Caregiving intensity and duration, cardiovascular disease, and race/ethnicity in family caregivers of persons with dementia

We investigated if caregiving intensity and duration affected cardiovascular disease (CVD) risks and diagnosis and whether the relationship differed by race and ethnicity in family caregivers (FCGs) of persons with dementia. We conducted a secondary analysis of the 2015-2020 CDC Behavioral Risk Factor Surveillance System data using a logistic regression analysis. A total of 6132 dementia FCGs were included. We found that the more time FCGs spent providing care per week (intensity) or over time (duration), the more likely they reported CVD risks and diagnosis. However, the associations between caregiving intensity and CVD risks and diagnosis did not differ by race and ethnicity, nor did the associations between caregiving duration and the outcomes. These findings suggest future studies should be conducted to develop preventive strategies for FCGs' cardiovascular health. Further work is needed to identify the impact of race and ethnicity on the relationship between caregiving conditions and CVD with larger samples of racial and ethnic minorities.

Assessing Racial and Ethnic Differences in Cardiovascular Disease in U.S. Family Caregivers of Persons With Dementia: Analysis of Data from the 2015-2020 Behavioral Risk Factor Surveillance System

The current study examined racial and ethnic differences in psychological, behavioral, and metabolic risk factors for cardiovascular disease (CVD) and CVD conditions among family caregivers (FCGs) of persons with dementia. We used the 2015-2020 Behavioral Risk Factor Surveillance System data. The sample included a total of 6,132 FCGs of persons with dementia. Compared to non-Hispanic White FCGs, non-Hispanic Black and non-Hispanic Asian FCGs were less likely to have depression. The Other racial/ethnic FCG group was more likely to currently smoke. Non-Hispanic Black FCGs were less likely to have exercised, more likely to be obese, and more likely to have been diagnosed with diabetes. No differences in CVD conditions (e.g., angina/coronary heart disease, stroke, myocardial infarction) were detected between racial/ethnic minority FCGs and non-Hispanic White FCGs. Future studies should investigate relationships between racial/ethnic minority-specific caregiving and CVD by including a larger, racially and ethnically diverse population of FCGs. [Research in Gerontological Nursing, 16(5), 241-249.].

Heart Failure Family Caregivers' Perspectives of Physical Activity Engagement: A Qualitative Study

Research on caregiver burden and related psychological distress has been widely studied. However, little research has focused on perspectives and experiences of older family caregivers of persons with heart failure on engaging in physical exercise to improve their health and wellness. We investigated barriers and facilitators influencing physical activity engagement for older family caregivers of persons with heart failure through a qualitative descriptive study design utilizing participant interviews. The social cognitive theory framework guided the thematic analysis. Identified themes and subthemes that emerged were centered around the framework's interrelated personal, environmental, and behavioral factors. Self-efficacy emerged as a central construct facilitating engagement in physical activity. The older family caregivers embraced technology for physical activity interventions more readily since the COVID-19 pandemic encouraged increased technology use. The age-related and caregiving barriers to physical activity found in this study highlight considerations for an older family caregiver and guide interventions for future family caregivers' engagement.

Perceptions and Attitudes toward a Proposed Digital Health Physical Activity Program among Older Family Caregivers of Persons with Heart Failure: A Qualitative Study

Tailored physical activity (PA) programs using digital health technologies in the home can promote family caregivers' (FCGs) physical function and psychological wellbeing. However, there is a gap in research for digital health PA interventions targeting older FCGs of persons with HF (HF-FCGs). The burden of caregiving for persons with HF may displace the FCG's self-care, including PA. Therefore, we examined older HF-FCGs' perceptions and attitudes toward three technology components (video-conferencing, fitness tracker, text messaging) that would be most useful in delivering a digital health PA program. Interviews were conducted with 13 HF-FCGs (≥65 years old) between January and April 2021. Directed content analysis was used and the analysis was guided by the adapted unified theory of acceptance and use of technology (UTAUT) model. In addition to HF-FCGs' perceptions and attitudes toward each technology component in each construct of the adapted UTAUT model (ease of use, usefulness, facilitating conditions), three additional factors were associated with intention to use technology. These were: (1) HF patients' positive experience, (2) digital skills, and (3) quality of internet connectivity. The findings provide digital health requirements for design and modification of a technology-supported PA program that engages older FCGs who care for persons with HF.

ASSOCIATION OF CARDIOVASCULAR DISEASE WITH RACE/ETHNICITY IN FAMILY CAREGIVERS OF PERSONS LIVING WITH DEMENTIA

Family caregivers of persons with dementia (dementia FCGs) experience high caregiving burden, and caregiving-related stressors have been linked to cardiovascular disease (CVD). Racially and ethnically diverse FCGs face additional challenges in managing their own health; however, racial/ethnic disparities in caregiving-associated cardiovascular health are understudied and poorly understood. To fill the gap, we evaluated racial/ethnic differences in CVD risk and CVD conditions among dementia FCGs in the U.S. Using 2015-2020 Behavioral Risk Factor Surveillance System data (N = 6,132), we compared CVD risk and CVD conditions in racial/ethnic dementia FCG minorities to non-Hispanic White dementia FCGs. Logistic regression models were used to estimate unadjusted (OR) and adjusted odds ratios (AOR) with 95% confidence intervals (CI) for association of race/ethnicity with CVD risk and CVD conditions, adjusting for potential confounders. Compared to non-Hispanic White FCGs, non-Hispanic Black FCGs (AOR 0.33, 95% CI 0.2-0.53) and non-Hispanic Asian FCGs (AOR 0.16, 95% CI 0.05-0.51) were less likely to have depressive symptoms. Hispanic FCGs (OR 0.69, 95% CI 0.5-0.95), non-Hispanic Black FCGs (AOR 0.6, 95% CI 0.41-0.86), and non-Hispanic Asian FCGs (AOR 0.51, 95% CI 0.28-0.94) were less likely to smoke. Non-Hispanic Black FCGs were less likely to exercise (OR 0.69, 95% CI 0.52-0.91) and more likely to be obese (AOR 1.64, 95% CI 1.14-2.36). The findings confirm racial/ethnic disparities in psychological, behavioral, and metabolic risk factors for CVD among dementia FCGs. Future studies should investigate how dementia FCGs’ caregiving-related conditions affect CVD and how racial/ethnic considerations can inform culturally appropriate prevention-care strategies.

Caregiving experiences of older family caregivers of persons with heart failure: A mixed methods study

Older family caregivers of persons with heart failure (HF-FCGs) are an understudied and vulnerable population, who are at heightened risk for age-related physical and cognitive declines. We explored caregiving experiences of older HF-FCGs and examined levels of their caregiver burden, psychological distress, caregiving self-efficacy and quality of life (QoL) using descriptive mixed methods. We conducted telephone-based surveys and semi-structured interviews (N=13). Low levels of caregiver burden, psychological distress, and high levels of caregiving self-efficacy and QoL were reported. Through qualitative interviews, three qualitative themes emerged: (1) Impact of Being a Caregiver, (2) Managing Caregiver Distress, and (3) Embracing the Caregiver Role. Psychological distress was the most frequently reported. Physical, psychological, and social distress experienced by older HF-FCGs might be offset by their coping strategies and willingness to accept their caregiver role. FCG-centered support programs that help older HF-FCGs develop and apply their own coping strategies should be considered.

Experiences of Older Family Care Partners of Persons With Heart Failure 1 Year After the Onset of the COVID-19 Pandemic: A Qualitative Study

The coronavirus disease 2019 (COVID-19) pandemic has negatively affected the health and well-being of family care partners of older adults with heart failure (HF-FCPs). The purpose of the current study was to examine the caregiving experiences and coping strategies of older HF-FCPs during the ongoing pandemic. Qualitative telephone interviews were conducted with 13 HF-FCPs (aged ≥65 years) from January to April 2021. Three themes emerged: (1) Impact on Physical, Mental, and Social Health; (2) Limitations of Using Health Care Services; and (3) Coping Strategies. During the pandemic, HF-FCPs had increased caregiving burden due to managing their own age-related health and providing care to their family member with heart failure. After 1 year of COVID-19, they adjusted by increasing use of telecommunication platforms and following prevention and protection strategies. During the ongoing pandemic, emotional and social support, respite care, and digital health support for older HF-FCPs would be beneficial for improving their physical, mental, and social health. [Journal of Gerontological Nursing, 48(10), 47-52.].

Use of Digital Health Technology for Seeking Health Information Among Older Family Caregivers

There is little research on the relationship between digital health technology use and health services, self-efficacy, health status, and health information seeking behavior among older family caregivers. We conducted a secondary analysis of the US Health Information National Data and found that older family caregivers with a regular healthcare provider are more likely to use digital health technology, which increases their confidence in obtaining health information (β=0.075, z=2.015, p<0.044).

A Systematic Review of Effects of Physical Activity of Family Caregivers of Older Adults With Chronic Disease

More than 17 million family caregivers (FCGs) provide care for older adults with chronic illness in the US. Caregiving for older adults with chronic disease places a considerable burden on FCGs and they tend to neglect their personal health. Generally, physical activity (PA) programs benefit the physical and psychological health of FCGs. However, no review of PA randomized clinical trials (RCTs) focused on FCGs of older adults with chronic disease. In this systematic review, we analyzed the most recent trends (2010-2020) in RCTs identifying the effects of PA in this population. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases (PubMed, CINAHL, Embase, PsycInfo, Cochrane Library) were searched for publications dated from 2010 to 2020. All studies included were appraised for quality using the Cochrane Collaboration Risk of Bias Tool. Of the resulting 16 studies, most studies (n=11) targeted FCGs of older adults with dementia or cancer. Most FCGs were non-Hispanic white. PA interventions with mixed modes (e.g., aerobic and resistance exercise), mixed delivery methods (e.g., in-person and telephone) and mixed settings (e.g., supervised gym- and unsupervised home sessions) were used most frequently. PA interventions significantly improved psychological health but had inconsistent effects on physical health. Tailored PA programs, designed based on FCGs’ goals, preferences and limitations, may improve upon physical health outcomes. Future PA studies should include samples of racially and ethnically diverse FCGs of older adults representing a broader range of chronic diseases.

Effects of Physical Activity Programs on Health Outcomes of Family Caregivers of Older Adults with Chronic Diseases: A Systematic Review

This systematic review was conducted to analyze and capture the most recent trends in physical activity interventions for family caregivers of older adults with chronic disease as found in randomized clinical trials over the last 10 years (2010-2020). We used PubMed, CINAHL, Embase, PsycInfo, and the Cochrane Library. We synthesized participants' demographics, physical activity interventions and family caregivers' health outcomes. The Cochrane Collaboration Risk of Bias Tool was used to assess risk of bias of the included studies. Sixteen studies were included and most studies (n = 11) had a moderate risk of bias. Physical activity programs with mixed modes (e.g., aerobic and resistance exercise), mixed delivery methods (e.g., in-person and telephone) and mixed settings (e.g., supervised gym-based sessions and unsupervised home-based sessions) were used most frequently. Physical activity interventions significantly improved psychological health but had inconsistent effects on physical health. This review provides current trends and research findings that suggest types of physical activity interventions and components that improve family caregivers' health and wellness.

Eliciting the educational needs and priorities of home care workers on end-of-life care for patients with heart failure using nominal group technique

BACKGROUND

Home care workers, as paid caregivers, assist with many aspects of home-based heart failure care. However, most home care workers do not receive systematic training on end-of-life care for heart failure patients.

AIM

To elicit the educational needs and priorities of home care workers caring for community- dwelling adults with heart failure at the end-of-life.

DESIGN

Nominal group technique involving a semi-quantitative structured group process and point rating system was used to designate the importance of priorities elicited from home care workers. Individual responses to the question, "If you have ever cared for a heart failure patient who was dying (or receiving end-of-life care on hospice), what are some of the challenges you faced?", were aggregated into categories using directed content analysis methods.

SETTING/PARTICIPANTS

Forty-one home care workers were recruited from a non-profit training and education organization in New York City.

RESULTS

Individual responses to the question were aggregated into five categories: (1) how to cope and grieve; (2) assisting patients with behavior changes, (3) supporting patients to improve their quality of life, (4) assisting patients with physical symptom management, and (5) symptom recognition and assessment.

CONCLUSIONS

Our findings confirm the need for the formal development and evaluation of an educational program for home care workers to improve the care of heart failure patients at the end-of-life. There is also a need for research on integrating home care workers into the interprofessional healthcare team to support optimal health outcomes for patients with heart failure.

Visual analogies, not graphs, increase patients' comprehension of changes in their health status

OBJECTIVES

Patients increasingly use patient-reported outcomes (PROs) to self-monitor their health status. Visualizing PROs longitudinally (over time) could help patients interpret and contextualize their PROs. The study sought to assess hospitalized patients' objective comprehension (primary outcome) of text-only, non-graph, and graph visualizations that display longitudinal PROs.

MATERIALS AND METHODS

We conducted a clinical research study in 40 hospitalized patients comparing 4 visualization conditions: (1) text-only, (2) text plus visual analogy, (3) text plus number line, and (4) text plus line graph. Each participant viewed every condition, and we used counterbalancing (systematic randomization) to control for potential order effects. We assessed objective comprehension using the International Organization for Standardization protocol. Secondary outcomes included response times, preferences, risk perceptions, and behavioral intentions.

RESULTS

Overall, 63% correctly comprehended the text-only condition and 60% comprehended the line graph condition, compared with 83% for the visual analogy and 70% for the number line (P = .05) conditions. Participants comprehended the visual analogy significantly better than the text-only (P = .02) and line graph (P = .02) conditions. Of participants who comprehended at least 1 condition, 14% preferred a condition that they did not comprehend. Low comprehension was associated with worse cognition (P < .001), lower education level (P = .02), and fewer financial resources (P = .03).

CONCLUSIONS

The results support using visual analogies rather than text to display longitudinal PROs but caution against relying on graphs, which is consistent with the known high prevalence of inadequate graph literacy. The discrepancies between comprehension and preferences suggest factors other than comprehension influence preferences, and that future researchers should assess comprehension rather than preferences to guide presentation decisions.

Factors Related to Biological Sex Differences in Engagement with Healthcare Providers in Persons Living with HIV

Little is known about how engagement with healthcare providers mediates the relationship between psychosocial factors (anxiety, depression, stigma) and medication adherence among persons living with HIV (PLWH). Moreover, little research has investigated potential biological sex differences in this relationship. We conducted a secondary analysis of data collected from four projects (N = 281) focused on improving health outcomes in PLWH. Males displayed (a) negative association between depression and engagement with healthcare providers (β = - 0.02, z = - 3.20, p = 0.001) and (b) positive association between engagement with healthcare providers and medication adherence (β = 0.55, OR = 1.73, z = 2.62, p = 0.009). Females showed no association between any of these factors. Anxiety and stigma were not significantly associated with medication adherence. Path analysis modeling for males had a very good fit (CFI = 1, TLI = 1, RMSEA = 0); none of the regression coefficients was significant for females. The significant relationship between depression and medication adherence among males was fully mediated by engagement with healthcare providers. Findings suggest that adherence interventions for PLWH should be tailored by biological sex.

Building trust and facilitating goals of care conversations: A qualitative study in people with heart failure receiving home hospice care

BACKGROUND

Despite a majority of persons receiving hospice care in their homes, there are gaps in understanding how to facilitate goals of care conversations between persons with heart failure and healthcare providers.

AIM

To identify barriers and facilitators which shape goals of care conversations for persons with heart failure in the context of home hospice.

DESIGN

A qualitative descriptive study design was used with semi-structured interviews.

SETTING/PARTICIPANTS

We conducted qualitative interviews with persons with heart failure, family caregivers, and interprofessional healthcare team members at a large not-for-profit hospice agency in New York City between March 2018 and February 2019.

RESULTS

A total of 39 qualitative interviews were conducted, including with healthcare team members (e.g. nurses, physicians, social workers, spiritual counselors), persons with heart failure, and family caregivers. Three themes emerged from the qualitative interviews regarding facilitators and barriers in goals of care conversations for better decision-making: (1) trust is key to building and maintaining goals of care conversations; (2) lack of understanding and acceptance of hospice inhibits goals of care conversations; and (3) family support and engagement promote goals of care conversations.

CONCLUSION

Findings from this study suggest that interventions designed to improve goals of care conversations in the home hospice setting should focus on promoting understanding and acceptance of hospice, family support and engagement, and building trusting relationships with interprofessional healthcare teams.

The Development and Implementation of a Cardiac Home Hospice Program: Results of a RE-AIM Analysis

BACKGROUND

Use of hospice has grown among patients with heart failure; however, gaps remain in the ability of agencies to tailor services to meet their needs.

AIM

This study describes the implementation of a cardiac home hospice program and insights for dissemination to other hospice programs.

DESIGN

We conducted a multimethod analysis structured around the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework.

SETTINGS/PARTICIPANTS

We used electronic medical records for our quantitative data source and interviews with hospice clinicians from a not-for-profit hospice agency (N = 32) for our qualitative data source.

RESULTS

Reach-A total of 1273 participants were enrolled in the cardiac home hospice program, of which 57% were female and 42% were black or Hispanic with a mean age was 86 years. Effectiveness-The cardiac home hospice program increased hospice enrollment among patients with heart failure from 7.9% to 9.5% over 1 year (2016-2017). Adoption-Institutional factors that supported the program included the acute need to support medically complex patients at the end of life and an engaged clinical champion. Implementation-Program implementation was supported by interdisciplinary teams who engaged in care coordination. Maintenance-The program has been maintained for over 3 years.

CONCLUSION

The cardiac home hospice program strengthened hospice clinicians' ability to confidently provide care for patients with heart failure, expanded awareness of their symptoms among clinicians, and was associated with increased enrollment of patients with heart failure over the study period. This RE-AIM evaluation provides lessons learned and strategies for future adoption, implementation, and maintenance of a cardiac home hospice program.

Older Adults Can Successfully Monitor Symptoms Using an Inclusively Designed Mobile Application

OBJECTIVES

Patient-Reported Outcomes Measurement Information System (PROMIS) measures can monitor patients with chronic illnesses outside of healthcare settings. Unfortunately, few applications that collect electronic PROMIS measures are designed using inclusive design principles that ensure wide accessibility and usability, thus limiting use by older adults with chronic illnesses. Our aim was to establish the feasibility of using an inclusively designed mobile application tailored to older adults to report PROMIS measures by examining (1) PROMIS scores collected with the application, (2) patient-reported usability of the application, and (3) differences in usability by age.

DESIGN

Cross-sectional feasibility study.

SETTING

Inpatient and outpatient cardiac units at an urban academic medical center.

PARTICIPANTS

A total of 168 English- and Spanish-speaking older adults with heart failure.

INTERVENTION

Participants used an inclusively designed mobile application to self-report PROMIS measures.

MEASUREMENTS

Eleven PROMIS Short-Form questionnaires (Anxiety, Ability to Participate in Social Roles and Activities, Applied Cognition-Abilities, Depression, Emotional Distress-Anger, Fatigue, Global Mental Health, Global Physical Health; Pain Interference, Physical Function, Sleep Disturbance), and a validated health technology usability survey measuring Perceived Ease-of-Use and Usefulness of the application.

RESULTS

Overall, 27% of participants were between 65 and 74 years of age, 10% were 75 years or older, 63% were male, 32% were white, and 96% had two or more medical conditions. There was no missing PROMIS data, and mean PROMIS scores showed the greatest burden of pain, fatigue, and physical function in the sample. Usability scores were high and not associated with age (Perceived Ease-of-Use P = .77; Perceived Usefulness P = .91).

CONCLUSION

It is feasible for older adults to use an inclusively designed application to report complete PROMIS data with high perceived usability. To ensure data completeness and the opportunity to study multiple domains of physical, mental, and social health, future work should use inclusive design principles for applications collecting PROMIS measures among older adults. J Am Geriatr Soc 68:1313-1318, 2020.

SOCIAL AND CULTURAL FACTORS FOR HOSPICE CARE OUTCOMES: PERSPECTIVES OF PATIENTS, CAREGIVERS, AND PROVIDERS

Use of hospice services in the U.S. has grown to cover an expanding number of patients with varying conditions and demographic characteristics. Notably, hospice agencies increasingly serve patients with diverse socio-cultural and linguistic backgrounds. Limited research has explored how these factors act to influence the course and outcomes of hospice care, or their role in shaping race/ethnic and socioeconomic disparities in burdensome outcomes like acute hospitalization. This presentation uses the theoretical lens of Cultural Health Capital to explore how socio-cultural factors affect patient-provider interactions within the home hospice setting. Qualitative interviews were conducted with both providers (N=32) and patients/caregivers (N=7) at a large not-for-profit hospice agency in New York City. Themes identified from these interviews included prior knowledge and familiarity with hospice, family dynamics and social support, and linguistic and cultural barriers to care. Findings indicate the need for greater attention to socio-cultural influences on interactional dynamics within home hospice.

PERSPECTIVES ON SETTING GOALS OF CARE AMONG HOSPICE PATIENTS WITH HEART FAILURE, THEIR FAMILIES, AND HEALTHCARE TEAM

Older adults with heart failure (HF) face many end-of-life care issues. Shared decision making (SDM) in hospice is an important process that allows HF patients and their family caregivers to discuss their preferences on goals of care (GOC) with their healthcare team. Yet, little research has explored how the values and preferences of HF patients and their family are integrated into their care plans through SDM process. This presentation examines facilitators and barriers to setting GOC among hospice HF patients. Qualitative interviews were conducted with HF patients/family caregivers (n=7) and providers (n=32) at a large not-for-profit hospice agency. Several facilitators emerged: building trust, active listening, helping patients and family caregivers understand hospice and prognosis. Barriers included acceptance, family conflict, language discordance between patients and providers and lack of communication about care transition. Findings confirmed the need for individually-tailored goal-setting approaches to navigating the end-of-life trajectory among HF patients.

THE DEVELOPMENT AND IMPLEMENTATION OF A CARDIAC HOME HOSPICE PROGRAM FOR ADVANCED STAGE HEART FAILURE PATIENTS

Heart failure (HF) patients encounter distressing symptoms at the end-of-life including dyspnea, edema, and fatigue. Left untreated, these symptoms increase risk for hospice disenrollment. This presentation used the RE-AIM framework to examine a cardiac home hospice program for HF patients. Qualitative interviews with hospice providers (N=32) and quantitative medical record data were used to examine the program. Reach—1,183 HF participants were served between 2013-2016. Effectiveness—Enrollment of HF patients in the hospice program increased from 7.9% to 9.5% after the cardiac protocol was implemented. Adoption—implementation was spearheaded by a clinical champion aware of the challenges of HF symptom management. Implementation— additional support services (i.e., paramedicine, infusion services, cardiac comfort medication kits) were incorporated in the cardiac protocol to better manage complex clinical cases in the home. Maintenance— Reinforcing factors include ongoing training for nursing staff and a 3.5-hour introduction module providing information about HF case management and symptoms/treatments.

CARE MANAGEMENT CHALLENGES AND PROGNOSTIC TOOLS FOR HEART FAILURE PATIENTS IN HOSPICE

Heart failure (HF) patients enroll in hospice at lower rates despite their worse prognosis. This multi-method study explores the characteristics and challenges associated with caring for HF patients. Data from qualitative interviews with hospice providers (n=32) and quantitative records (N=1,114) were used to identify care management issues and prognostic tools. Hospice providers described HF patients unique and often unpredictable symptomatology, their limited understanding and discordant hospice expectations, and difficulties managing symptoms at home. Providers also highlighted HF patients use of assistive medical devices and complex medication regimens. Palliative Performance Scale (PPSv2) scores at hospice enrollment were found to be strongly associated with hospice survival (AUC: 7 days=0.80; 14 days=0.77) and live discharge risk (PPSv2 50-70% AOR=5.68 [CI=3.66-8.79]). Findings underscore the need for specially-tailored trainings and protocols for providers to prevent unplanned discharges and support HF patients at end-of-life.

A Systematic Review of Patient-Facing Visualizations of Personal Health Data

OBJECTIVES

As personal health data are being returned to patients with increasing frequency and volume, visualizations are garnering excitement for their potential to facilitate patient interpretation. Evaluating these visualizations is important to ensure that patients are able to understand and, when appropriate, act upon health data in a safe and effective manner. The objective of this systematic review was to review and evaluate the state of the science of patient-facing visualizations of personal health data.

METHODS

We searched five scholarly databases (PubMed, Embase, Scopus, ACM Digital Library [Association for Computing Machinery Digital Library], and IEEE Computational Index [Institute of Electrical and Electronics Engineers Computational Index]) through December 1, 2018 for relevant articles. We included English-language articles that developed or tested one or more patient-facing visualizations for personal health data. Three reviewers independently assessed quality of included articles using the Mixed methods Appraisal Tool. Characteristics of included articles and visualizations were extracted and synthesized.

RESULTS

In 39 articles included in the review, there was heterogeneity in the sample sizes and methods for evaluation but not sample demographics. Few articles measured health literacy, numeracy, or graph literacy. Line graphs were the most common visualization, especially for longitudinal data, but number lines were used more frequently in included articles over past 5 years. Article findings suggested more patients understand the number lines and bar graphs compared with line graphs, and that color is effective at communicating risk, improving comprehension, and increasing confidence in interpretation.

CONCLUSION

In this review, we summarize types and components of patient-facing visualizations and methodologies for development and evaluation in the reviewed articles. We also identify recommendations for future work relating to collecting and reporting data, examining clinically actionable boundaries for diverse data types, and leveraging data science. This work will be critically important as patient access of their personal health data through portals and mobile devices continues to rise.

Factors Associated With Live Discharge of Heart Failure Patients From Hospice: A Multimethod Study

OBJECTIVES

This study identified sociodemographic and clinical factors that predicted live discharge among home hospice patients with heart failure, and related these findings to perspectives among health care providers about challenges to caring for these patients.

BACKGROUND

Hospice patients with heart failure are frequently discharged from hospice before death ("live discharge"). However, little is known about the factors and circumstances associated with live discharge among patients with heart failure.

METHODS

Quantitative analyses of patient medical records (N = 1,498) and qualitative interviews were performed with health care providers (n = 19) at a not-for-profit hospice agency in New York City.

RESULTS

Thirty percent of home hospice patients with heart failure experienced a live discharge, most frequently due to 911 calls that led to acute hospitalization. The odds of acute hospitalization were higher for younger patients (age 18 to 74 years: adjusted odds ratio [AOR]: 2.10; 95% confidence interval [CI]: 1.34 to 3.28), African American (AOR: 2.06; 95% CI: 1.31 to 3.24) or Hispanic (AOR: 2.99; 95% CI: 1.99 to 4.50) patients, and higher functioning patients (Palliative Performance Scores of 50% to 70%; AOR: 5.68; 95% CI: 3.66 to 8.79). Qualitative interviews with health care providers highlighted the unique characteristics of heart failure (e.g., sudden changes in patients' condition), the importance of patients' understanding of hospice and their own prognosis, and the role of sociocultural and family context in precipitating and potentially preventing live discharge (e.g., absence of social supports in the home).

CONCLUSIONS

Live discharge from hospice, especially due to acute hospitalization, is common with heart failure. Greater attention is needed for patients' knowledge of and readiness for hospice care, especially among younger and diverse populations, and for factors related to the social and family context in which hospice care is provided.

Measuring health status and symptom burden using a web-based mHealth application in patients with heart failure

BACKGROUND

Symptoms of heart failure markedly impair a patient's health status. The aim of this study was to identify predictors of health status in a sample of racially and ethnically diverse patients with heart failure using a web-based mobile health application, mi.Symptoms.

METHODS

We conducted a cross-sectional study at an urban academic medical center. Patients with heart failure self-reported symptoms using validated symptom instruments (e.g. patient-reported outcome measurement information system) by way of the mobile health application, mi.Symptoms. The primary study outcome was health status, measured with the Kansas City cardiomyopathy questionnaire clinical summary score. Data were analyzed using descriptive statistics and multiple linear regression.

RESULTS

The mean age of the sample ( n=168) was 58.7 (±12.5) years, 37% were women, 36% were Black, 36% identified as Hispanic/Latino, 48% were classified as New York Heart Association class III, and 44% reported not having enough income to make ends meet. Predictors of better health status in heart failure included higher physical function ( β=0.89, p=0.001) and ability to participate in social roles and activities ( β=0.58, p=0.002), and predictors of poorer health status were New York Heart Association class IV ( β=-11.68, p=0.006) and dyspnea ( β=-0.77, p<0.001). The predictors accounted for 73% of the variance in health status.

CONCLUSION

Patient-centered interventions should focus on modifiable risk factors that reduce dyspnea, improve functional status, and enhance engagement in social roles to improve the health status of patients with heart failure.

Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure

AIMS

Estimating survival is challenging in the terminal phase of advanced heart failure. Patients, families, and health-care organizations would benefit from more reliable prognostic tools. The Palliative Performance Scale Version 2 (PPSv2) is a reliable and validated tool used to measure functional performance; higher scores indicate higher functionality. It has been widely used to estimate survival in patients with cancer but rarely used in patients with heart failure. The aim of this study was to identify prognostic cut-points of the PPSv2 for predicting survival among patients with heart failure receiving home hospice care.

METHODS AND RESULTS

This retrospective cohort study included 1114 adult patients with a primary diagnosis of heart failure from a not-for-profit hospice agency between January 2013 and May 2017. The primary outcome was survival time. A Cox proportional-hazards model and sensitivity analyses were used to examine the association between PPSv2 scores and survival time, controlling for demographic and clinical variables. Receiver operating characteristic curves were plotted to quantify the diagnostic performance of PPSv2 scores by survival time. Lower PPSv2 scores on admission to hospice were associated with decreased median (interquartile range, IQR) survival time [PPSv2 10 = 2 IQR: 1-5 days; PPSv2 20 = 3 IQR: 2-8 days] IQR: 55-207. The discrimination of the PPSv2 at baseline for predicting death was highest at 7 days [area under the curve (AUC) = 0.802], followed by an AUC of 0.774 at 14 days, an AUC of 0.736 at 30 days, and an AUC of 0.705 at 90 days.

CONCLUSIONS

The PPSv2 tool can be used by health-care providers for prognostication of hospice-enrolled patients with heart failure who are at high risk of near-term death. It has the greatest utility in patients who have the most functional impairment.

Informal Caregiver Decision-Making Factors Associated With Technology Adoption and Use in Home Healthcare: A Systematic Scoping Review

Technology systems to alleviate the burden of caregiving are increasing in use. The home is a unique place where chronic disease management is often performed by informal caregivers, yet how caregivers make decisions about adopting a specific technology has not been thoroughly explored. This systematic scoping review mapped evidence on decision-making factors associated with technology adoption and use by caregivers of patients receiving care at home. We followed the recommendations developed by members of the Joanna Briggs Institute. Four electronic databases (PubMed, Medline, CINAHL, and Embase) were searched using both medical subject headings (MeSH terms) and key words. A total of six papers were included for data synthesis. Factors such as information, comprehension, motivation, time, perceived burden, and perceived caregiving competency were found to affect adoption of technology. There are other factors uniquely springing from the patient and technology, as well as shared issues between caregivers and patient, and caregivers and technology. Although some factors depend on technology type and patient diagnosis, there were some common factors across the research. Those factors can be carefully considered in referring technology use for caregivers. More focused study in this underinvestigated area is much needed.

Purposeful interprofessional team intervention improves relational coordination among advanced heart failure care teams

Effective delivery of healthcare is highly interdependent within and between interprofessional (IP) care teams and the patients they serve. This is particularly true for complex health conditions such as advanced heart failure (AHF). Our Academic Practice Partnership received funding to carry out IP workforce development with inpatient AHF care teams. Our objectives were to (a) identify challenges in team functioning that affected communication and relationships among the AHF care teams, (b) collaboratively identify a focal work process in need of improvement, and (c) test whether facilitated the implementation of team training and work process changes would lead to improvements in team communication, relationships, and process outcomes. The health-care team identified implementation of structured IP bedside rounds (SIBR) as the preferred approach to improving collaborative care. Utilizing a cross-sectional pre/post design, changes in team communication and relationships before and after a team intervention that included TeamSTEPPS training and SIBR implementation, were assessed using a validated Relational Coordination (RC) survey. The study population included AHF care team members (n ~ 100) representing seven workgroups (e.g., nurses, pharmacists) from two inpatient cardiology units at a 450-bed academic medical center in the Pacific Northwest during 2015-2016. Improvements in RC scores were demonstrated across all seven RC dimensions from baseline (Year 1) to follow-up (Year 2). Percent change on each of the seven dimensions ranged from 3.57% to 9.85%. Changes were statistically significant for improvements between baseline and follow-up on all but one of the seven RC dimensions (shared knowledge). The IP team intervention was associated with improvements in RC from baseline to follow-up. Additional research is needed to assess patient perspectives and outcomes of the IP team intervention. Findings of this study are consistent with the growing body of RC and SIBR research and provide a useful model of an IP team-based intervention in clinical practice.

Factors Influencing Sustained Engagement with ECG Self-Monitoring: Perspectives from Patients and Health Care Providers

BACKGROUND

Patient-generated health data (PGHD) collected digitally with mobile health (mHealth) technology has garnered recent excitement for its potential to improve precision management of chronic conditions such as atrial fibrillation (AF), a common cardiac arrhythmia. However, sustained engagement is a major barrier to collection of PGHD. Little is known about barriers to sustained engagement or strategies to intervene upon engagement through application design.

OBJECTIVE

This article investigates individual patient differences in sustained engagement among individuals with a history of AF who are self-monitoring using mHealth technology.

METHODS

This qualitative study involved patients, health care providers, and research coordinators previously involved in a randomized, controlled trial involving electrocardiogram (ECG) self-monitoring of AF. Patients were adults with a history of AF randomized to the intervention arm of this trial who self-monitored using ECG mHealth technology for 6 months. Semistructured interviews and focus groups were conducted separately with health care providers and research coordinators, engaged patients, and unengaged patients. A validated model of sustained engagement, an adapted unified theory of acceptance and use of technology (UTAUT), guided data collection, and analysis through directed content analysis.

RESULTS

We interviewed 13 patients (7 engaged, 6 unengaged), 6 providers, and 2 research coordinators. In addition to finding differences between engaged and unengaged patients within each predictor in the adapted UTAUT model (perceived ease of use, perceived usefulness, facilitating conditions), four additional factors were identified as being related to sustained engagement in this population. These are: (1) internal motivation to manage health, (2) relationship with health care provider, (3) supportive environments, and (4) feedback and guidance.

CONCLUSION

Although it required some modification, the adapted UTAUT model was useful in understanding of the parameters of sustained engagement. The findings of this study provide initial requirement specifications for the design of applications that engage patients in this unique population of adults with AF.

Using the Palliative Performance Scale to Estimate Survival for Patients at the End of Life: A Systematic Review of the Literature

BACKGROUND

The Palliative Performance Scale (PPS) has been widely used for survival prediction among patients with cancer; however, few studies have reviewed PPS scores in heterogeneous palliative care populations across multiple care settings.

OBJECTIVE

The aim of this systematic review was to determine how the PPS tool has been used to estimate survival at the end of life.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, and the Cochrane Library were searched for the existing literature published from 2008 to 2017. We synthesized study characteristics, the PPS scores at baseline, and primary outcomes, and explored differences in survival estimates by diagnosis. The quality of the studies was assessed using the Good ReseArch for Comparative Effectiveness (GRACE) checklist.

RESULTS

Seventeen studies were included in this review (nine with cancer and eight with mixed diagnoses). All included studies reported that the PPS exhibited a significant association with survival. Survival estimates ranged from 1 to 3 days for patients with PPS scores of 10% compared with 5 to 36 days for those with scores of 30%. The categorical cut-points for the PPS scores were not consistently reported across studies.

CONCLUSION

This review provides a broad overview on the prognostic value of the PPS tool for survival among multiple patient populations across care settings. Consistent reporting of PPS scores would facilitate the comparison of survival estimates across end-of-life diagnoses.

Examining interprofessional team interventions designed to improve nursing and team outcomes in practice: a descriptive and methodological review

Effective interprofessional (IP) team-based care is critical to enhance the delivery of efficient care and improve nursing and IP team outcomes. This study aims to review the most recent IP team intervention studies that focused on outcomes related to nursing and IP teams. PubMed, CINAHL, PsycINFO, and Embase were searched for existing literature published between January 2011 and December 2016. The search strategy was developed through both literature review and consultation with a health sciences librarian. This review included IP team intervention studies published in peer-reviewed journals and written in English. Studies were included if they conducted an IP team intervention for healthcare teams that include nurses and examined outcomes related to nursing and the IP teams. Based on inclusion and exclusion criteria, 41 articles were included for the final review. Two authors extracted data on the characteristics of IP team interventions, assessment methods, and their outcomes related to nursing and IP teams using a data abstraction tool developed by the research team. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. We found that most of the included studies were conducted in the US and on inpatient units. A quasi-experimental study design was most commonly employed. Most studies conducted IP team training such as TeamSTEPPS® as a one-time activity. The most common outcomes measured were attitudes or perceptions about IP teamwork or communication, followed by patient-related outcomes, and knowledge or skills about IP competencies. The quality of the included studies was generally low. The findings from this review will contribute to understanding the characteristics of current IP intervention studies and call for IP scholars to design more rigorous yet realistic IP intervention studies.

Examining Interventions Designed to Support Shared Decision Making and Subsequent Patient Outcomes in Palliative Care: A Systematic Review of the Literature

BACKGROUND:

Shared decision making (SDM) is a key attribute of patient-centered care, which empowers palliative care patients to be able to make optimal medical decisions about end-of-life treatments based on their own values and preferences.

AIM:

The aim of this systematic literature review is to detail and compare interventions supporting SDM over the last 10 years (January 2008 to December 2017) and to analyze patient/caregiver outcomes at the end of life.

METHODS:

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, CINAHL, Embase, and Cochrane Library were searched with key search terms: SDM, decision aid, decision support, palliative care, and hospice care. The Mixed Methods Appraisal Tool was used to assess the quality of the included studies.

RESULTS:

The initial search yielded 2705 articles, and 12 studies were included in the final review. The quality of the studies was modest and technology-enabled delivery modes (e.g., video, DVD, web-based tool) were most commonly used. Patient/caregiver knowledge of end-of-life care was the most common primary outcome across studies. The strength of the association between the SDM interventions and patient/caregiver outcomes varied.

CONCLUSION:

The findings from the studies that examined the effects of the SDM intervention on patient outcomes were inconsistent, highlighting the need for further SDM intervention studies among diverse patient populations using consistent measures. Given the availability of health technologies, future studies should focus on developing individual-tailored, technology-enabled interventions to support patient-centered medical decision making.

Understanding the predisposing, enabling, and reinforcing factors influencing the use of a mobile-based HIV management app: A real-world usability evaluation

OBJECTIVE

To conduct an in-depth analysis of users' experiences using an HIV self-management app.

MATERIALS AND METHODS

We conducted four follow-up focus groups at the end of a 3-month randomized feasibility trial. All focus group sessions were audio-recorded and transcribed. A thematic analysis was conducted to explore emerging themes. All of the themes were categorized into three factors of the PRECEDE component of the PRECEDE-PROCEED framework. For a finer granularity of analysis, the codes of each theme were broken into positive, negative, and neutral codes by study group.

RESULTS

36 participants, including 24 from the intervention group and 12 from the control group, participated in the focus group sessions. A total of 14 themes organized by the PRECEDE factors were identified from focus group transcripts. Five themes related to predisposing factors were: 1) ease of app use; 2) user-friendly functionality; 3) self-efficacy for symptom management; 4) design preference of illustrated strategies with videos; and 5) user-control (convenience vs. security). Four themes related to enabling factors were: 1) information needs of symptom management; 2) symptom-tracking; 3) fit in lifestyle/schedule/living conditions; and 4) additional languages (e.g., Spanish). Five themes related to reinforcing factors were: 1) communication with healthcare providers; 2) individual-tailored information visualization; 3) social networking; 4) individual-tailored information quality; and 5) improvement in quality of life.

DISCUSSION AND CONCLUSION

Usability evaluation in a real-world setting enabled us to measure users' actual experiences when interacting with the app during their everyday lives. Our work highlights the importance of using mobile technology for persons living with HIV, specifically those with low income/housing instability, and adds to the body of literature on the potential for implementation and dissemination of symptom self-management strategies through a mobile platform.

RN Job Satisfaction and Retention After an Interprofessional Team Intervention

Despite continuing interest in interprofessional teamwork to improve nurse outcomes and quality of care, there is little research that focuses on nurse job satisfaction and retention after an interprofessional team intervention. This study explored registered nurse (RN) job satisfaction and retention after a purposeful interprofessional team training and structured interprofessional bedside rounds were implemented. As part of a larger study, in this comparative cross-sectional study, pre- and post-intervention data on RN job satisfaction and turnover rate were collected and analyzed. It was found that RNs had significantly higher job satisfaction after the interprofessional team intervention. The 6-month period turnover rate in the post-intervention period was slightly lower than the 6-month period turnover rate in pre-intervention period; however, the rate was too low to provide statistical evidence. Ongoing coaching and supportive work environments to improve RN outcomes should be considered to enhance quality of care and patient safety in healthcare.

Abdominal diameter index is a stronger predictor of prevalent Barrett's esophagus than BMI or waist-to-hip ratio

Abdominal obesity is associated with gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE). Increased body mass index (BMI) and waist-to-hip ratio (WHR) have been associated with BE. Abdominal diameter index (ADI, sagittal abdominal diameter divided by thigh circumference) was previously shown to be a more accurate predictor of incident cardiovascular disease compared to other measurements. Our aim is to examine whether abdominal diameter index was a more accurate predictor of prevalent BE compared to other anthropometric measurements. We conducted a case-control study of patients presenting to our institution. Our study population was consecutive Caucasian men with a known history of BE, and we recruited control patients who had GERD without BE. Both groups completed a questionnaire about demographics, smoking, and medications and underwent a series of anthropometric body measurements using standardized measuring tools. BMI, waist-to-hip ratio, and abdominal diameter index were calculated. Thirty-one BE patients and 27 control patients were recruited. The BE cohort were older and had a higher rate of hiatal hernia. The mean abdominal diameter index for patients with BE was 0.65 ± 0.07 and without BE was 0.60 ± 0.07 (p = 0.01). The predictive value of abdominal diameter index was analyzed using a receiver-operator characteristic (ROC) curve and was a more powerful predictor of BE than waist-to-hip ratio or BMI (AUROC = 0.70 vs. 0.60 vs. 0.52, respectively). Using a cut-point abdominal diameter index value of 0.60, abdominal diameter index had a sensitivity of 77.4% and a specificity of 63.0% for the presence of BE. When controlling for age, smoking status, and BMI, an abdominal diameter index ≥0.60 was a significant independent risk factor for BE (OR = 5.7, 95% CI = 1.29-25.4). In this pilot study, the abdominal diameter index appears to be a more powerful predictor of the presence of BE than BMI and waist-to-hip ratio and remained the only significant predictor of BE in multivariate analysis. We propose further validation of abdominal diameter index before inclusion in future prediction tools for BE.

Team-Based Care: A Concept Analysis

AIM

The purpose of this concept analysis is to clarify and analyze the concept of team-based care in clinical practice.

BACKGROUND

Team-based care has garnered attention as a way to enhance healthcare delivery and patient care related to quality and safety. However, there is no consensus on the concept of team-based care; as a result, the lack of common definition impedes further studies on team-based care.

METHODS

This analysis was conducted using Walker and Avant's strategy. Literature searches were conducted using PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO, with a timeline from January 1985 to December 2015.

RESULTS

The analysis demonstrates that the concept of team-based care has three core attributes: (a) interprofessional collaboration, (b) patient-centered approach, and (c) integrated care process. This is accomplished through understanding other team members' roles and responsibilities, a climate of mutual respect, and organizational support. Consequences of team-based care are identified with three aspects: (a) patient, (b) healthcare professional, and (c) healthcare organization.

CONCLUSION

This concept analysis helps better understand the characteristics of team-based care in the clinical practice as well as promote the development of a theoretical definition of team-based care.