Phenotyping patient-reported health profiles in octogenarians with coronary artery disease – a latent profile analysis

Background

Percutaneous coronary intervention (PCI) has demonstrated to be an effective treatment strategy also in octogenarian patients (≥80 years). However, limited studies describe patient-reported outcomes in older adults two months after the PCI procedure.

Purpose

To identify latent health profiles concerning fatigue, generic and disease-specific physical and mental health, anxiety and depression, insecurity, dependency and angina frequency. Further, to investigate if these profiles were associated with sex or cohabitation status.

Method

A prospective cohort multicenter study including 3417 patients was conducted. The following patient-reported outcome measures were used: Level of fatigue was assessed using de novo created questions. Generic physical and mental health was assessed using RAND-12. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale. Disease-specific physical and mental health status, insecurity and dependency were assessed with Myocardial Infarction Dimensional Assessment Scale, and disease-specific physical limitation, quality of life and angina frequency was assessed with Seattle Angina Questionnaire (SAQ-7). All scales were converted to a 0–100 scale (worst to best). Latent profile analysis was used for phenotyping health profiles and multinomial logistic regression analysis for investigating the association of sex and cohabitation status across health profiles.

Result

A total of 318 octogenarians were included. The mean age was 83.6 years, and 69% were males. Three health profiles differing in the level of fatigue, health status, insecurity and dependency and angina frequency were identified (Figure 1). Health profile 1 (26.1%) represents “Low-level of life satisfaction, high level of insecurity and dependency and monthly frequency of angina”. Health profile 2 (38.1%) represents “Medium-level of life satisfaction, medium-level of insecurity and dependency and monthly frequency of angina”. Health profile 3 (35.8%) represents “High-level of life satisfaction, low level of insecurity and dependency and angina free”. Importantly, female sex was strongly associated with being classified into Health profile 1 compared to Health profile 3 [OR 3.6, 95% CI 1.3–7.9]. Living alone however, did not predict a likelihood of being classified into any particular health profile.

Conclusion

We identified three unique health profiles of octogenarians with coronary artery disease. A quarter of the participants were classified into the “Low-level of life satisfaction” profile. In addition, female sex was strongly associated with being identified into the “Low-level of life satisfaction” profile. These result suggest a need for a more tailored and patient-centered aftercare in octogenarians undergoing PCI.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): MTG Holding AS

Informing patients about potential adverse drug reactions after percutaneous coronary intervention reduces the occurrence of self-reported adverse drug reactions

Background

Healthcare providers are commonly reluctant to inform patients about potential adverse drug reactions (ADRs) from prescribed therapy to avoid increasing the incidence of ADRs through the nocebo effect. However, patients need information on all aspects of prescribed therapy to facilitate informed decision-making and take ownership of their care.

Purpose

To describe wether patients received information about potential ADRs from prescribed therapy before hospital discharge after percutaneous coronary intervention (PCI). Furthermore, to determine whether receiving information about ADRs is associated with incidence of self-reported ADRs.

Methods

CONCARDPCI is a prospective multicentre cohort study including 3417 patients after PCI. The study was conducted between June 2017 and May 2020 at seven large referral PCI centres in Norway and Denmark. Clinical data were collected from patients' medical records. Socio-demographic characteristics were obtained by self-report during index hospitalization after PCI. Two questions from the Heart Continuity of Care Questionnaire were used to determine if information about potential ADRs was received before hospital discharge. De novo created questions were used to determine if patients reported ADRs from prescribed therapy. Questionnaires were distributed two (T1), six (T2), and twelve months (T3) after hospital discharge to assess the incidence of self-reported ADRs in a longitudinal perspective. Logistic regression was utilised to scrutinize the aims, reported as odds ratios (ORs) with 95% confidence intervals (CIs).

Results

Patients were predominantly men (78%), with a mean age of 66 years (SD 11, range 20–96 years), and married or living with a partner (75%). Stable coronary artery disease was the most frequent cause of admission for PCI (30%). Before hospital discharge, 59% were informed of potential ADRs from prescribed therapy and 50% were informed what to do if ADRs occurred. The incidence of self-reported ADRs were significantly lower for those who were informed of potential ADRs compared to those who were not informed at T1 (OR 0.54, CI: 0.45–0.65, p<0.001), T2 (OR 0.56, CI: 0.46–0.70, p<0.001) and T3 (OR 0.51, CI: 0.42–0.67, p<0.001) (Figure 1). After controlling for socio-demographic and clinical variables, the incidence of self-reported ADRs were similar at T1 (OR 0.58, CI: 0.47–0.71, p<0.001), T2 (OR 0.56, CI: 0.46–0.70, p<0.001) and T3 (OR 0.53, CI: 0.42–0.66, p<0.001). Those less likely to receive information about ADRs were living alone (OR 0.75, CI: 0.59–0.97; p=0.029), women (OR 0.58, CI: 0.45–0.75, p<0.001) and those with three or more comorbidities (OR 0.68, CI: 0.47–0.98, p=0.029) compared to their counterparts.

Conclusion

Our study showed that informing patients about potential ADRs after PCI reduces the occurrence of self-reported ADRs. Information about potential ADRs should be provided regardless of cohabitation status, sex and comorbidities.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Western Norway Health Authority

Caught between competing emotions and tensions - a focus group study exploring experiences of family caregivers of out-of-hospital cardiac arrest survivors

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Being a family member caring for an out-of-hospital cardiac arrest (OHCA) survivor may impact family caregivers’ lives due to the sudden onset of the illness and possible secondary cognitive, emotional and physical challenges. However, experiences of caring for an OHCA survivor are sparsely described.

Purpose

This purpose of this study was to explore the subjective experiences of family caregivers of OHCA survivors as a means of understanding the potential burden they face.

Methods

Using an explorative qualitative approach, six focus group interviews were conducted with a sample of 25 family caregivers of OHCA survivors and analysed using a phenomenological hermeneutic approach inspired by the philosophy of Ricoeur. OHCA survivors and their family caregivers were attenting at a residential rehabilitation course, where the caregivers were interviewed as part of the course.

Results

Three themes emerged: i) Feeling unexpectedly alone and invisible; the family caregivers felt an emotional burden that could not be shared – leading to caregiving being a lonely and anxious experience. The family caregiver felt alone with the responsibility of the shared life, ii) Fear of loss; the fear of losing a loved one was a constant companion contributing to the burden of caregiving, and iii) Adjusting to a new everyday life; the family caregivers had difficulties adjusting to living their lives on the basis of the survivors’ needs. This often resulted in an existential crisis trying to adapt (Figure 1).

Conclusion

The findings of this study illuminate and emphasise the burden experienced by family caregivers and how they can be caught between competing emotions and tensions. The possible caregiver burden following OHCA should be acknowledged.

Systematic screening is needed to identify those at risk of high caregiver burden. Further, collaboration with family care givers should be an essential part of post-cardiac arrest care, and interventions to reduce the burden should be tested and implemented as part of the clinical care of OHCA survivors and their families.

Health literacy and physical and mental health status in octogenarian patients with coronary artery disease - a prospective cohort multicentre study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): MTG Holding AS

Introduction

The number of octogenarians (≥80 years of age) receiving percutaneous coronary intervention (PCI) is rising. Evidence supports that PCI improves quality of life and functional status in this group. Optimal health-promoting behaviour is strongly influenced by health literacy. However, there is limited knowledge about the association between health literacy, physical and mental health status in octogenarians.

Purpose

To determine if octogenarians health literacy is associated with generic and disease-specific physical and mental health status after PCI.

Methods

A prospective cohort study recruited 3417 participants from seven Danish and Norwegian PCI centres, and was conducted from June 2017 until May 2019. Multiple linear regression analysis was used. Health literacy was assessed by four of the nine scales from the Health Literacy Questionnaire (HLQ) (were higher score are better); "Social support for health" (scale range 1-4) "Appraisal of health information", (scale range 1-4) "Ability to find good health information" (scale range 1-5) and "Understand health information well enough to know what to do" (scale range 1-5). Generic physical and mental health status was assessed with RAND-12 at baseline (scale range 0-100, were higher score are better). After two months, disease-specific physical and mental health status was assessed with Myocardial Infarction Dimensional Assessment Scale (scale range 0-100, were lower score are better). Socio-demographic (age, gender, cohabitation status, education) and clinical variables (number of comorbidities) were included as covariates.

Results

In all, 318 octogenarians with mean age 83.4 years (range 80-96) participated, of which 69% were males. Three aspects of health literacy, "Social support for health", "Ability to find good health information" and "Understand health information well enough to know what to do", were significantly associated with health status. Specifically, for a unit increase of "Social support for health", the generic mental health status increased by 3 units (B: 3.0 [0.2 to 5.8] P=0.034). Further, a unit increase of "Ability to find good health information" was associated with a significant 4.2 higher disease-specific physical health and significant 5.3 higher disease-specific mental health (B:-4.2 [-8.0 to -0.4] P=0.029, B:-5.3 [-9.0 to -1.6] P=0.005, respectively). Finally, for a unit increase of "Understand health information well enough to know what to do" the disease-specific physical health improved by 5.1 units (B:-5.1 [-9.7 to -0.5] P=0.029) and disease-specific mental health improved by 5.2 units (B:-5.2 [-9.7 to -0.7] P=0.025).

Conclusion

In this study, we found that elements of health literacy were associated with both physical and mental health status in octogenerians. These findings highlight the importance of adequate health literacy and the need to support those with lower health literacy following PCI.

Psychometric evaluation of the danish version of the electronic health literacy scale (eHEALS) in patients treated with percutaneous coronary intervention (PCI): A cross-sectional validation study

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

As many use the internet as a major source of health information, eHealth literacy has emerged as a potential concept for digital health care consumption. Therefore, healthcare professionals need to consider the eHealth literacy of patients when delivering health information to cardiac patients.

Purpose

The aim of this study was to translate and evaluate the psychometric properties of the Danish version of the Electronic Health Literacy Scale (eHEALS) in a population of Danish PCI treated patients.

Methods

The eHEALS was translated into Danish from the original English version, including forward translation, synthesis, backward translation and expert group consensus. The questionnaire was applied to a group of Danish PCI treated patients to be answered during hospital stay. Psychometric properties were assessed including internal consistency by Cronbach α, and confirmatory factor analysis (CFA) with a priori specified 1-, 2- and 3-factor models were performed to explore construct validity. Socio-demographic and patient-reported outcomes including health literacy, health-related internet use, and health status were collected to examine correlations with eHEALS scores.

Results

A total of 1473 PCI treated patients were included in the analysis. The mean age was 66 years (SD 10.70) and more patients were males (n=1130, 78%). The mean value for the eHEALS score was 28.87 (SD 6.34), and the Cronbach α 0.94. The CFA indicated a good fit for three out of four of the goodness-of -fit indices. A mean difference on the eHEALS score between patients with the highest and lowest educational level was found to be 4.64 (95%CI, 2.43-6.85), p<0.0001.

Strong correlations were observed between eHEALS scores and "ability to find good information"(r=0.636), "Understanding health information well enough to know what to do" (r=0.505), ‘patients’ perceived usefulness’ (r= 0.650) and ‘importance of using the internet’ (r=0.621). Moderate correlations were observed to ‘having used the internet to find information about health’ (r=0.464), and "Appraisal of health information" (r=0.462), and weak correlations to self-rated physical health (r=0.119), self-rated mental health (r=0.110), and social support (r=0.207).

Conclusion

The psychometric evaluation indicates that the Danish version of the eHEALS questionnaire is a valid instrument to measure eHealth literacy in patients treated with PCI, suggesting a multidimensional construct.

Perceptions of efficacy and safety of generic medicines in patients after percutaneous coronary intervention

Background

Generic medicines are bioequivalents to brand-name medicines, and compelling evidence for the safety and efficacy of generic medicines exists. However, negative perceptions about generic medicines can potentially reduce adherence to prescribed therapy and thereby efficacy of the treatment.

Purpose

To describe patients' perceptions of generic medicines after percutaneous coronary intervention (PCI), and to investigate the association between perceptions and sociodemographic and clinical factors. Furthermore, we sought to investigate if these perceptions change over time.

Methods

CONCARDPCI is a large-scale prospective multicentre cohort study on 3251 patients after PCI. The study was conducted between June 2017 and May 2020 at seven large referral PCI centres in Norway and Denmark. Clinical data, including invasive procedures and patient characteristics, were collected from the patients' medical records. Sociodemographic characteristics were obtained by self-report during index hospitalization after PCI. Postal or electronic questionnaires comprising questions regarding perceptions of generic medicines were distributed two (T1) and six (T2) months after discharge from hospital to included patients. The time intervals ensured that a sufficient amount of time had passed so that refill of prescriptions was necessary. To investigate perceptions of generic medicines and the associations with sociodemographic and clinical characteristics, logistic regression analysis was performed.

Results

Most patients were men (78%), married or living with a partner (75%), elderly (mean age 66 years, SD11, range 20–96 years), and 28% were admitted to hospital due to non-ST-segment elevation myocardial infarction. At T1, 70% perceived generic medicines to be as effective, safe (68%), produce the same side effects (64%), and contain the same active ingredients as brand-name medicines (64%). Perceptions of generic medicines were similar at T2. No significant associations were found with age, marital status, living alone, taking ≥5 medications, or participation in cardiac rehabilitation. However, Danish patients (p<0.001), those with a higher education level (college/university≥4 years) (p=0.01), total household income >83,000 Euro (p=0.007), female gender (p<0.001), and history of coronary artery disease (p=0.048) had more positive perceptions of generic medicines.

Conclusion

Approximately one third of the patients had negative perceptions of generic medicines after PCI, and these negative perceptions do not seem to change substantially during the first six months after PCI. As negative perceptions of generic medicines have been found to be a barrier to medication adherence, improving patients' knowledge and confidence in generic medicines after PCI may be pivotal to reach treatment goals set forth by the 2018 ESC/EACTS Guidelines on myocardial revascularization.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The Western Norway Health Authority

Implementation of shared decision-making for aortic stenosis: Development of a patient decision aid

Funding Acknowledgements

Type of funding sources: None.

Background

 People living with aortic stenosis (AS) experience poor quality of life (QOL), repeat hospitalizations, and a poor prognosis in the absence of valve replacement. There is increasing equipoise in the evidence supporting the use of surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in patients likely to derive survival and QOL benefit. A transition to a palliative approach may be a better option in the setting of excessive frailty and comorbid burden. Shared decision-making (SDM) is a bidirectional exchange between patients and health care providers that enables an information exchange about the best available evidence and decisions that consider patients" priorities. The goal is to inform and empower patients to participate in choosing the right decision. Patient decision aids (PDAs) are designed to support the process of SDM and help guide these conversation. To date, Canadians living with AS have not had access to a validated PDA. 

Study Design

  We will report on the design of the SharEd DEcision-MaKing for AS (SEEK-AS) study that aims to refine and comprehensively evaluate a set of PDAs and to build capacity for SDM through a unique partnership of patient and clinical knowledge users, multidisciplinary health care providers and researchers, and policy-makers. We will summarize the pilot work completed to obtain a debrief of patient resources used in all Canadian provinces, the draft development of a PDA in concert with a health policy initiative, and the design of an electronic platform to individualize risk in real time during a consultation. We will outline the components of SEEK-AS and the use of a cross-provincial comparative case study design to investigate how to establish an effective and sustainable approach for the implementation of the PDAs using the Knowledge-to-Action conceptual framework. 

Implications

 There is a pressing need for the development of evidence-based tools to strengthen the integration of patients" perspectives in the treatment of complex valvular heart disease given the rapid pace of change in technology, indications and practice. The study of the implementation of innovative strategies to achieve this goal is essential to accelerate the pace of change in clinical care.

Patient-reported health and 1-year mortality in patients with ischemic heart disease – findings from the Denheart study

Background

Though survival has improved markedly in ischemic heart disease (IHD), it remains a leading cause of death worldwide. Screening tools to identify patients at risk are ever in demand. Large-scale studies exploring the association between patients' self-reported mental and physical health and mortality are lacking.

Purpose

(i) to describe patient-reported outcomes (PROs) at discharge in IHD patients deceased and alive at one year, (ii) to investigate the discriminant predictive performance of PRO instruments on mortality, (iii) to investigate differences in time to death among survey responders/non-responders and among three diagnostic sub-groups (chronic ischemic heart disease/stable angina, non-STEMI/unstable angina and STEMI), and (iv) to investigate predictors of one-year mortality among sociodemographic, clinical and self-reported factors.

Methods

Data from the national DenHeart survey with register-data linkage was used. A total of 14,115 adults with IHD were discharged during one year. Eligible (n=13,476) were invited to complete a questionnaire and 7,167 (53%) responded. Questionnaires included the Health survey short form 12-items (SF-12), Hospital Anxiety and Depression Scale (HADS), EuroQoL-5-dimensions (EQ-5D), HeartQoL, Edmonton Symptom Assessment Scale (ESAS) and ancillary questions. Clinical and demographic characteristics were obtained from registries as were data on one-year mortality. Comparative analyses investigated differences in PROs, and discriminant PRO-performance was explored by Receiver Operating Characteristics (ROC) curves. Kaplan-Meier survival analysis explored differences in time to death across sub-groups. Predictors of mortality were explored using multifactorially adjusted cox regression analyses with time to death as underlying timescale.

Results

Highly significant and clinically important differences in PROs were found between those alive and those deceased at one year. The best discriminant performance was observed for the physical component scale of the SF-12 (Area Under the Curve (AUC) 0.706) (Figure 1). One-year mortality among responders and non-responders was 2% and 7%, respectively. Significant differences in time to death was observed between responders and non-responders (p<0.001) and among diagnostic subgroups (p<0.001). Strongest predictors of one-year mortality included STEMI (hazard ratio (HR) 2.9 95% confidence interval (CI) 2.3–3.7), Tu comorbidity index score 3+ (HR 3.6, 95% CI 2.7–4.8) and patient-reported feeling unsafe about returning home from hospital (HR 2.07, 95% CI 1.2–3.61).

Conclusions

One-year post-discharge mortality was expectedly low, however notably higher in certain subgroups. Though clinical predictors may be difficult to modify, factors such as feeling unsafe about returning home should be addressed at discharge. PRO-performance estimates may guide clinicians and researchers in choosing appropriate predictive patient-reported outcome tools.

Figure 1. PRO instruments ROC curves

Funding Acknowledgement

Type of funding source: None

Symptoms of depression at discharge after PCI are associated with an increased risk of 1-year mortality: findings from the national DenHeart study

Background

Although survival rates among patients with coronary artery disease have increased since the introduction of treatment with percutaneous coronary intervention, PCI, the effect of psychological factors such as symptoms of anxiety and depression on adverse outcomes are sparsely described.

Purpose

The objective of the current study was to investigate the association between symptoms of anxiety and depression and 1-year mortality after PCI.

Methods

A national cross-sectional survey at hospital discharge (responders, n=3,366) with register-based follow-up among patients having undergone elective or emergency PCI. Mental health was measured using the Hospital Anxiety and Depression Scale, HADS, and divided into symptoms of anxiety (HADS-A) and symptoms of depression (HADS-D). The association between mental health (HADS-A and HADS-D) and 1-year all-cause mortality were investigated with Cox Proportional Hazard models with time to death as the underlying time scale. The results are presented as hazard ratios (HR) with 95% confidence intervals (CI) and adjusted for sex, age and Tu-comorbidity score.

Results

At discharge, 32% of the population reported symptoms of anxiety (HADS-A ≥8) and 19% reported symptoms of depression (HADS-D ≥8). After one year, the mortality rate among patients being alive at discharge was 2.1%. All-cause mortality did not differ among patients reporting symptoms of anxiety compared to patients without symptoms of anxiety (2.3% vs 1.9%, p=0.454), whereas all-cause mortality was higher among patients reporting symptoms of depression compared to those, who did not (4.3% vs 1.6%, p≤0.001).

In the regression analyses, symptoms of anxiety (HADS-A ≥8) was not associated with 1-year mortality (HR 1.16 95% CI 0.70–1.92); however, symptoms of depression was (HADS-D ≥8, HR 2.27 95% CI 1.38–3.73, adjusted analyses). Based on the continuous scores of HADS-D, a one-point increase in scores was associated with a 12% higher risk of 1-year mortality (HR 1.12 95% CI 1.05–1.18) (Figure 1).

Conclusion

After PCI, nearly one-third of patient report symptoms of anxiety and one-fifth symptoms of depression. Symptoms of anxiety was not associated with 1-year mortality, whereas symptoms of depression increased the risk of 1-year mortality.

Figure 1

Funding Acknowledgement

Type of funding source: None

4071Early changes in quality of life after transcatheter aortic valve replacement: One-year results from the 3M TAVR Study

Background

In patients with severe calcific aortic stenosis, transcatheter aortic valve replacement (TAVR) has been shown to significantly improve quality of life (QOL). However, changes in QOL at early follow-up (<1 month), and following next-day discharge are poorly understood.

Methods

A total of 411 patients at 13 centers were enrolled in the Multimodality, Multidisciplinary but Minimalist TAVR (3M TAVR) study in 2015–2017. QOL was evaluated using the Kansas City Cardiomyopathy Questionnaire (KCCQ-12) in participants with a baseline score and at least one score at 2 weeks, 30 days and 1 year. Study endpoints were change in (1) KCCQ-Overall Summary Score (KCCQ-OS) and (2) minimal clinically important differences (MCID). Mixed effects models were used to explore patterns of change from baseline, with fixed terms for time, status at 1-year and their interaction terms, and a random intercept for subject to account for within subject correlation. Descriptive statistics were used to report MCID.

Results

Data were available for 358 (87.1%) participants. 216 (60.3%) were men with a median age 84.0 and STS 5.0 There was significant increase in QOL 2 weeks after TAVR (p≤0.01), and further significant improvement at the 1-month timepoint (p<0.01) for participants who were alive at 1 year. Sex, age category, and STS score category did not have a significant effect on the change in QOL (p>0.05). In the first 2 weeks, moderate (10–20 points) and large (>20 points) improvements were observed in 19.9% and 49.0% of the surviving patients, respectively; at 1-year, similar MCID were seen in 14.6% and 64.0% respectively.

Figure 1

Conclusion

This is the first study to report significant increase in QOL 2 weeks after TAVR, with sustained improvement during the first year in patients treated with the Vancouver TAVR Clinical Pathway with a goal of next-day discharge. Further studies are necessary to determine whether alternative TAVR clinical pathways yield similar findings.

Acknowledgement/Funding

Investigator-initiated unrestricted research grant, Edwards