failure patients and consequences for outcomes

Persons with heart failure (HF) symptoms delay up to 7 days before seeking treatment. Delay can result in worse symptoms and potentially impact outcomes. The purpose of this review was to describe predictors and outcomes of delay in HF patients. Demographic factors, increased symptom number, social factors, greater HF knowledge, lower anxiety, and depression predicted increased delay. HF patients had difficulty recognizing and interpreting symptoms of HF. Results are conflicting related to symptom pattern, time of care seeking, and history of HF as predictors of delay. The only outcome predicted by delay was length of stay with those delaying longer reporting longer lengths of stay. Future research related to delay should include theoretical frameworks and larger, more ethnically diverse samples from multiple sites and link delay to outcomes. Valid and reliable instruments are needed to measure delay and related factors. HF education should include supportive others.

ESUMS: a mobile system for continuous home monitoring of rehabilitation patients

The pressure on the healthcare services is building up for several reasons. The ageing population trend, the increase in life-style related disease prevalence, as well as the increased treatment capabilities with associated general expectation all add pressure. The use of ambient healthcare technologies can alleviate the situation by enabling time and cost-efficient monitoring and follow-up of patients discharged from hospital care. We report on an ambulatory system developed for monitoring of physical rehabilitation patients. The system consists of a wearable multisensor monitoring device; a mobile phone with client application aggregating the data collected; a service-oriented-architecture based server solution; and a PC application facilitating patient follow-up by their health professional carers. The system has been tested and verified for accuracy in controlled environment trials on healthy volunteers, and also been usability tested by 5 congestive heart failure patients and their nurses. This investigation indicated that patients were able to use the system, and that nurses got an improved basis for patient follow-up.

Reduction of heart failure rehospitalization using a weight management education intervention

BACKGROUND

Previous investigators have demonstrated that patient adherence to optimal weight monitoring resulted in fewer heart failure (HF)-related rehospitalizations.

OBJECTIVE

The aim of this study was to determine whether a weight management (WM) intervention can improve patients' WM ability and cardiac function and reduce HF-related rehospitalizations.

METHODS

Heart failure patients were randomly assigned to an intervention group (n = 32) or a control group (n = 34). The intervention group received the WM intervention, including education about regular daily weight monitoring and coping skills when detecting sudden weight gain, with a WM booklet and scheduled telephone visits. Patients' WM ability was measured by the Weight Management Questionnaire (WMQ). We compared scores on the WMQ, New York Heart Association (NYHA) classification, and HF-related rehospitalizations between the 2 groups at enrollment and at 6 months. We also analyzed the association of adherence to weight monitoring and rehospitalization in the intervention group during the 6-month follow-up.

RESULTS

There were no significant differences in weight monitoring adherence, WM ability, and NYHA classification between the 2 groups at baseline. At 6 months, scores on all 4 subscales of the WMQ significantly increased within the intervention group, and the WM-practice subscale significantly improved within the control group. Adherence to weight monitoring was significantly improved in the intervention group compared with the control group (81.25% vs 11.76%; P < .01). At 6 months, there was a significant improvement in NYHA class in the intervention group compared with the control group (P = .03). Rehospitalizations related to HF were also fewer in the intervention group (0.28 ± 0.63 vs 0.79 ± 1.18; P = .03) during the follow-up duration. In the intervention group, those who weighed themselves regularly reported less HF-related rehospitalizations than did those who did not (0.23 ± 0.43 vs 0.50 ± 1.23; P = .62).

CONCLUSION

This study demonstrates that the WM intervention had a positive impact on patients' adherence to weight monitoring, WM ability, and NYHA classification and reduced HF-related rehospitalization.

Multidisciplinary group clinic appointments: the Self-Management and Care of Heart Failure (SMAC-HF) trial

BACKGROUND

This trial tested the effects of multidisciplinary group clinic appointments on the primary outcome of time to first heart failure (HF) rehospitalization or death.

METHODS AND RESULTS

HF patients (n=198) were randomly assigned to standard care or standard care plus multidisciplinary group clinics. The group intervention consisted of 4 weekly clinic appointments and 1 booster clinic at month 6, where multidisciplinary professionals engaged patients in HF self-management skills. Data were collected prospectively for 12 months beginning after completion of the first 4 group clinic appointments (2 months post randomization). The intervention was associated with greater adherence to recommended vasodilators (P=0.04). The primary outcome (first HF-related hospitalization or death) was experienced by 22 (24%) in the intervention group and 30 (28%) in standard care. The total HF-related hospitalizations, including repeat hospitalizations after the first time, were 28 in the intervention group and 45 among those receiving standard care. The effects of treatment on rehospitalization varied significantly over time. From 2 to 7 months post randomization, there was a significantly longer hospitalization-free time in the intervention group (Cox proportional hazard ratio=0.45 (95% confidence interval, 0.21-0.98; P=0.04). No significant difference between groups was found from month 8 to 12 (hazard ratio=1.7; 95% confidence interval, 0.7-4.1).

CONCLUSIONS

Multidisciplinary group clinic appointments were associated with greater adherence to selected HF medications and longer hospitalization-free survival during the time that the intervention was underway. Larger studies will be needed to confirm the benefits seen in this trial and identify methods to sustain these benefits.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00439842.

Building skill in heart failure self-care among community dwelling older adults: results of a pilot study

OBJECTIVE

Most of the day-to-day care for heart failure (HF) is done by the patient at home and requires skill in self-care. In this randomized controlled trial (RCT) we tested the efficacy of a community-based skill-building intervention on HF self-care, knowledge and health-related quality of life (HRQL) at 1- and 3-months.

METHODS

An ethnically diverse sample (n=75) of patients with HF (53% female; 32% Hispanic, 27% Black; mean age 69.9±10 years) was randomized to the intervention group (IG) or a wait-list control group (CG). The protocol intervention focused on tactical and situational HF self-care skill development delivered by lay health educators in community senior centers. Data were analyzed using mixed (between-within subjects) ANOVA.

RESULTS

There was a significant improvement in self-care maintenance [F(2,47)=3.42, p=.04, (Cohen's f=.38)], self-care management [F(2,41)=4.10, p=.02, (Cohen's f=.45) and HF knowledge [F(2,53)=8.00, p=.001 (Cohen's f=.54)] in the IG compared to the CG.

CONCLUSIONS

The skill-building intervention improved self-care and knowledge but not HRQL in this community-dwelling sample.

PRACTICE IMPLICATIONS

Delivering an intervention in a community setting using lay health educators provides an alternative to clinic- or home-based teaching that may be useful across diverse populations and geographically varied settings.

Heart failure patients' experiences of a self-management peer support program: a qualitative study

OBJECTIVES

Explore the experiences of patients with heart failure in a self-management support program to inform the development of future interventions that support and motivate patients to engage in self-management.

BACKGROUND

Peer-support programs have led to improved outcomes among patients with other chronic conditions and may result in similar improvements for heart failure patients. Yet, among patients recently hospitalized for heart failure, over half had no or minimal engagement with a reciprocal peer support program.

METHODS

Qualitative semi-structured interviews with a purposive sample of 28 patients (mean age 72; 71% Female; 21% African-American; 75% Caucasian) with different levels and types of engagement in a heart failure self-management support program.

RESULTS

Key themes that emerged included the importance of heart failure specific-social support, sharing information, comparing self to others, depression, and functional status.

CONCLUSIONS

Useful services for heart failure patients provide comfort, restore confidence, and offer practical solutions.

A comprehensive symptom diary intervention to improve outcomes in patients with HF: a pilot study

BACKGROUND

Patients with heart failure must monitor for and recognize escalating symptoms to take action to relieve symptoms and decrease hospitalizations. However, symptom monitoring is not commonly performed. One way to promote patients' engagement in symptom monitoring is by providing a symptom diary.

PURPOSE

The aim of this study was to test the effect of a comprehensive daily symptom diary intervention on event-free survival and health-related quality of life (HRQOL).

METHODS

Patients were randomized into either intervention (n = 23) or usual-care groups (n = 21). The intervention group received a symptom diary with self-care education and counseling at baseline with 5 follow-up calls for 3 months. All patients were interviewed to obtain survival data at 1 month and 3 months. HRQOL was measured at baseline, 1 month, and 3 months. Kaplan-Meier curves with the log-rank test were used to compare group differences in time to first event. Linear mixed models were conducted to examine the relationship between groups and changes in HRQOL over 3 months.

RESULTS

The intervention group had longer event-free survival than the usual-care group (P = .03). There were no differences in changes in HRQOL scores between the groups over 3 months.

CONCLUSIONS

Positive effects of the intervention on survival were found. However, there was no significant difference in changes in HRQOL.

Implementing guideline based heart failure care in the Northern Territory: challenges and solutions

The Northern Territory of Australia is a vast area serviced by two major tertiary hospitals. It has both a unique demography and geography, which pose challenges for delivering optimal heart failure services. The prevalence of congestive heart failure continues to increase, imposing a significant burden on health infrastructure and health care costs. Specific patient groups suffer disproportionately from increased disease severity or service related issues often represented as a "health care gap". The syndrome itself is characterised by ongoing symptoms interspersed with acute decompensation requiring lifelong therapy and is rarely reversible. For the individual client the overwhelming attention to heart failure care and the impact of health care gaps can be devastating. This gap may also contribute to widening socio-economic differentials for families and communities as they seek to take on some of the care responsibilities. This review explores the challenges of heart failure best practice in the Northern Territory and the opportunities to improve on service delivery. The discussions highlighted could have implications for health service delivery throughout regional centres in Australia and health systems in other countries.

Barriers to health information seeking in Iranian patients with cardiovascular disease: a qualitative study

OBJECTIVE

Providing patients with health care information is a critical component of the process of cardiovascular disease (CVD) management. The purpose of this study was to explore obstacles to seeking health care information among cardiovascular patients from the perspectives of patients, their family caregivers, and health care providers.

METHODS

This study was conducted with a qualitative approach using conventional qualitative content analysis. The study included 31 Iranian participants including 16 cardiovascular patients, 5 family members, and 10 health care providers (multidisciplinary). Data were collected with semi-structured interviews and continued to the point of data saturation. Analysis of the data was performed continually and concurrently with data collection of using a comparative method.

RESULTS

Five themes emerged including 'poor quality of information provision,' 'mutual ambiguity,' 'beliefs, faith, and expectations,' 'from routine life to obtaining information,' and 'conditions governing information seekers.' Seven sub-themes indicated participants' experiences and understandings of obstacles in health care information seeking.

CONCLUSION

Health care information seeking in cardiovascular patients and their family members occurs as a result of the influence of beliefs, interaction with numerous information sources, and in the context and structure that the care and information are provided. Understanding the nature of obstacles to health information seeking will help health care policy makers to provide evidence-based, reliable, and patient-centered information to encourage cardiovascular patients' involvement in treatment decisions.

What should we tell patients with heart failure about sodium restriction and how should we counsel them?

This article is a review of current evidence regarding the recommended level of dietary sodium, involvement of family members in adoption of a low sodium diet, and evidence-based strategies to increase patient and family member willingness and ability to a follow a low sodium diet. The available evidence suggests that recommending a 2.5 to 3 g sodium diet will meet nutritional needs and decrease risk of hospitalizations. The best strategy identified for patient success is to fully involve both patients and family members in jointly reducing sodium intake. Motivational interviewing techniques should be used before counseling begins to guide patients and family members toward realization of the need to follow a low sodium diet. Successful counseling starts with determining perceptions, barriers, and individual characteristics that impede adherence. This information is incorporated into theory-based teaching strategies to promote behavior change and successful adoption of a low sodium diet.

Predictors of excess heart failure readmissions: implications for nursing practice

In this study of California, Massachusetts, and New York hospitals, 6 factors predicted 27.6% of readmissions for patients with heart failure (HF). We found that higher admissions per bed, teaching hospitals, and poor nurse-patient communication increased HF readmissions. Conversely, the HF readmissions were lower when nurse staffing was greater, more patients reported receiving discharge information, and among hospitals in California. The implications for nursing practice in the delivery of care to patients with HF are discussed.

Validity and reliability of the caregiver contribution to self-care of heart failure index

BACKGROUND

Caregivers make an important contribution to the self-care of patients with heart failure (HF), but few instruments are available to measure this contribution.

OBJECTIVE

The objective of this study was to test the psychometric properties of the Caregiver Contribution to Self-care of Heart Failure Index (CC-SCHFI), an instrument derived from the Self-care of Heart Failure Index version 6.2. The CC-SCHFI measures the contribution of caregivers to the self-care maintenance and self-care management of HF patients, as well as their confidence in their ability to contribute to the patients' HF self-care.

METHODS

A cross-sectional design was used to study 291 Italian caregivers whose HF patients were cared for in 17 cardiovascular centers across Italy. Caregivers completed the CC-SCHFI and a sociodemographic questionnaire. Caregivers were retested on the CC-SCHFI 2 weeks later to assess test-retest reliability.

RESULTS

Most caregivers were women (66%) with a mean age of 59 years. First- and second-order confirmatory factor analysis (CFA) for each CC-SCHFI scale showed good model fit: χ2 = 37.22, P = .08, Comparative Fit Index (CFI) = 0.97, Non-Normed Fit Index (NNFI) = 0.96 for caregiver contribution to self-care maintenance (second-order CFA); χ2 = 14.05, P = .12, CFI = 0.96, NNFI = 0.93 for caregiver contribution to self-care management (first-order CFA); and χ2 = 10.63, P = .15, CFI = 0.99, NNFI = 0.98 for caregiver confidence in contributing to self-care (second-order CFA). The CC-SCHFI was able to discriminate statistical and clinical differences between 2 groups of caregivers who had received or not received HF self-care education. Internal consistency reliability measured by factor score determinacy was more than .80 for all factors and scales except for 1 factor in the caregiver contribution to self-care management scale (.65). Test-retest reliability computed by intraclass correlation coefficient was high (>0.90) for most factors and scales.

CONCLUSION

The CC-SCHFI showed good psychometric properties of validity and reliability and can be used to measure the contribution of caregiver to HF patient self-care.

Cross-cultural adaptation and psychometric testing of the brazilian version of the self-care of heart failure index version 6.2

Objective. To adapt and evaluate the psychometric properties of the Brazilian version of the SCHFI v 6.2. Methods. With the approval of the original author, we conducted a complete cross-cultural adaptation of the instrument (translation, synthesis, back translation, synthesis of back translation, expert committee review, and pretesting). The adapted version was named Brazilian version of the self-care of heart failure index v 6.2. The psychometric properties assessed were face validity and content validity (by expert committee review), construct validity (convergent validity and confirmatory factor analysis), and reliability. Results. Face validity and content validity were indicative of semantic, idiomatic, experimental, and conceptual equivalence. Convergent validity was demonstrated by a significant though moderate correlation (r = −0.51) on comparison with equivalent question scores of the previously validated Brazilian European heart failure self-care behavior scale. Confirmatory factor analysis supported the original three-factor model as having the best fit, although similar results were obtained for inadequate fit indices. The reliability of the instrument, as expressed by Cronbach's alpha, was 0.40, 0.82, and 0.93 for the self-care maintenance, self-care management, and self-care confidence scales, respectively. Conclusion. The SCHFI v 6.2 was successfully adapted for use in Brazil. Nevertheless, further studies should be carried out to improve its psychometric properties.

Barriers and facilitators to self-care in chronic heart failure: a meta-synthesis of qualitative studies

Chronic heart failure (CHF) is a costly condition that places large demands on self-care. Failure to adhere with self-care recommendations is common and associated with frequent hospitalization. Understanding the factors that enable or inhibit self-care is essential in developing effective health care interventions. This qualitative review was conducted to address the research question, "What are the barriers and facilitators to self-care among patients with CHF?" Electronic databases including Medline, EMBASE, CINAHL, Web of Science, Scopus and Google scholar were searched. Articles were included if they were peer reviewed (1995 to 2012), in English language and investigated at least one contextual or individual factor impacting on self-care in CHF patients > 18years. The criteria defined by Kuper et al. including clarity and appropriateness of sampling, data collection and data analysis were used to appraise the quality of articles. Twenty-three articles met the inclusion criteria. Factors impacting on self-care were included factors related to symptoms of CHF and the self-care process; factors related to personal characteristics; and factors related to environment and self-care system. Important factors such as socioeconomic situation and education level have not been explored extensively and there were minimal data on the influence of age, gender, self-confidence and duration of disease. Although there is an emerging literature, further research is required to address the barriers and facilitators to self-care in patients with CHF in order to provide an appropriate guide for intervention strategies to improve self-care in CHF.

One size does not fit all: the different experiences of those with chronic heart failure, type 2 diabetes and chronic obstructive pulmonary disease

INTRODUCTION

The Australian federal government is developing a policy response to chronic disease in Australia. The Serious and Continuing Illness Policy and Practice Study examined the experience of individuals with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) or type 2 diabetes mellitus (diabetes) in the Australian Capital Territory (ACT) and Western Sydney. This paper describes the disease-specific experiences of people interviewed.

METHODS

We conducted semi-structured interviews with 40 individuals aged 45-85 years with CHF, COPD or diabetes in 2008. Interviews were recorded and transcribed. Qualitative content analysis was performed, assisted by QSR Nvivo 8 qualitative data software.

RESULTS

Participants with CHF (n=9) came to terms with the prospect of unpredictable sudden death. Participants with COPD (n=15) were angry about limitations it imposed on their lives. Participants with diabetes (n=16) experienced a steep learning curve in self-management of their condition surrounded by high levels of uncertainty.

CONCLUSION

Although people with chronic illness share many experiences, a person's overall experience of living with chronic illness is significantly shaped by the nature of their specific dominant disease. Policies for patient-centred care must take account of both generic and disease-specific elements.

Differences between heart failure clinics and primary health care

There is a paucity of knowledge concerning how people with heart failure experience differences between specialised heart failure clinics and primary healthcare in Sweden. This study aimed to describe differences regarding information and follow-up in heart failure clinics and primary healthcare. The study was conducted in Sweden in 2011. Four people (three men, one woman; aged 60 to 84) with heart failure (NYHA II) were interviewed. The interviews were analysed with qualitative content analysis. The findings revealed after referral from the heart failure clinic to primary healthcare, follow-ups were omitted. Still, the patients needed care, support and information. The findings are illuminated in four themes. The patients' varying and individual needs can be difficult to recognise and manage unless they are followed-up from either HFC or PHC on a regular basis.

Home care safety markers: a scoping review

Safety in home care is a new research frontier, and one in which demand for services continues to rise. A scoping review of the home care literature on chronic obstructive pulmonary disease and congestive heart failure was thus completed to identify safety markers that could serve to develop our understanding of safety in this sector. Results generated seven safety markers: (a) Home alone; (b) A fixed agenda in a foreign language; (c) Strangers in the home; (d) The butcher, the baker, the candlestick maker; (e) Medication mania; (f) Out of pocket: The cost of caring at home; and (g) My health for yours: Declining caregiver health.

A middle-range theory of self-care of chronic illness

Nearly 50% of adults have one or more chronic illnesses. Self-care is considered essential in the management of chronic illness, but the elements of self-care in this context have not been specified in a middle-range theory. This article describes a middle-range theory of self-care that addresses the process of maintaining health with health promoting practices within the context of the management required of a chronic illness. The key concepts include self-care maintenance, self-care monitoring, and self-care management. Assumptions and propositions of the theory are specified. Factors influencing self-care including experience, skill, motivation, culture, confidence, habits, function, cognition, support from others, and access to care are described.

Impact of telehealth on patient self-management of heart failure: a review of literature

PURPOSE

The objective of the study was to explore the impact of telehealth interventions on individuals' self-care of heart failure (HF).

BACKGROUND

Heart failure is a chronic illness that requires a complex treatment regimen over a long period. Historically, effective self-care has been difficult for this population. There is a need for innovative and effective approaches to improve individual self-care. Telehealth can potentially help individuals with HF follow the plan of care resulting in improved health outcomes and a better quality of life.

REVIEW METHODS

A comprehensive computer-assisted literature search using the terms "(telemedicine OR telehealth) AND (self-care OR self-management) AND (heart failure)" was conducted using electronic databases of ASP, CINAHL, Cochrane reviews, ERIC, PubMed, PsychINFO, Social Sciences Abstracts Index, and Web of Science for studies published between 2000 and 2010 to find research that met the inclusion criteria.

RESULTS

Fourteen studies were included in the review. Telehealth resulted in significant improvement of HF self-care behaviors of daily weighing, medication management, exercise adherence, fluid and alcohol restriction, salt restriction, or stress reduction in the telehealth intervention group in 5 studies. Participants reported improved HF self-care behaviors in 3 other studies with pretest-posttest design. Five others found no difference between the intervention and control groups. Content analysis of the data in the qualitative study revealed themes suggesting that telehealth can be effective in promoting self-care for individuals with HF. However, small sample size and inadequate measurement methods limit the generalizability of the findings of the studies included in this review.

CONCLUSION

Although this review included several studies with flawed design issues, the available evidence supports the use of telehealth in enabling self-care of HF. Further exploration is needed to determine the effect of telehealth on HF self-care outcomes using studies with high-quality design and improved data collection procedures.

Self care in patients with chronic heart failure

'Heart failure self care' refers to the practices in which patients engage to maintain their own health, and to the decisions that they make about managing signs or symptoms. In this article, we base our discussion of self care in chronic heart failure on the classification of patients as being 'expert', inconsistent', or 'novice' in heart failure self-care behaviors. The available literature on factors predicting heart failure self care and its outcomes are reviewed within this context. Factors known to influence heart failure self care include experience with the illness, physical functioning, depression and anxiety, social support, daytime sleepiness, and attitudes such as confidence. Further research is needed to understand the contributions of comorbidities, patient sex, and health disparities on heart failure self care. The evidence to support a link between heart failure self care and health outcomes is limited, but early evidence suggests that adequate self care is associated with an improvement in health status, a decrease in the number and duration of hospitalizations, and a decline in levels of biomarkers of stress and inflammation, and in intrathoracic impedance. Implications of heart failure self care for clinical practice, policy, and public health are also described.