Perceived family criticism and primary care utilization: psychosocial and biomedical pathways

The Mediator Effects of Depressive Symptoms on the Relationship between Family Functioning and Quality of Life in Caregivers of Patients with Heart Failure

BACKGROUND

Caregivers of patients with heart failure (HF) report depressive symptoms and poor quality of life (QOL) related to caregiving and poor family functioning, placing them at risk for poor health.

OBJECTIVES

The purpose of this study was to examine the effect of depressive symptoms on the relationship between family functioning and quality of life in the HF caregiver.

METHODS

A sample of 92 HF caregivers were enrolled from an ambulatory clinic at a large academic medical center. A mediation analysis was used to analyze data obtained from the Family Assessment Device (FAD), the Patient Health Questionaire-9 (PHQ-9), and the Short Form-12 Health Survey Version 2 (SF-12v2).

RESULTS

Depressive symptoms were found to be a significant mediator in the relationship between family functioning and caregiver quality of life.

CONCLUSIONS

The results of this study suggest that interventions targeting caregiver depression and family functioning could be effective in enhancing HF caregivers' physical and mental QOL.

Association between overexpression of Wip1 and prognosis of patients with non-small cell lung cancer

Wild-type p53-induced phosphatase 1 (Wip1), also termed PPM1D, is a member of the protein phosphatase 2C family, which is characterized by distinctive oncogenic properties. Overexpression of Wip1 is observed in certain types of human tumors that are associated with significantly poor prognosis. The present study aimed to detect the expression of Wip1 in non-small cell lung cancer (NSCLC) and to analyze its prognostic value in such patients. The protein expression level of Wip1 was compared between NSCLC and normal lung tissue specimens using by immunohistochemistry, and it was found that Wip1 was highly expressed in NSCLCs but was absent or weakly expressed in normal lung tissues. Detailed clinical and demographic information of patients were retrospectively collected pre- and postoperatively, and Kaplan-Meier survival and Cox's regression analyses were performed to evaluate the prognosis of patients. Survival analysis revealed that the overall survival rate for patients in the Wip1-positive expression group was significantly lower than that of the Wip1-negative group, and Cox multivariate analysis indicated that positive Wip1 expression, pN classification and pathological stage were significant prognostic predictors. The results of the current study suggest that Wip1 may be associated with pathological diagnosis and prognostic evaluation of NSCLC.

Family partner intervention influences self-care confidence and treatment self-regulation in patients with heart failure

BACKGROUND

Heart failure self-care requires confidence in one's ability and motivation to perform a recommended behavior. Most self-care occurs within a family context, yet little is known about the influence of family on heart failure self-care or motivating factors.

AIMS

To examine the association of family functioning and the self-care antecedents of confidence and motivation among heart failure participants and determine if a family partnership intervention would promote higher levels of perceived confidence and treatment self-regulation (motivation) at four and eight months compared to patient-family education or usual care groups.

METHODS

Heart failure patients (N=117) and a family member were randomized to a family partnership intervention, patient-family education or usual care groups. Measures of patient's perceived family functioning, confidence, motivation for medications and following a low-sodium diet were analyzed. Data were collected at baseline, four and eight months.

RESULTS

Family functioning was related to self-care confidence for diet (p=0.02) and autonomous motivation for adhering to their medications (p=0.05) and diet (p=0.2). The family partnership intervention group significantly improved confidence (p=0.05) and motivation (medications (p=0.004; diet p=0.012) at four months, whereas patient-family education group and usual care did not change.

CONCLUSION

Perceived confidence and motivation for self-care was enhanced by family partnership intervention, regardless of family functioning. Poor family functioning at baseline contributed to lower confidence. Family functioning should be assessed to guide tailored family-patient interventions for better outcomes.

Family context influences psychological outcomes of depressive symptoms and emotional quality of life in patients with heart failure

BACKGROUND

Although family influences in heart failure (HF) care are considered important, little evidence is available regarding relationships between the family context and specific outcomes for patients with HF.

OBJECTIVE

The aim of this study was to examine the relationships of patient perceptions of family functioning, autonomy support, and perceived criticism, as well as their family member's (FM) HF knowledge, with patient outcomes of depressive symptoms and HF quality of life (QOL).

METHODS

Participants (n = 117) with HF were enrolled in a family partnership intervention study. Self-report questionnaires measuring the HF patient's perceptions of family context and the FM's knowledge were analyzed relative to the HF patient's outcomes using correlations and sequential multivariate regression analyses. Only preintervention, baseline data are reported here.

RESULTS

Age, ethnicity, Charlson comorbidity index, global family functioning, and FM's HF knowledge accounted for 37.8% (P < .001) of the variance in the patient's depressive symptoms. An additional moderating effect of ethnicity on the association between global family functioning and patient's depressive symptoms was significant (change R2 = 0.06, P = .001), resulting in a final model that accounted for 43.3% of depressive symptom variance. Age, ethnicity, global family functioning, and autonomy support accounted for 24.9% (P < .001) of the variance in emotional HF QOL. An additional moderating effect of ethnicity on the association between global family functioning and patient's emotional HF QOL was significant (change R2 = 0.05, P = .009), resulting in a final model that accounted for 28.9% of emotional QOL variance.

CONCLUSIONS

This study underscores the importance of the patient's perspective on family functioning and autonomy support, along with FM's HF knowledge, on HF patient outcomes moderated by ethnicity. Future interventions could target the modifiable patient-family context relationships for improving depressive symptoms and QOL in HF patients. These findings point to the need for greater family assessment to identify those at risk for worse outcomes and to guide family focused interventions.

The prospective association of perceived criticism with dyspnea in chronic lung disease

OBJECTIVE

Perceived criticism from family members influences mental health. The link between perceived criticism and physical health has not been thoroughly investigated. The objective of this study was to examine the association of perceived criticism with dyspnea in chronic obstructive pulmonary disease (COPD).

METHODS

401 individuals with alpha-1 antitrypsin deficiency-associated COPD completed questionnaires at baseline, 1- and 2-year follow-up. Perceived criticism at baseline was examined as a predictor of dyspnea at all three time points using a linear mixed model that adjusted for demographic and health characteristics.

RESULTS

There was an interaction between perceived criticism and psychological distress (p=0.038). Perceived criticism was associated with dyspnea only among individuals with elevated psychological distress (b=0.32, SE=0.13, p=0.018).

CONCLUSION

Further research is needed to replicate these findings and determine the extent to which they apply to other common subjective physical symptoms such as pain.

Risks for depression onset in primary care elderly patients: potential targets for preventive interventions

OBJECTIVE

Prevention of late-life depression, a common, disabling condition with often poor outcomes in primary care, requires identification of seniors at highest risk of incident episodes. The authors examined a broad range of clinical, functional, and psychosocial predictors of incident depressive episodes in a well-characterized cohort of older primary care patients.

METHOD

In this observational cohort study, patients age >/=65 years without current major depression, recruited from practices in general internal medicine, geriatrics, and family medicine, received annual follow-up assessments over a period of 1 to 4 years. Of 617 enrolled subjects, 405 completed the 1-year follow-up evaluation. The Structured Clinical Interview for DSM-IV (SCID) determined incident major depressive episodes. Each risk indicator's predictive utility was examined by calculating the risk exposure rate, incident risk ratio, and population attributable fraction, leading to determination of the number needed to treat in order to prevent incident depression.

RESULTS

A combination of risks, including minor or subsyndromal depression, impaired functional status, and history of major or minor depression, identified a group in which fully effective treatment of five individuals would prevent one new case of incident depression.

CONCLUSIONS

Indicators routinely assessed in primary care identified a group at very high risk for onset of major depressive episodes. Such markers may inform current clinical care by fostering the early detection and intervention critical to improving patient outcomes and may serve as the basis for future studies refining the recommendations for screening and determining the effectiveness of preventive interventions.

Family influences on heart failure self-care and outcomes

Many patient education guidelines for teaching heart failure patients recommend inclusion of the family; however, family-focused interventions to promote self-care in heart failure are few. This article reviews the state of the science regarding family influences on heart failure self-care and outcomes. The literature and current studies suggest that family functioning, family support, problem solving, communication, self-efficacy, and caregiver burden are important areas to target for future research. In addition, heart failure patients without family and those who live alone and are socially isolated are highly vulnerable for poor self-care and should receive focused attention. Specific research questions based on existing science and gaps that need to be filled to support clinical practice are posed.

Family Partnership Intervention

While family focused care is recommended in standards of care for heart failure (HF), little data exist to guide the structure, content, and delivery of family care. The purpose of this article is to describe what is known about the impact of HF, and to examine a family based approach to improve self-management and adherence in HF. A scientific and theoretical background was used to formulate a family based approach to HF care, the Family Partnership Intervention (FPI), and to determine the feasibility and acceptability of the intervention to family members and HF patients. The components of the intervention are described as well as examples of how it was used. Lessons learned in implementing the intervention during a pilot study are addressed.

Patient vs. physician as the target of educational outreach about screening for an inherited susceptibility to colorectal cancer

Are patients identified from a cancer registry better educated directly or via their physician about screening for an inherited susceptibility for colorectal cancer? Of 974 patients diagnosed with colorectal cancer at < or = 60 years from 1987 to 1999 in a five-county area including Rochester, the physicians of 651 patients (67%) forwarded a cancer family history survey to their patient; 459 (71%) completed the survey. Of these 459, 167 (36%) reported having at least one first- or second-degree relative with colon cancer and were sent a set of questionnaires and a more detailed family cancer history form. Of the 167, a total of 101 (60%) continued to qualify by returning the questionnaires. These 101 qualifying patients were randomized to either the patient-education or physician-education group. Of the 101, a total of 47 (47%) came for a free genetic evaluation. Individuals were more likely to accept evaluation if they were parents (p = 0.001), had more cancers of all kinds in their families (p = 0.02), and had a larger social network (p = 0.04). Of the 47 counseled, 36 (77%) chose to have DNA testing at no cost. Of these 47, individuals were more likely to choose DNA testing if they had more cancers in the family (p = 0.04) and fewer symptoms of depression (p = 0.05). Of the 36 tested patients, 6 (20%) were found to have mutations. In summary, acceptance of genetic services was related to the magnitude of the threat (more cancers in the family), perceived ability to deal with the threat (perceived good health and a supportive network), and a desire to inform relatives (being a parent). The two approaches to educating patients, viz. direct patient education vs. education via their physician, did not significantly differ in terms of percentages of patients receiving counseling (42% vs. 51%, respectively) or the percentage choosing DNA testing (32% vs. 37%, respectively).

Confirmatory factor analysis of the Family Emotional Involvement and Criticism Scale: evidence of the dimensionality of expressed emotion

Using a convenience sample of 152 married couples, the present study tested models that alternately considered family members' perceptions of Expressed Emotion to be a one-, two-, three-, or four-factor construct as measured by the Family Emotional Involvement and Criticism Scale. Results of confirmatory factor analysis procedures indicated that perceptions of Expressed Emotion were best represented by a four-factor model that consisted of involvement, criticism, upset feelings, and approval. The methodological implications of these findings are discussed.

Evaluating advanced practice nursing care through use of a heuristic framework

In our modification of a quality of care framework, we blended the labels of both models with respect to structure, labeling it structure/inputs. We then specified the types of characteristics in each of the 12 cells that can guide the evaluation of the areas of interest in a primary care system. The identification of characteristics of this conceptual framework and its subsequent application are important for a number of reasons. Specifically, this framework systematically organizes standardized data elements that are critical to monitoring and subsequently improving quality of care, guiding research, influencing policy, and developing nurse-sensitive patient outcomes.

Factors distinguishing families of patients with psychogenic seizures from families of patients with epilepsy

PURPOSE

Psychogenic seizures (PS) (emotionally based nonelectrical seizures) have been explained by psychodynamics and trauma. However, the family health literature suggests that somatization, of which psychogenic seizures are a form, may run in families and be determined by family patterns of response to distress. This study compared families of patients with PS and those of patients with epilepsy on variables of distress (anxiety and depression) and somatization.

METHODS

Eighteen patients (9 with PS and 9 with epilepsy) matched for age and education, and their families answered the Health Status Questionnaire (HSQ), the Weinberger Adjustment Inventory (WAI), the Family Emotional Involvement and Criticism Scale (FEICS), Barsky's Somatization Symptom Inventory (SS), and the Dissociation Experience Scale (DES). Family members' scores were averaged to obtain "family scores."

RESULTS

Patients with PS and those with epilepsy did not differ in any of the measures. However, families of patients with PS reported more health problems, distress, and criticism than did families of patients with epilepsy (p < 0.05). Families of patients with PS had increased criticism and somatic problem scores comparable to those of both types of patients.

CONCLUSIONS

Although epilepsy causes patients physical and emotional problems, their families are relatively healthy. In contrast, families of patients with PS are more troubled and may unwittingly contribute to PS through family distress, criticism, and tendencies to somatize.