The emotional and social burden of heart failure: integrating physicians', patients', and caregivers' perspectives through narrative medicine

Quality of Life in Heart Failure Patients: The Effect of Anxiety and Depression (Patient-Caregiver) and Caregivers' Quality of Life

Patients with heart failure (HF) and their caregivers are a dyad inextricably linked that exert influence on patients' quality of life (QoL).

PURPOSE

The aim of this study was to explore factors affecting HF patients' QoL. Factors were: (a) HF patients' characteristics, (b) anxiety/depression of the dyad (patient-caregiver) and (c) caregivers' QoL.

MATERIAL AND METHODS

In this cross-sectional study, we enrolled 340 patients and 340 caregivers. Data collection was performed by the method of an interview using "The Hospital Anxiety and Depression Scale", HADS) to assess anxiety and depression (patient-caregiver) as well as the "Minnesota Living with Heart Failure" and the "SF-36 Health Survey (SF-36)" to assess QoL (patient-caregiver, respectively).

RESULTS

From the 340 dyads who comprised the sample, 81.3% and 77.5% of patients experienced anxiety and depression, respectively, while 79.3% and 62.2% of caregivers experienced anxiety and depression, respectively. A statistically significant difference between patients and caregivers was only detected for depression (p = 0.001) and not for anxiety (p = 0.567). Patients with scores in HADS that indicate anxiety and depression had a worse QoL (total, physical, and mental). All subscales of the caregiver's QoL were significantly associated with the patient's QoL (p < 0.001) apart from the physical functioning scale. The correlation coefficients were all negative, indicating that a better caregiver's QoL (higher SF36 scores) is associated with a better patient's QoL (lower Minnesota scores). After controlling for the patient's characteristics, the anxiety and depression of caregivers did not affect the patient's QoL (confounding effect) whereas the patient's anxiety/depression remained significant factors. Patients with anxiety and depression had 5.58 and 6.49 points, respectively, higher QoL score, meaning a worse QoL, compared to those with no anxiety/depression.

CONCLUSIONS

Evaluating the impact of HF on patients' QoL and anxiety/depression along with their caregivers permits acknowledgment of this dyadic relationship.

Studying gender in the experiences of patients with heart failure: A scoping review of qualitative studies and methodological recommendations

BACKGROUND

Considering how gendered experiences play a role in the lives of patients with heart failure (HF) is critical in order to understand their experiences, optimise clinical care and reduce health inequalities.

OBJECTIVES

The aim of our study was to review how gender is being studied in qualitative research in HF, specifically to (1) analyse how gender is conceptualised and applied in qualitative HF research; and (2) identify methodological opportunities to better understand the gendered experiences of patients with HF.

ELIGIBILITY CRITERIA

We conducted a systematic search of literature, including qualitive or mixed-methods articles focussing on patients' perspectives in HF and using gender as a primary analytical factor, excluding articles published before 2000.

SOURCES OF EVIDENCE

Our search returned 3121 records, which were independently screened by two authors, resolving disagreements through a consensus procedure.

CHARTING METHODS

Two reviewers extracted the characteristics of the included studies and methodological quality. We applied the Integrating Sex and Gender Checklist and gender theory as an analytical tool to synthesise results relating to the conceptualisation and application of gender in the included studies.

RESULTS

We included 11 qualitative articles that used interviews (n = 10) or focus groups (n = 1) to investigate the role of gender in experiences of patients with HF. None of the included studies defined their conceptual approach to gender, or used gender-related theoretical frameworks. This led to results and conclusions which were drawn along binary lines - representing gender as two separate, oppositional and mutually exclusive categories, and paying little attention to the dynamic, relational and context-dependent aspects of gender.

CONCLUSIONS

Although researchers have investigated the role of gender in the experiences of patient with HF, methodological improvements are needed to prevent the current retelling of gender as a binary variable with two opposed and mutually exclusive categories. To better understand gendered experiences in HF, researchers need to avoid a reductionist and essentialist approach to gender. To this end, researchers should clearly state their conceptual approach to gender and analyse their findings using state-of-the-art gender theoretical frameworks and intersectional approaches. Ultimately, this will allow the development of tailored and effective clinical care.

Narrative Medicine: theory, clinical practice and education - a scoping review

BACKGROUND

The origin of Narrative Medicine dates back to more than 20 years ago at an international level. Narrative Medicine is not an alternative to evidence-based medicine, however these two approaches are integrated. Narrative Medicine is a methodology based on specific communication skills where storytelling is a fundamental tool to acquire, understand and integrate several points of view related to persons involving in the disease and in the healthcare process. Narrative Medicine, henceforth NM, represents a union between disease and illness between the doctor's clinical knowledge and the patient's experience. According to Byron Good, "we cannot have direct access to the experience of others' illness, not even through in-depth investigations: one of the ways in which we can learn more from the experience of others is to listen to the stories of what has happened to other people." Several studies have been published on NM; however, to the best of our knowledge, no scoping review of the literature has been performed.

OBJECTIVE

This paper aims to map and synthetize studies on NM according to theory, clinical practice and education/training.

METHOD

The scoping review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist. A search was conducted in PubMed, APA PsycNet and Jstor. Two authors independently assessed the eligibility and methodological quality of the studies and extracted the data. This review refers to the period from 1998 to 2022.

RESULTS

A total of 843 abstracts were identified of which 274 papers were selected based on the title/abstract. A total of 152 papers in full text were evaluated and 76 were included in the review. Papers were classified according to three issues: ✘ Nineteen studies focused on the definition and concept of NM (Theoretical). ✘ Thirty-eight papers focused on the collection of stories, projects and case reports (Clinical practice). ✘ Nineteen papers focused on the implementation of the Narrative Medicine approach in the education and training of medical doctors (Education and training).

CONCLUSIONS

This scoping review presents an overview of the state of the art of the Narrative Medicine. It collect studies performed mainly in Italy and in the United States as these are the countries developing the Narrative Medicine approach in three identified areas, theoretical, clinical practice and education and training. This scoping review will help to promote the power of Narrative Medicine in all three areas supporting the development of methods to evaluate and to measure the Narrative Medicine approach using key performance indicators.

Heart failure patients' experiences of telerehabilitation

In the UK, almost 1 million people are living with heart failure, with heart and circulatory diseases accounting for 27% of all deaths, according to the British Heart Foundation. Current heart failure guidelines support cardiac rehabilitation as an intervention to reduce cardiovascular events, increase exercise tolerance and enhance patients' quality of life. Research indicates that telerehabilitation is an effective component of heart failure management, which helps overcome perceived barriers to cardiac rehabilitation including travel to appointments, long waiting times and accessibility. Understanding patient experiences and increasing telerehabilitation among heart failure patients is pertinent to implementing person-centred care, reducing risk and optimising quality of life.

A machine learning-derived risk score to predict left ventricular diastolic dysfunction from clinical cardiovascular magnetic resonance imaging

Introduction

The evaluation of left ventricular diastolic dysfunction (LVDD) by clinical cardiac magnetic resonance (CMR) remains a challenge. We aimed to train and evaluate a machine-learning (ML) algorithm for the assessment of LVDD by clinical CMR variables and to investigate its prognostic value for predicting hospitalized heart failure and all-cause mortality.

Methods

LVDD was characterized by echocardiography following the ASE guidelines. Eight demographic and nineteen common clinical CMR variables including delayed enhancement were used to train Random Forest models with a Bayesian optimizer. The model was evaluated using bootstrap and five-fold cross-validation. Area under the ROC curve (AUC) was utilized to evaluate the model performance. An ML risk score was used to stratify the risk of heart failure hospitalization and all-cause mortality.

Results

A total of 606 consecutive patients underwent CMR and echocardiography within 7 days for cardiovascular disease evaluation. LVDD was present in 303 subjects by echocardiography. The performance of the ML algorithm was good using the CMR variables alone with an AUC of 0.868 (95% CI: 0.811-0.917), which was improved by combining with demographic data yielding an AUC 0.895 (95% CI: 0.845-0.939). The algorithm performed well in an independent validation cohort with AUC 0.810 (0.731-0.874). Subjects with higher ML scores (>0.4121) were associated with increased adjusted hazard ratio for a composite outcome than subjects with lower ML scores (1.72, 95% confidence interval 1.09-2.71).

Discussion

An ML algorithm using variables derived from clinical CMR is effective in identifying patients with LVDD and providing prognostication for adverse clinical outcomes.

Development of a scale to gain insight into the experience of living with chronic heart failure: The UNAV-Experience of Living with Chronic Heart Failure Scale

BACKGROUND

To date, there are no tools for the nursing staff to gain systematic insight on the experience lived by patients with chronic heart failure. The objective of this study was to develop a scale for this purpose.

METHODS

The study was conducted between January 2018 and December 2020 in three Spanish hospitals. The process described by DeVellis was used for the development of the scale. The items were built based on a phenomenological study and a systematic review of the literature. Next, feedback from a panel of experts was obtained, the scale was administered to a sample of patients with chronic heart failure, and a cognitive interview and an observational study were conducted to create the final version of the scale.

RESULTS

The first version of the scale had in seven domains and 76 items. After its evaluation by a panel of experts, it was reduced to a second version with six domains and 55 items. Following the administration of Version 2 to 17 patients (58.8% male, mean age 59.53, 70.6% classified as NYHA functional class II), five items were modified and two eliminated. Thus, the third version of the UNAV-CHF Experience Scale was composed of six domains and 53 items.

CONCLUSIONS

This study presents the development of the UNAV-experience of living with chronic heart failure scale. It is an original and novel instrument that allows systematically explore this experience. A larger-scale study is necessary to confirm the validity of our scale.

Burden among informal caregivers of individuals with heart failure: A mixed methods study

AIMS

To develop a comprehensive understanding of caregiver burden and its predictors from a dyadic perspective.

METHOD

A convergent mixed methods design was used. This study was conducted in three European countries, Italy, Spain, and the Netherlands. A sample of 229 HF patients and caregivers was enrolled between February 2017 and December 2018 from the internal medicine ward, outpatient clinic, and private cardiologist medical office. In total, 184 dyads completed validated scales to measure burden, and 50 caregivers participated in semi-structured interviews to better understand the caregiver experience. The Care Dependency Scale, Montreal Cognitive Assessment, and SF-8 Health Survey were used for data collection. Multiple regression analysis was conducted to identify the predictors and qualitative content analysis was performed on qualitative data. The results were merged using joint displays.

RESULTS

Caregiver burden was predicted by the patient's worse cognitive impairment, lower physical quality of life, and a higher care dependency perceived by the caregivers. The qualitative and mixed analysis demonstrated that caregiver burden has a physical, emotional, and social nature.

CONCLUSIONS

Caregiver burden can affect the capability of informal caregivers to support and care for their relatives with heart failure. Developing and evaluating individual and community-based strategies to address caregiver burden and enhance their quality of life are warranted.

Challenges and opportunities for increasing patient involvement in heart failure self-care programs and self-care in the post-hospital discharge period

BACKGROUND

People living with heart failure (HF) are particularly vulnerable after hospital discharge. An alliance between patient authors, clinicians, industry, and co-developers of HF programs can represent an effective way to address the unique concerns and obstacles people living with HF face during this period. The aim of this narrative review article is to discuss challenges and opportunities of this approach, with the goal of improving participation and clinical outcomes of people living with HF.

METHODS

This article was co-authored by people living with HF, heart transplant recipients, patient advocacy representatives, cardiologists with expertise in HF care, and industry representatives specializing in patient engagement and cardiovascular medicine, and reviews opportunities and challenges for people living with HF in the post-hospital discharge period to be more integrally involved in their care. A literature search was conducted, and the authors collaborated through two virtual roundtables and via email to develop the content for this review article.

RESULTS

Numerous transitional-care programs exist to ease the transition from the hospital to the home and to provide needed education and support for people living with HF, to avoid rehospitalizations and other adverse outcomes. However, many programs have limitations and do not integrally involve patients in the design and co-development of the intervention. There are thus opportunities for improvement. This can enable patients to better care for themselves with less of the worry and fear that typically accompany the transition from the hospital. We discuss the importance of including people living with HF in the development of such programs and offer suggestions for strategies that can help achieve these goals. An underlying theme of the literature reviewed is that education and engagement of people living with HF after hospitalization are critical. However, while clinical trial evidence on existing approaches to transitions in HF care indicates numerous benefits, such approaches also have limitations.

CONCLUSION

Numerous challenges continue to affect people living with HF in the post-hospital discharge period. Strategies that involve patients are needed, and should be encouraged, to optimally address these challenges.

Symptom burden, psychosocial distress and palliative care needs in heart failure - A cross-sectional explorative pilot study

BACKGROUND

Beyond guideline-directed treatments aimed at improving cardiac function and prognosis in heart failure (HF), patient-reported outcomes have gained attention.

PURPOSE

Using a cross-sectional approach, we assessed symptom burden, psychosocial distress, and potential palliative care (PC) needs in patients with advanced stages of HF.

METHODS

At a large tertiary care center, we enrolled HF patients in an exploratory pilot study. Symptom burden and psychosocial distress were assessed using the MIDOS (Minimal Documentation System for Patients in PC) questionnaire and the Distress Thermometer (DT), respectively. The 4-item Patient Health Questionnaire (PHQ-4) was used to screen for anxiety and depression. To assess PC needs, physicians used the "Palliative Care Screening Tool for HF Patients".

RESULTS

We included 259 patients, of whom 137 (53%) were enrolled at the Heart Failure Unit (HFU), and 122 (47%) at the outpatient clinic (OC). Mean age was 63 years, 72% were male. New York Heart Association class III or IV symptoms were present in 56%. With a mean 5-year survival 64% (HFU) vs. 69% (OC) calculated by the Seattle Heart Failure Model, estimated prognosis was comparatively good. Symptom burden (MIDOS score 8.0 vs. 5.4, max. 30 points, p < 0.001) and level of distress (DT score 6.0 vs. 4.8, max. 10 points, p < 0.001) were higher in hospitalised patients. Clinically relevant distress was detected in the majority of patients (HFU 76% vs. OC 57%, p = 0.001), and more than one third exhibited at least mild symptoms of depression or anxiety. Screening for PC needs revealed 82% of in- and 52% of outpatients fulfil criteria for specialized palliative support.

CONCLUSION

Despite a good prognosis, we found multiple undetected and unaddressed needs in an advanced HF cohort. This study's tools and screening results may help to early explore these needs, to further improve integrated HF care.

Narrative medicine: feasibility of a digital narrative diary application in oncology

Objectives

We implemented narrative medicine in clinical practice using the Digital Narrative Medicine (DNM) platform.

Methods

We conducted a preliminary, open, uncontrolled, real-life study in the oncology and radiotherapy departments of Istituto di Ricovero e Cura a Carattere Scientifico National Cancer Institute Regina Elena, Rome, Italy. We recruited adult Italian-speaking patients who then completed the DNM diary from the start of treatment. The primary endpoint was DNM feasibility; secondary endpoints were health care professionals’ opinions about communication, therapeutic alliance, and information collection and patients’ opinions about therapeutic alliance, awareness, and coping ability. We used open- and closed-ended questions (scores 1 to 5) and a structured interview.

Results

Thirty-one patients (67%) used the diary (84% women). Health care professionals’ mean scores for feasibility and utility were ≥4.0. Patients’ utility scores were related to health care professionals’ feedback regarding the narratives. The main advantages for health care professionals were the opportunity to obtain relevant patient data and to strengthen communication and patient relationships (mean scores 4.4–5.0). Both groups strongly encouraged introduction of the diary in clinical practice.

Conclusion

Use of the DNM in oncology patients assisted clinicians with understanding their patients experience.

Requirements for building educational and care technology on heart failure

ABSTRACT Objectives: to investigate the requirements for building an educational and care application about heart failure. Methods: exploratory study, carried out with 15 people with heart failure and 19 family members/caregivers, assisted in a tertiary unit in the Brazilian Northeast. Individual semi-structured interviews were carried out between November and December 2020. Hannah Arendt’s theoretical framework was adopted. Results: two units of meaning emerged: “The plurality of care in heart failure” and “Expectations on the construction and use of educational and care technology for heart failure”. The requirements involved the need to know the disease and its nuances, as well as the health network, through an application that can minimize individual and social precariousness; and highlighted the importance of the participation of the multidisciplinary team in the development and dissemination of the application. Conclusions: requirements on educational and care technology were identified and will support the creation of an application that promotes care, aiming to obtain positive health outcomes.