Patterns of caregiving among patients hospitalized with cardiovascular disease. J Cardiovasc Nurs. 2011;26:305-311. [PMID: 21330929 DOI: 10.1097/jcn.0b013e3181f34bb3]

Psychometric Testing of the Mutuality Scale in Patients and Caregiver Dyads After the Onset of Coronary Heart Disease

This study investigates the psychometric properties of the Mutuality Scale in a sample of patient-caregiver dyads following a recent episode of coronary heart disease. A cross-sectional analysis was conducted. Factorial validity was tested with confirmatory factory analysis. Internal consistency reliability was investigated with the model-based internal consistency reliability index. Pearson's correlation coefficient was used to test convergent validity between mutuality and other theoretical and empirical variables associated with it. We included 150 patient-caregiver dyads (patient: mean age 65 years, 77% males, 71% married; caregiver: mean age 54 years, 21% males, 71% married). The CFA testing the theoretical four-factors (love, shared pleasurable activities, shared values, and reciprocity) of mutuality demonstrated adequate fit to the data in both the patient and caregiver version of the scale. Reliability estimates were adequate for the whole scale (model-based internal consistency index = 0.95). Significant positive correlations were observed between mutuality and self-care behaviors, and caregiver preparedness, supporting convergent validity. The Mutuality Scale demonstrated satisfactory structural and convergent validity and reliability in patient-caregiver dyads after the onset of a coronary heart disease event.

The effect of emotional freedom techniques (EFT) on anxiety and caregiver burden of family caregivers of patients with heart failure: A quasi-experimental study

BACKGROUND

Family members are at the forefront of providing care to patients with chronic illnesses, such as heart failure (HF). Since patient caregiving can affect the mental and physical health of family caregivers, the implementation and training of new psychological interventions by nurses are considered important and necessary for family caregivers. Therefore, the aim of this study was to evaluate the effect of emotional freedom techniques (EFTs) on anxiety and caregiver burden of family caregivers of patients with HF.

MATERIALS AND METHODS

This study was a quasi-experimental study, in which 91 family caregivers participated. The family caregivers were assigned into two groups of intervention (n = 46) and control (n = 45). Data were collected using a demographic information form, Zung Self-Rating Anxiety Scale (SAS), and Caregiver Burden Inventory (CBI) developed by Novak and Guest. The intervention group underwent EFT training within six sessions, while the control group received no training. Descriptive statistics (mean, standard deviation, and absolute and relative frequency) and inferential statistical tests such as Chi-square, Fisher's exact, and independent t-tests were run, and the data were analyzed by Statistical Package for the Social Sciences (SPSS) version 23 software.

RESULTS

The findings showed that the intervention group had a significant improvement in reducing anxiety (P > 0.001). In addition, EFT significantly reduced caregiver burden among family caregivers of HF patients (P > 0.001).

CONCLUSION

EFT could significantly reduce anxiety and caregiver burden in family caregivers of patients with HF in our study. Therefore, nurses working in clinical settings are recommended to learn and use EFT to reduce the anxiety and caregiver burden of patients' family caregivers.

Understanding Caregiver Challenges: A Comprehensive Exploration of Available Resources to Alleviate Caregiving Burdens

INTRODUCTION

Aging is associated with significant alterations in physical, cognitive, and emotional functions, predisposing older adults to multimorbidity and functional dependence that necessitate assistance with the activity of daily living (ADL) and medical care from caregivers. With a substantial increase in the aging population comes a growing demand for caregivers, particularly informal caregivers who provide unpaid care to older adults with complex needs. However, they face substantial physical, emotional, and financial burdens as they balance caregiving with their family and job demands.

AIM

This study aimed to explore key challenges faced by caregivers and the resources they need to address their caregiving burden. Additionally, we wanted to identify whether the number of years of caregiving is associated with their burden. These study findings will inform the design and development of our smartphone app which aims to alleviate the burden of diseases for older adults and the burden of caregiving for caregivers.

METHODS

From October to December 2022, we invited 80 self-reported caregivers for an anonymous online survey. The caregivers were located in three cities (Galveston, Houston, and Dallas in Texas) and were affiliated with the International Buddhist Progress Society-Dallas (IBPS Dallas) and the University of Texas Medical Branch (UTMB) Osher Lifelong Learning Institute (OLLI). The collected data were subjected to content analysis through systematic examination for meaningful patterns, themes, and insights. Individual characteristics and caregiving experiences were divided by years of care: 0-4 vs. 5+ years to investigate whether the caregiving burden was affected by the duration of caregiving.

RESULTS

The results showed several important insights, including gender dynamics and traditional norms, the advanced age of caregivers, and the prevalent health conditions they are managing. Caregivers' roles ranged from medical (insurance and medication assistance, etc.) at 63.8% to the provision of non-medical related resources (basic needs, utility, transportation, financial assistance, etc.) at 96.3%. Caregiving is also associated with some positive outcomes, such as changes in knowledge and skills (77.5%) with more confidence in ADL support tasks and a deepening of caregiver/care recipient dyad relationships (56.3%). Some faced challenges in navigating complex healthcare and social service systems and others experienced neglect and received inadequate support from the government-supported social services (33.8%). However, there is no significant variation between those with 0-4 and 5+ years of experience across all identified themes, suggesting that the burdens and resource needs of caregivers can manifest early on and are likely to persist beyond the five-year mark.

CONCLUSION

Our findings reveal that the number of caregiving years does not significantly influence the types of caregiving burden experienced by caregivers or the resources they require. This indicates the need for providing long-term support to older adults with chronic conditions from the early stage, while also emphasizing the critical role of immediate assistance for caregivers to alleviate caregiving burden. A free-of-charge technology like our smartphone app has the potential to effectively reduce stress for caregivers, offering them support at any time and place. Future studies will focus on evaluating the outcomes of caregivers after utilizing our app.

Clinicians for CARE: A Systematic Review and Meta-Analysis of Interventions to Support Caregivers of Patients With Heart Disease

Background Caregivers provide critical support for patients with chronic diseases, including heart disease, but often experience caregiver stress that negatively impacts their health, quality of life, and patient outcomes. We aimed to inform health care teams on an evidence-based approach to supporting the caregivers of patients with heart disease. Methods and Results We conducted a systematic review and meta-analysis of randomized controlled trials written in English that evaluated interventions to support caregivers of patients with heart disease. We identified 15,561 articles as of April 2, 2020 from 6 databases; of which 20 unique randomized controlled trials were evaluated, representing a total of 1570 patients and 1776 caregivers. Most interventions focused on improving quality of life, and reducing burden, depression, and anxiety; 85% (17 of 20) of the randomized controlled trials provided psychoeducation for caregivers. Interventions had mixed results, with moderate non-significant effects observed for depression (Hedges' g=-0.64; 95% CI, -1.34 to 0.06) and burden (Hedges' g=-0.51; 95% CI, -2.71 to 1.70) at 2 to 4 months postintervention and small non-significant effects observed for quality of life and anxiety. These results were limited by the heterogeneity of outcome measures and intervention delivery methods. A qualitative synthesis of major themes of the interventions resulted in clinical recommendations represented with the acronym "CARE" (Caregiver-Centered, Active engagement, Reinforcement, Education). Conclusions This systematic review highlights the need for greater understanding of the challenges faced by caregivers and the development of guidelines to help clinicians address those challenges. More research is necessary to develop clinical interventions that consistently improve caregiver outcomes.

Assessment of Different Risk Factors Among Adult Cardiac Patients at a Single Cardiac Center in Saudi Arabia

Background 

Cardiovascular disease (CVD) has remained the leading cause of death in the last 15 years and is one of the main health problems in Saudi Arabia. Our study aims to assess the prevalence of different CVD risk factors and correlate them among King Faisal Cardiac Center patients in King Abdul-Aziz Medical City in Jeddah, Saudi Arabia.

Methods

We conducted a cross-sectional study using a convenient sampling technique. Data were collected by interviewing adult patients admitted to King Faisal Cardiac Center and diagnosed with hemodynamically stable cardiac disease. We excluded patients with multiple medical conditions that contribute to acute mental disorders. The sample size was calculated to be 200 patients.

Results

Overall, 163 patients completed the survey. The majority of the participants (49.1%) were between 46-65 years of age, males, non-smokers, and had more than 11 children. Diabetes was found to be the most common risk factor (66.3%). Most participants had mild to moderate anxiety (63.8%) and depression (66.9%). Most of the patients (51.5%) have a high 10-year risk of developing CVD, followed by moderate and low risk (33.1% and 15.3%, respectively).

In our study, a high 10-year risk of CVD was significantly associated with age between 46-80 years with a p-value=0.002, male gender with a p-value=0.007, cigarette smoking with a p-value=0.031, and diabetes with a p-value=0.035.

Conclusion

The study demonstrated a high prevalence of the following CVD risk factors: age, male gender, immobility, obesity, diabetes, dyslipidemia, and hypertension. In addition, a significant association was found between high 10-year risk of CVD and age, gender, smoking, number of children, and diabetes with a p-value<0.05. No significant association was found in the other risk factors such as obesity, body mass index (BMI), immobility, caregiver, dyslipidemia, depression, and anxiety.

"We are doing it together"; The integral role of caregivers in a patients' transition home from the medicine unit

Background

An admission to hospital for acute illness can be difficult for patients and lead to high levels of anxiety. Patients are given a lot of information throughout their hospital stay and instructions at discharge to follow when they get home. For complex medical patients, the ability to retain, understand, and adhere to these instructions is a critical marker of a successful transition. This study was undertaken to explore factors impacting the ability of patients to understand and adhere to instructions.

Methods

A qualitative design of interviews with patients and caregivers was used. Participants were adult patients and caregivers with congestive heart failure, chronic obstructive pulmonary disease, or community-acquired pneumonia being discharged home from three academic acute care hospitals in Ontario, Canada. Semi structured interviews were conducted with participants within one week following their discharge from hospital. Interviews were audiotaped and transcribed. Five independent researchers participated in an iterative process of coding, reviewing, and analyzing the interviews using direct content analysis.

Results

In total, 27 participants completed qualitative interviews. Analysis revealed the role of the caregiver to be critical in its relation to the ability of patients to understand and adhere to discharge instructions. Within the topic of caregiving, we draw on three areas of insight: The first clarified how caregivers support patients after they are discharged home from the hospital. The second highlighted how caregiver involvement impacts patient understanding and adherence to discharge instructions. The third revealed system factors that influence a caregiver’s involvement when receiving discharge instructions.

Conclusion

Caregivers play an important role in the transition of a complex medical patient by impacting a patient’s ability to understand and adhere to their discharge instructions. The themes identified in this paper highlight opportunities for healthcare providers and institutions to effectively involve caregivers during transitions from acute care hospitals to home.

Specific needs, concerns, strategies and advice of caregivers after coronary artery bypass surgery

OBJECTIVE

To describe concerns, needs, strategies and advice of coronary artery bypass (CABG) caregivers during the first 3 months post-surgery.

BACKGROUND

Nearly 400,000 patients underwent CABG surgery in 2010. While caregiving demand and difficulty has been investigated in early (4-8 weeks), mid (3 month), and later (6-12 months) recovery, no studies have explored early-to-mid concerns in-depth.

METHODS

In this qualitative study, a purposive sample of CABG partners participated in structured interviews. Themes for burden concerns, needs and strategies were derived using constant comparative analysis.

RESULTS

One global theme 'knowing what I'm supposed to be doing' emerged. Specific themes related to medications, mobility, symptom monitoring, memory, appetite, emotional spirits, and finances.

CONCLUSIONS

The resounding need for a dedicated caregiver program to prepare partners for their role, including what to expect, warrants exploration. Future research should validate these concerns in more diverse samples so interventions can be targeted to better support caregivers.

Practical Care Support During the Early Recovery Period After Acute Coronary Syndrome

OBJECTIVE

To describe the prevalence and predictors of receipt of practical support among acute coronary syndrome (ACS) survivors during the early post-discharge period.

METHOD

406 ACS patients were interviewed about receipt of practical (instrumental and informational) support during the week after discharge. Demographic, clinical, functional, and psychosocial predictors of instrumental and informational practical support were examined.

RESULTS

81% of participants reported receiving practical support during the early post-discharge period: 75% reported receipt of instrumental support and 51% reported receipt of informational support. Men were less likely to report receiving certain types of practical support, whereas married participants and those with higher education, impaired health literacy, impaired activities of daily living, and in-hospital complications were more likely to report receiving certain types of practical support.

CONCLUSION

Receipt of practical support is very common among ACS survivors during the early post-discharge period, and type of support received differs according to patient characteristics.

Racial and Ethnic Differences in Acute Coronary Syndrome and Myocardial Infarction Within the United States: From Demographics to Outcomes

In the United States, different races, ethnicities, and their subgroups experience disparities regarding acute coronary syndrome (ACS) and myocardial infarction (MI). This review highlights these differences across 4 stages that comprise the ACS/MI narrative: (1) patient demographics, (2) patient comorbidities and health risks, (3) treatments and their delays, and (4) outcomes. Overall, black and Hispanic ACS/MI patients are more likely to present with comorbidities, experience longer delays before treatment, and suffer worse outcomes when compared with non-Hispanic white patients. More specifically, across the studies analyzed, black and Hispanic ACS/MI patients were consistently more likely to be younger or female, or to have hypertension or diabetes, than non-Hispanic white patients. ACS/MI disparities also exist among Asian populations, and these are briefly outlined. However, black, Hispanic, and non-Hispanic white ACS/MI patients were the 3 most-studied racial and ethnic groups, indicating that additional studies of other minority groups, such as Native Americans, Asian populations, and black and Hispanic subgroups, are needed for their utility in reducing disparities. Despite notable improvement in ACS/MI treatment quality measures over recent decades, disparities persist. Causes are complex and extend beyond the healthcare system to culture and patients' personal characteristics; sophisticated solutions will be required. Continued research has the potential to further reduce or eliminate disparities in the comorbidities, delays, and treatments surrounding ACS and MI, extending healthy lifespans of many underserved and minority populations, while reducing healthcare costs.

Population-level differences in revascularization treatment and outcomes among various United States subpopulations

Despite recent general improvements in health care, significant disparities persist in the cardiovascular care of women and racial/ethnic minorities. This is true even when income, education level, and site of care are taken into consideration. Possible explanations for these disparities include socioeconomic considerations, elements of discrimination and racism that affect socioeconomic status, and access to adequate medical care. Coronary revascularization has become the accepted and recommended treatment for myocardial infarction (MI) today and is one of the most common major medical interventions in the United States, with more than 1 million procedures each year. This review discusses recent data on disparities in co-morbidities and presentation symptoms, care and access to medical resources, and outcomes in revascularization as treatment for acute coronary syndrome, looking especially at women and minority populations in the United States. The data show that revascularization is used less in both female and minority patients. We summarize recent data on disparities in co-morbidities and presentation symptoms related to MI; access to care, medical resources, and treatments; and outcomes in women, blacks, and Hispanics. The picture is complicated among the last group by the many Hispanic/Latino subgroups in the United States. Some differences in outcomes are partially explained by presentation symptoms and co-morbidities and external conditions such as local hospital capacity. Of particular note is the striking differential in both presentation co-morbidities and mortality rates seen in women, compared to men, especially in women ≤ 55 years of age. Surveillance data on other groups in the United States such as American Indians/Alaska Natives and the many Asian subpopulations show disparities in risk factors and co-morbidities, but revascularization as treatment for MI in these populations has not been adequately studied. Significant research is required to understand the extent of disparities in treatment in these subpopulations.

Effects of partners together in health intervention on physical activity and healthy eating behaviors: a pilot study

BACKGROUND

Despite proven efficacy of cardiac rehabilitation (CR) in helping patients initiate physical activity and healthy eating changes, less than 50% of CR participants maintain changes 6 months later.

OBJECTIVE

The objective of this feasibility study was to test the Partners Together in Health (PaTH) intervention versus usual care in improving physical activity and healthy eating behaviors in coronary artery bypass graft surgery patients and their spouses.

METHODS

An experimental, 2-group (n = 17 couples/group), repeated-measures design was used. Coronary artery bypass surgery patients in both groups participated in phase II outpatient CR. Spouses in the PaTH group attended CR with the patient and were asked to make the same physical activity and healthy eating changes as patients did. Spouses in the usual care attended educational classes with patients. It was theorized that "2 persons would be better than 1" at making changes and sticking with them in the long-term. Physical activity behavior was measured using the Actiheart accelerometer; the activity biomarker was an exercise tolerance test. Eating behavior was measured using 3-day food records; the biomarker was the lipid profile. Data were collected at baseline (entrance in CR), at 3 months (post-CR), and at 6 months. Changes over time were examined using Mann-Whitney U statistics and effect sizes.

RESULTS

The PaTH intervention was successful primarily in demonstrating improved trends in healthy eating behavior for patients and spouses. No differences were found between the PaTH and usual care patients or spouses at 3 or 6 months in the number of minutes per week of physical activity. By 6 months, patients in both groups were, on average, below the national guidelines for PA recommendations (≥150 min/wk at >3 metabolic equivalents).

CONCLUSIONS

The couple-focused PaTH intervention demonstrated promise in offsetting the decline in dietary adherence typically seen 6 months after CR.

Sex Differences in the Rate, Timing, and Principal Diagnoses of 30-Day Readmissions in Younger Patients with Acute Myocardial Infarction

BACKGROUND

Young women (<65 years) experience a 2- to 3-fold greater mortality risk than younger men after an acute myocardial infarction. However, it is unknown whether they are at higher risk for 30-day readmission, and if this association varies by age. We examined sex differences in the rate, timing, and principal diagnoses of 30-day readmissions, including the independent effect of sex following adjustment for confounders.

METHODS AND RESULTS

We included patients aged 18 to 64 years with a principal diagnosis of acute myocardial infarction. Data were used from the Healthcare Cost and Utilization Project-State Inpatient Database for California (07-09). Readmission diagnoses were categorized by using an aggregated version of the Centers for Medicare and Medicaid Services' Condition Categories, and readmission timing was determined from the day after discharge. Of 42,518 younger patients with acute myocardial infarction (26.4% female), 4775 (11.2%) had at least 1 readmission. The 30-day all-cause readmission rate was higher for women (15.5% versus 9.7%, P<0.0001). For both sexes, readmission risk was highest on days 2 to 4 after discharge and declined thereafter, and women were more likely to present with noncardiac diagnoses (44.4% versus 40.6%, P=0.01). Female sex was associated with a higher rate of 30-day readmission, which persisted after adjustment (hazard ratio, 1.22; 95% confidence interval, 1.15-1.30). There was no significant interaction between age and sex on readmission.

CONCLUSIONS

In comparison with men, younger women have a higher risk for readmission, even after the adjustment for confounders. The timing of 30-day readmission was similar in women and men, and both sexes were susceptible to a wide range of causes for readmission.

Gender differences in the trajectory of recovery in health status among young patients with acute myocardial infarction: results from the variation in recovery: role of gender on outcomes of young AMI patients (VIRGO) study

BACKGROUND

Despite the excess risk of mortality in young women (≤55 years of age) after acute myocardial infarction (AMI), little is known about young women's health status (symptoms, functioning, quality of life) during the first year of recovery after an AMI. We examined gender differences in health status over time from baseline to 12 months after AMI.

METHODS AND RESULTS

A total of 3501 AMI patients (67% women) 18 to 55 years of age were enrolled from 103 US and 24 Spanish hospitals. Data were obtained by medical record abstraction and patient interviews at baseline hospitalization and 1 and 12 months after AMI. Health status was measured by generic (Short Form-12) and disease-specific (Seattle Angina Questionnaire) measures. We compared health status scores at all 3 time points and used longitudinal linear mixed-effects analyses to examine the independent effect of gender, adjusting for time and selected covariates. Women had significantly lower health status scores than men at each assessment (all P values <0.0001). After adjustment for time and all covariates, women had Short Form-12 physical/mental summary scores that were -0.96 (95% confidence interval [CI], -1.59 to -0.32) and -2.36 points (95% CI, -2.99 to -1.73) lower than those of men, as well as worse Seattle Angina Questionnaire physical limitations (-2.44 points lower; 95% CI, -3.53 to -1.34), more angina (-1.03 points lower; 95% CI, -1.98 to -0.07), and poorer quality of life (-3.51 points lower; 95% CI, -4.80 to -2.22).

CONCLUSION

Although both genders recover similarly after AMI, women have poorer scores than men on all health status measures, a difference that persisted throughout the entire year after discharge.

Racial/Ethnic differences in medication uptake and clinical outcomes among hospitalized cardiovascular patients with hypertension and diabetes

BACKGROUND

In the United States, hypertension and diabetes are more common among blacks and Hispanics than among others; the comorbidity is associated with worse clinical outcomes than each condition alone. Racial/ethnic differences in outcomes may be related to differential uptake of antihypertensive therapies, but data to evaluate this in real-world settings are limited. We aimed to determine the association between race/ethnicity and odds of rehospitalization or death, accounting for medication prescription, among a cohort of patients with hypertension and diabetes hospitalized for cardiovascular disease.

METHODS

This was a 1-year prospective study of individuals that participated in a National Heart, Lung, and Blood Institute clinical outcomes study. Clinical/medication data and outcomes (rehospitalization and death at 30 days and at 1 year) were documented by electronic medical record, National Death Index, and standardized mail survey. Logistic regression was used to evaluate associations between race/ethnicity and outcomes adjusted for type of antihypertensive medication, demographics, and comorbidity.

RESULTS

Participants (n = 1,126) were 14% black, 28% Hispanic, and 58% white/other. A total of 611 (54%) participants were rehospitalized at 1 year. Predictors of rehospitalization at 1 year included Hispanic ethnicity, diuretic prescription, lack of health insurance, peripheral vascular disease, and heart failure (P < 0.05). Race/ethnicity was not associated with rehospitalization at 30 days or death at 30 days or at 1 year. Increased odds of rehospitalization at 1 year among Hispanics remained significant after multivariable adjustment (odds ratio = 1.6; 95% confidence interval = 1.2-2.1).

CONCLUSIONS

In this study of hospitalized hypertension patients with diabetes, Hispanics had higher odds of rehospitalization than whites/others at 1 year but not at 30 days, and this was not explained by type of antihypertension medication prescribed.

Factors associated with medication adherence among heart failure patients and their caregivers

BACKGROUND

Reducing the rate of rehospitalization among heart failure patients is a major public health challenge; medication non-adherence is a crucial factor shown to trigger rehospitalizations. Objective: To collect pilot data to inform the design of educational interventions targeted to heart failure patients and their caregivers to improve medication adherence.

METHODS

Heart failure patients with an implantable cardioverter defibrillator and their family caregivers were recruited from an outpatient electrophysiology clinic at an urban university medical center (N = 10 caregiver and patient dyads, 70% race/ethnic minority, mean patient age = 63 years). Quantitative and qualitative research methods were utilized. Semi-structured individual interviews were conducted to assess patients' and caregivers' individual interest in, and access to, new medication adherence technologies. Patient adherence to medications, medication self-efficacy, and depression were assessed by validated questionnaires. Medication adherence and hospitalization rates were assessed among patients at 30-days post-clinic visit by mailed survey.

RESULTS

At baseline, 60% of patients reported sometimes forgetting to take their medications. The most common factors associated with non-adherence included forgetfulness (50%), having other medications to take (20%), and being symptom-free (20%). At 30-day follow-up, half of patients reported non-adherence to their medications, and 1 in 10 reported being hospitalized within the past month. Dyads reported widespread access to technology, with the majority of dyads showing interest in mobile applications and text messaging. There was less acceptance of medication-dispensing technologies; caregivers and patients were concerned about added burden.

CONCLUSIONS

The majority of etiologies of medication non-adherence were subject to intervention. Enthusiasm from patients and caregivers in new technologies to aid in adherence was tempered by potential burden, and should be considered when designing interventions to promote adherence.

Medication adherence is associated with having a caregiver among cardiac patients

BACKGROUND

Medication non-adherence is a significant contributor to suboptimal control of blood pressure and lipids.

PURPOSE

This study determined if having a paid and/or family caregiver was associated with medication adherence in patients hospitalized for cardiovascular disease.

METHODS

Consecutive patients admitted to the cardiovascular service at a university medical center who completed a standardized questionnaire about medication adherence and caregiving (paid/professional or family member/friend) were included in this analysis (N = 1,432; 63 % white; 63%male).

RESULTS

Among cardiac patients, 39 % reported being prescribed ≥ 7 different medications, and one in four reported being non-adherent to their medication(s). Participants who reported having/planning to have a paid caregiver were 40 % less likely to be non-adherent to their medications compared to their counterparts. The association remained significant after adjustment for demographic confounders and comorbid conditions (OR = 0.49; 95 %CI = 0.29-0.82).

CONCLUSION

Cardiac patients with a paid caregiver were half as likely to be non-adherent to medications as those without caregivers.

Caregiver status: a simple marker to identify cardiac surgery patients at risk for longer postoperative length of stay, rehospitalization, or death

BACKGROUND

Patients who have undergone cardiac surgery, especially those with greater comorbidities, may be cared for by family members or paid aides.

OBJECTIVE

The purpose of this study was to evaluate the association between having a caregiver among patients who underwent cardiac surgery and clinical outcomes at 1 year. We hypothesized that patients with a caregiver would have longer lengths of stay and higher rehospitalization or death rates 1 year after surgery.

METHODS

We studied 665 patients consecutively admitted for cardiac surgery as part of the Family Cardiac Caregiver Investigation To Evaluate Outcomes sponsored by the National Heart, Lung, and Blood Institute. The participants (mean age, 65 years; women, 35%; racial/ethnic minorities, 21%) completed an interviewer-assisted questionnaire to determine caregiver status. Outcomes were documented by a hospital-based information system; demographics/comorbidities, by electronic records. Associations between having a caregiver and outcomes were evaluated by logistic regression, adjusted for demographic and comorbid conditions.

RESULTS

At baseline, 28% of the patients (n = 183) had a caregiver (8%, paid; 20%, informal only). Having a caregiver was associated with longer (>7 days) postoperative length of stay in univariate analysis among the patients with paid (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.57-5.74) or informal (OR, 1.55; 95% CI, 1.04-2.31) caregivers versus none; the association remained significant for the patients with paid (OR, 2.13; 95% CI, 1.00-4.55) but not with informal (OR, 1.12; 95% CI, 0.70-1.80) caregivers after adjustment. Having a paid caregiver was significantly associated with rehospitalization/death at 1 year in univariate analysis (OR, 2.09; 95% CI, 1.18-3.69); having an informal caregiver was not (OR, 1.39; 95% CI, 0.94-2.06). Increased odds of rehospitalization/death associated with having a paid caregiver attenuated after adjustment (OR, 1.39; 95% CI, 0.74-2.62).

CONCLUSIONS

The patients who underwent cardiac surgery who had a paid caregiver had a significantly longer length of stay independent of comorbidity. The increased risk of rehospitalization/death associated with having a paid caregiver was explained by demographics and comorbidity. These data suggest that caregiver status assessment may be a simple method to identify cardiac surgery patients at increased risk for adverse clinical outcomes.

Challenges, needs, and experiences of recently hospitalized cardiac patients and their informal caregivers

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in the United States. Unpaid family caregivers of patients who experienced a cardiac event may occupy a key position in disseminating continuous health messages to these patients, yet more information is needed to guide the development of educational and behavioral interventions targeting caregivers.

OBJECTIVE

The purpose of this qualitative study was to assess the challenges, needs, and personal experiences of cardiac patients and their informal caregivers to explore the types of programs and services that would be most beneficial in promoting adherence to national CVD guidelines among cardiac patients and their caregivers.

METHODS

Patients who had been admitted to the cardiovascular service line of a large urban academic medical center and their informal caregivers (N = 38, 63% women, 74% white) participated in semistructured interviews and focus groups. Participants were asked to speak about 4 major categories of their personal experiences: support, challenges, coping, and program delivery, to determine their needs, the kind of educational interventions that would be most helpful to them, and how they would prefer this information/education to be delivered.

RESULTS

Both patients and caregivers ranked diet as the most pressing challenge (91% and 78%, respectively). The Internet, television, and social media were the preferred methods of delivery of such programs. Challenges most commonly cited by caregivers and patients included issues related to taking/administering prescribed medications and medication side effects, and mental stress. Caregivers expressed that not knowing what to expect after the patient's discharge from the hospital was a major stressor.

CONCLUSION

These findings may inform the development of educational interventions targeted to cardiac caregivers so that they may be more effective in assisting the patients in their care to adhere to national CVD prevention guidelines.

The association between neighborhood socioeconomic status and clinical outcomes among patients 1 year after hospitalization for cardiovascular disease

Residing in lower socioeconomic status (SES) neighborhoods is associated with increased risk of morbidity and mortality. Few studies have examined this association for cardiovascular disease (CVD) outcomes in a treated population in New York City (NYC). The purpose of this study was to determine the relationship between neighborhood level poverty and 1-year clinical outcomes (rehospitalization and/or death) among hospitalized patients with CVD. Data on rehospitalization and/or death at 1-year were collected from consecutive patients admitted at a university medical center in NYC from November 2009 to September 2010. NYC residents totaled 2,198. U.S. Census 2000 zip code data was used to quantify neighborhood SES into quintiles of poverty (Q1 = lowest poverty to Q5 = highest poverty). Univariate analyses were used to determine associations between neighborhood poverty and baseline characteristics and comorbidities. A logistic regression analysis was used to calculate odds ratios for the association between quintiles of poverty and rehospitalization/death at 1 year. Fifty-five percent of participants experienced adverse outcomes. Participants in Q5 (9 %) were more likely to be female [odds ratio (OR) = 0.49, 95 % confidence interval (CI) 0.33-0.73], younger (OR = 0.50, 95 % CI 0.34-0.74), of minority race/ethnicity (OR = 18.24, 95 % CI 11.12-29.23), and have no health insurance (OR = 4.79, 95 % CI 2.92-7.50). Living in Q5 was significantly associated with increased comorbidities, including diabetes mellitus and hypertension, but was not a significant predictor of rehospitalization/death at 1 year. Among patients hospitalized with CVD, higher poverty neighborhood residence was significantly associated with a greater prevalence of comorbidities, but not of rehospitalization and/or death. Affordable, accessible resources targeted at reducing the risk of developing CVD and these comorbidities should be available in these communities.

Racial and ethnic differences in statin prescription and clinical outcomes among hospitalized patients with coronary heart disease

We aimed to evaluate the association among race and ethnicity, statin prescription, and clinical outcomes among hospitalized patients with coronary heart disease (CHD), adjusted for confounders. Racial and ethnic disparities in CHD outcomes may be related to differential uptake of preventive medications, but data from real-world settings are limited. This was a 1-year prospective study of patients with preexisting CHD without a documented contraindication to statin (n = 3,067, 35% black or Hispanic, 65% white or Asian, 35% women) who participated in an National Heart, Lung and Blood Institute clinical outcome study of patients admitted to a cardiovascular service. Baseline clinical and medication data and 30-day and 1-year outcomes (death or rehospitalization) were documented by electronic medical record, National Death Index, and/or standardized mail survey. Logistic regression was used to evaluate associations among race and ethnicity, statin prescription, and outcomes adjusted for demographics and co-morbidities. Black and Hispanic patients were more likely to be dead or rehospitalized at 1 year (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.06 to 1.43) and less likely to report statin use before admission (62% vs 72%, adjusted OR 0.64, 95% CI 0.54 to 0.76) than whites and Asians; statin prescription was similar at discharge among blacks and Hispanics (81%) versus whites and Asians (84%). Black and Hispanic patients were more likely to have hypertension, diabetes, or renal failure and less likely to have health insurance than whites and Asians (p <0.05). The increased 1-year odds of death or rehospitalization in minorities versus whites and Asians were explained by demographics and co-morbidities not by differential statin prescription (adjusted OR 1.10, 95% CI 0.93 to 1.30). In conclusion, in this study of hospitalized patients with preexisting CHD, differential statin prescription did not explain racial and ethnic disparities in 1-year outcomes. Efforts to reduce CHD rehospitalizations should consider the greater burden of co-morbidities among racial and ethnic minorities.

Family caregivers of patients with heart failure: a longitudinal study

BACKGROUND

The family caregivers of patients with heart failure (HF) report burden and poor quality of life, but little is known about changes in their perceptions over time.

OBJECTIVES

The aims of this study were (1) to evaluate changes in caregiver burden (perceived time spent and difficulty with caregiving tasks), perceived control, depressive symptoms, anxiety, perceived life changes, and physical and emotional health-related quality of life; (2) to determine differences in perceptions between caregivers of patients with low HF symptoms (New York Heart Association class I and II) and caregivers of patients with high HF symptoms (New York Heart Association class III and IV); and (3) to the estimate time spent performing caregiving tasks.

METHODS

Sixty-three HF patients and 63 family caregivers were enrolled; 53 caregivers completed the longitudinal study. Data were collected from medical records and interviews conducted by advanced practice nurses at baseline and 4 and 8 months later.

RESULTS

Caregivers who completed the study had significant improvements in perceived time spent on and difficulty of caregiving tasks from baseline to 4 and 8 months, and depressive symptoms decreased from baseline to 8 months. Perceived life changes resulting from caregiving became more positive from baseline to 4 and 8 months. Perceived control, anxiety, and health-related quality of life did not change. Compared with caregivers of patients with low symptoms, caregivers of patients with high symptoms perceived that they spent more time on tasks and that tasks were more difficult, had higher anxiety, and had poorer physical health-related quality of life. Estimated time in hours spent providing care was high.

CONCLUSIONS

In this sample, perceptions of the caregiving experience improved over 8 months. Health-related quality of life was moderately poor over the 8 months. Caregivers of patients with more severe HF symptoms may be particularly in need of interventions to reduce time and difficulty of caregiving tasks and improve physical health-related quality of life.

Gender differences in clinical outcomes among diabetic patients hospitalized for cardiovascular disease

BACKGROUND

The risk of incident cardiovascular disease (CVD) has been shown to be greater among diabetic women than men, but gender differences in clinical outcomes among diabetic patients hospitalized with CVD are not established. We aimed to determine if hemoglobin A1c (HbA1c) was associated with 30-day and 1-year CVD rehospitalization and total mortality among diabetic patients hospitalized for CVD, overall and by gender.

METHODS

This was a prospective analysis of diabetic patients hospitalized for CVD, enrolled in an National Heart, Lung and Blood Institute-sponsored observational clinical outcomes study (N = 902, 39% female, 53% racial/ethnic minority, mean age 67 ± 12 years). Laboratory, rehospitalization, and mortality data were determined by hospital-based electronic medical record. Poor glycemic control was defined as HbA1c ≥7%. The association between HbA1c and clinical outcomes was evaluated using logistic regression; gender modification was evaluated by interaction terms and stratified models.

RESULTS

Hemoglobin A1c ≥7% prevalence was 63% (n = 566) and was similar by gender. Hemoglobin A1c ≥7% vs <7% was associated with increased 30-day CVD rehospitalization in univariate (odds ratio [OR] = 1.63, 95% CI 1.05-2.54) and multivariable-adjusted models (OR 1.74, 95% CI 1.06-2.84). There was an interaction between glycemic control and gender for 30-day CVD rehospitalization risk (P = .005). In stratified univariate models, the association was significant among women (OR 4.83, 95% CI 1.84-12.71) but not among men (OR 1.02, 95% CI 0.60-1.71). The multivariate-adjusted risk for HbA1c ≥7% versus <7% among women was 8.50 (95% CI 2.31-31.27) and 1.02 (95% CI 0.57-1.80) for men. A trend toward increased 30-day/1-year mortality risk was observed for HbA1c <6% vs ≥6% for men and women.

CONCLUSIONS

Risk of 30-day CVD rehospitalization was 8.5-fold higher among diabetic women hospitalized for CVD with HbA1c ≥7% vs <7%; no association was observed among men. A trend for increased 30-day/1-year mortality risk with HbA1c <6% deserves further study.

Effect of gender, caregiver, on cholesterol control and statin use for secondary prevention among hospitalized patients with coronary heart disease

Women with coronary heart disease (CHD) are consistently less likely than men with CHD to be at low-density lipoprotein (LDL) cholesterol goals, and the reasons for the gender gap are not established. We studied 2,190 patients with CHD or equivalent (34% women, 42% racial/ethnic minority) who participated in the Family Cardiac Caregiver Investigation to Evaluate Outcomes (FIT-O) Study and had baseline lipid data to determine whether having a paid or informal caregiver was independently associated with adherence to LDL cholesterol goals (<100, <70 mg/dl) and statin use and to determine if the association varied by gender. Caregiver status was assessed by standardized questionnaire and lipid levels/statin use were obtained from a hospital-based informatics system. Associations between caregiving and LDL cholesterol and statin use were assessed in univariate and multivariable models and the interaction was evaluated in gender stratified models. Men with CHD were more likely to be at LDL cholesterol goals <100 and <70 mg/dl and on statins than women with CHD (79% vs 69%, p <0.001; 48% vs 36%, p <0.001; 73% vs 67%, p = 0.004, respectively). No significant association was observed between LDL cholesterol <100 mg/dl and informal caregiving or between paid caregiving and lipid goals or statin use. Having an informal caregiver was associated with having an LDL cholesterol <70 mg/dl (p = 0.016), which remained significant after adjustment in multivariable models (odds ratio 1.25, 95% confidence interval 1.00 to 1.56). Multivariable association between informal caregiving and LDL cholesterol was significant in men (odds ratio 1.37, 95% confidence interval 1.04 to 1.80) but not women. In conclusion, there was a significant association between informal caregiving and LDL cholesterol control that was limited to men with informal caregivers.

Caregiver burden and nonachievement of healthy lifestyle behaviors among family caregivers of cardiovascular disease patients

PURPOSE

To determine whether caregiver burdens are associated with lifestyle behaviors 1 year following the hospitalization of a family member with cardiovascular disease (CVD).

DESIGN

Prospective follow-up study of National Heart Lung and Blood Institute sponsored Family Intervention Trial for Heart Health participants.

SETTING

Hospital-based recruitment/baseline visit with 1-year follow-up.

SUBJECTS

Family members of hospitalized CVD patients (N  =  423; 67% female; 36% racial/ethnic minority; mean age 49 years).

MEASURES

Systematic evaluation at 1 year to determine heart-healthy diet (defined as <10% kcal from saturated fat; Block 98 Food Frequency Questionnaire) and physical activity (defined as ≥4 d/wk; Behavioral Risk Factor Surveillance System Survey) behaviors and caregiver burdens (five domains: employment, financial, physical, social, and time; Caregiver Strain Questionnaire).

ANALYSIS

Logistic regression adjusted for covariates.

RESULTS

Heart-healthy diet was less frequent among caregivers citing feeling overwhelmed (odds ratio [OR]  =  .50; 95% confidence interval [CI]  =  .26-.97), sleep disturbance (OR  =  .51; 95% CI  =  .27-.96), financial strain (OR  =  .41; 95% CI  =  .20-.86), upsetting behavior (OR  =  .48; 95% CI  =  .25-.92), and/or time demands (OR  =  .47; 95% CI  =  .26-.85) as burdens. Physical activity was less frequent among caregivers reporting financial strain (OR  =  .32; 95% CI  =  .13-.81) or upsetting patient behavior (OR  =  .33; 95% CI  =  .15-.76) as burdens. The most commonly cited caregiver burdens included changes in personal plans (39%), time demands (38%), and sleep disturbance (30%).

CONCLUSION

Caregiver burdens were associated with nonachievement of heart-healthy diet and physical activity behaviors among family caregivers 1 year after patient discharge. When developing heart-health promotion interventions, caregiver burden should be considered as a possible barrier to prevention among family members of CVD patients.

Association between having a caregiver and clinical outcomes 1 year after hospitalization for cardiovascular disease

Caregivers might represent an opportunity to improve cardiovascular disease outcomes, but prospective data are limited. We studied 3,188 consecutive patients (41% minority, 39% women) admitted to a university hospital medical cardiovascular service to evaluate the association between having a caregiver and rehospitalization/death at 1 year. The clinical outcomes at 1 year were documented using a hospital-based clinical information system supplemented by a standardized questionnaire. Co-morbidities were documented by hospital electronic record review. At baseline, 13% (n = 417) of the patients had a paid caregiver and 25% (n = 789) had only an informal caregiver. Having a caregiver was associated with rehospitalization or death at 1 year (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.45 to 1.95), which varied by paid (OR 2.46, 95% CI 1.96 to 3.09) and informal (OR 1.40, 95% CI 1.18 to 1.65) caregiver status. Having a caregiver was significantly (p <0.05) associated with age ≥65 years, racial/ethnic minority, lack of health insurance, medical history of diabetes mellitus or hypertension, a Ghali co-morbidity index >1, chronic obstructive pulmonary disease, or taking ≥9 prescriptions medications. The relation between caregiving and rehospitalization/death at 1 year was attenuated but remained significant after adjustment (paid, OR 1.64, 95% CI 1.26 to 2.12; and informal, OR 1.20, 95% CI 1.00 to 1.44). In conclusion, the risk of rehospitalization/death was significantly greater among cardiac patients with caregivers and was not fully explained by the presence of traditional co-morbidities. Systematic determination of having a caregiver might be a simple method to identify patients at a heightened risk of poor clinical outcomes.