Quality of life in heart failure patients undergoing hybrid comprehensive telerehabilitation versus usual care – results of the Telerehabilitation in Heart Failure Patients (TELEREH-HF) Randomized Clinical Trial

IntroductionHybrid comprehensive telerehabilitation (HCTR) consisting of telecare (with psychological telesupport), telerehabilitation and remote monitoring of implantable devices might be an innovative option improving heart failure (HF) patients’ quality of life (QoL) and emotional health. The aim of the study was to investigate the influence of HCTR on various facets of QoL in HF patients in comparison with usual care (UC) alone.Material and methodsThe present analysis formed part of a multicenter, randomized trial that enrolled 850 HF patients (NYHA I–III, LVEF ≤ 40%). Patients were randomized 1 : 1 to HCTR plus UC or UC only. Patients underwent either an HCTR program or UC with observation. The psychological intervention in the HCTR group included supportive psychological counseling via mobile phone. The Medical Outcome Survey Short Form 36 Questionnaire was used to assess QoL. Measurements were made before and after a 9-week intervention (HCTR group)/observation (UC group).ResultsAfter the intervention, the HCTR group showed significant improvement in overall QoL, physical domain (PD) of QoL, and 4 areas of QoL (physical functioning (PhF), role functioning related to physical state (RF), general health (GH), vitality (VI)). A significant positive change in QoL in the UC group was observed only in VI and social functioning. There were also significant differences in QoL after 9-week intervention/observation between the two groups. The results showed greater improvement in HCTR for overall QoL (p = 0.009), PD of QoL (p = 0.0003) and three specific areas of QoL: PhF (p = 0.001), RF (p = 0.003), bodily pain (BP) (p = 0.015).ConclusionsIn comparison to UC, HCTR resulted in improvement in overall QoL, PD of QoL and 3 specific areas of QoL: PhF, RF and BP.     

Effects of educational intervention on mortality and patient-reported outcomes in individuals with heart failure: A randomized controlled trial

ObjectiveTo examine the effects of an educational intervention on patient-reported outcomes and all-cause mortality in heart failure (HF) patientsMethodsIn this randomized controlled trial, we enrolled 122 hospitalized patients with HF. The intervention group (n = 60) received an individual nurse-led education session on HF self-management during hospitalization and three telephone calls after discharge. The control group (n = 62) received care as usual. Patient-reported outcomes were measured at baseline and at 3 and 6 months. Mortality status was determined using the National Death Records. Intervention effects were evaluated using the Cox proportional hazards regression model and linear mixed models.ResultsDuring the follow-up (median: 568 days), 7 deaths (12%) in the intervention group and 15 deaths (24%) in the control group occurred (adjusted hazard ratio, 0.40; 95% confidence interval, 0.16–0.98; P = .046). From baseline to 3 and 6 months, the intervention group showed greater improvements in HF knowledge (difference=6.14, P = .03; difference=5.76, P = .02, respectively), self-care (difference=?6.08, P < .001; difference=?6.16, P < .001, respectively), and health-related quality of life (difference=?11.90, P = .01; difference=?14.57, P = .004, respectively) than the control group.ConclusionEducational intervention with telephone follow-up reduced all-cause mortality and improved patient-reported outcomes.Practice implicationEducational intervention should be considered as part of routine care for HF patients.     

The effect of education through motivational interviewing compared with conventional education on self-care behaviors in heart failure patients with depression

ObjectiveTo determine the effect of education based on motivational interviewing on self-care behaviors in heart failure patients with depression.MethodsIn this study, 82 patients suffering from heart failure whose depression had been confirmed were selected and divided into two groups. The Self-Care Heart Failure Index was utilized to evaluate self-care behavior. The intervention group received four sessions of self-care behavior education based on the principles of motivational interviewing, and the control group received four sessions of conventional education on self-care behavior. At 8 weeks after finishing the interventions, the self-care behaviors of both groups were evaluated. Data were analyzed using paired and independent t-tests, Chi-square, and analysis of covariance, as appropriate.ResultsThe average increase in the overall scores and the scores on the three sub-scales of self-care behavior (maintenance, management, and confidence) of the heart failure patients with depression were significantly higher after education based on motivational interviewing than after conventional self-care education (p < 0.05).ConclusionsMotivational interviewing had a significant positive effect on self-care behaviors in patients with heart failure and depression.Practice implicationsDue to the effectiveness of the MI, using motivational interviewing for education in depressed HF patients is recommended.     

Randomized study of the effect of video education on heart failure healthcare utilization,symptoms, and self-care behaviors

ObjectiveAdherence to self-care behaviors improves heart failure (HF) morbidity and life quality. We examined short-term impact of video education (VE) in addition to standard education (SE) on HF healthcare utilization and self-care behavior adherence.MethodsOne hundred and twelve hospitalized patients were randomly assigned to SE (n = 53) or SE plus VE (n = 59). Differences between groups were analyzed in patients who underwent 3-month follow-up (39 SE and 37 VE patients). Mean age was 60 ± 14 years; mean HF length was 57 months.ResultsThree-month healthcare utilization was similar between groups but VE patients needed less extra diuretic dosing (P < 0.02), received more HF literature (P < 0.03), and had less healthcare team telephone communication (P < 0.04). VE patients had greater sign/symptom reduction (P < 0.04); especially related to edema (P < 0.01) and fatigue (P < 0.01) and initiated more actions for edema (P < 0.05) and dyspnea (with exercise or rest, both P < 0.01). Overall, VE patients had a higher mean self-care behavior score (P < 0.01), reflecting greater self-care adherence.ConclusionVideo education prompts self-care behavior adherence to control worsening signs/symptoms of volume overload. During 3-month follow-up, utilization of most healthcare resources was unchanged.Practice implicationsVE is a useful adjunct to in-person education.     

Trajectory of self-care in people with stable heart failure and insomnia after two self-care interventions

ObjectiveTo describe (1) self-care trajectories among adults with heart failure (HF) and insomnia over 1-year; (2) the extent to which trajectories varied between cognitive behavioral therapy for insomnia (CBT-I) or HF self-care intervention; and (3) the associations between self-care trajectories and clinical and demographic characteristics, sleep, symptoms and stress, and functional performance.MethodsWe conducted secondary analysis of data from a randomized controlled trial of the effects of CBT-I compared with HF self-care education among adults with stable HF and insomnia. We used the Self-Care of Heart Failure Index v6.2. The analytic approaches included t-tests, group-based trajectory modeling, ANOVA, and chi-square.ResultsWe included 175 participants (M age=63.0 (12.9) years, White, N = 100]. We found four self-care trajectories: Low self-care (N = 47, 26.8%); Moderate self-care (N = 68, 38.9%): Adequate self-care (N = 42, 24.0%); and Optimal self-care (N = 18, 10.3%). There was no difference in self-care trajectories between interventions. The low self-care group had the most severe baseline fatigue, anxiety, and perceived stress, and lowest cognitive abilities.ConclusionBoth interventions prevented declining self-care. Future research is needed to determine the most efficacious intervention to improve self-care trajectories.Practice ImplicationsHealthcare providers should provide ongoing self-care support for those with persistently low and moderate self-care.     

Length of stay and readmission in older adults hospitalized for heart failure

IntroductionHospital length of stay (LoS) and hospital readmissions are metrics of healthcare performance. We examined the association between these two metrics in older patients hospitalized with decompensated heart failure (HF).Material and methodsEight thousand and forty-nine patients hospitalized for HF in 106 U.S. hospitals had a median LoS of 5 days; among them, 3777 had a LoS > 5 days. Using propensity scores for LoS > 5 days, we assembled 2723 pairs of patients with LoS 1–5 vs. > 5 days. The matched cohort of 5446 patients was balanced on 40 baseline characteristics. We repeated the above process in 7045 patients after excluding those with LoS > 10 days, thus assembling a second matched cohort of 2399 pairs of patients with LoS 1–5 vs. 6–10 days. Hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with longer LoS were estimated in matched cohorts.ResultsIn the primary matched cohort (n = 5446), LoS > 5 days was associated with a higher risk of all-cause readmission at 30 days (HR = 1.16; 95% CI: 1.04–1.31; p = 0.010), but not during longer follow-up. A longer LoS was also associated with a higher risk of mortality during 8.8 years of follow-up (HR = 1.13; 95% CI: 1.06–1.21; p < 0.001). LoS had no association with HF readmission. Similar associations were observed among the matched sensitivity cohort (n = 4798) that excluded patients with LoS > 10 days.ConclusionsIn propensity score-matched balanced cohorts of patients with HF, a longer LoS was independently associated with poor outcomes, which persisted when LoS > 10 days were excluded.     

Building skill in heart failure self-care among community dwelling older adults: Results of a pilot study

Objective

Most of the day-to-day care for heart failure (HF) is done by the patient at home and requires skill in self-care. In this randomized controlled trial (RCT) we tested the efficacy of a community-based skill-building intervention on HF self-care, knowledge and health-related quality of life (HRQL) at 1- and 3-months.

Methods

An ethnically diverse sample (n = 75) of patients with HF (53% female; 32% Hispanic, 27% Black; mean age 69.9 ± 10 years) was randomized to the intervention group (IG) or a wait-list control group (CG). The protocol intervention focused on tactical and situational HF self-care skill development delivered by lay health educators in community senior centers. Data were analyzed using mixed (between–within subjects) ANOVA.

Results

There was a significant improvement in self-care maintenance [F(2, 47) = 3.42, p = .04, (Cohen's f = .38)], self-care management [F(2, 41) = 4.10, p = .02, (Cohen's f = .45) and HF knowledge [F(2, 53) = 8.00, p = .001 (Cohen's f = .54)] in the IG compared to the CG.

Conclusions

The skill-building intervention improved self-care and knowledge but not HRQL in this community-dwelling sample.

Practice implications

Delivering an intervention in a community setting using lay health educators provides an alternative to clinic- or home-based teaching that may be useful across diverse populations and geographically varied settings.     

Mechanisms of change in self-care in adults with heart failure receiving a tailored,motivational interviewing intervention

Self-care is challenging but we previously demonstrated that motivational interviewing (MI) was effective in improving heart failure (HF) self-care.ObjectiveTo identify the mechanisms of intervention effectiveness by elucidating the MI techniques used and the relationship between the techniques and changes in self-care.MethodsAudiotaped sessions (first and subsequent sessions) from 8 participants were transcribed verbatim and coded to evaluate changes in self-care. Using a sequential mixed method design, quantitative and qualitative self-care data were triangulated; congruence was 97%. The MI techniques used and mechanisms of intervention effectiveness were identified from the qualitative data.ResultsThree MI techniques used were related to improved self-care: 1) reflection and reframing, 2) genuine empathy, affirmation, and humor, and 2) individualized problem solving. These techniques stimulated openness to goal setting, positive self-talk, perceived ability to overcome barriers, and change talk. The mechanisms by which the techniques achieved the desired outcomes were the development of discrepancy and self-efficacy, which are consistent with the principles of MI.ConclusionThis study contributes to clarifying the mechanism by which MI facilitates behavioral change.Practice implicationsUsing MI to discuss self-care can help to overcome barriers and engage HF patients in goal setting for behavior change.     

Effects of a HAPA-based multicomponent intervention to improve self-management precursors of older adults with tuberculosis: A community-based randomised controlled trial

ObjectiveTo evaluate the effectiveness of a multicomponent intervention based on the Health Action Process Approach (HAPA) model to improve the self-management precursors of older adults with tuberculosis (TB).MethodsA cluster-randomised controlled trial was conducted. Older adults with TB in the intervention communities received HAPA-based multicomponent interventions at the beginning of treatment and in the first and sixth months after treatment initiation, and those in the control communities received health education alone. Self-management precursors were measured at baseline and 1 week after each intervention.ResultsAmong 262 randomized patients, 244 (93%) completed the trial. Compared with the control group, self-management precursor scores for the intervention group increased significantly over time (β_group*time = 2.92, p < 0.001) in the following 3 precursors: behaviour belief (β_group*time = 0.35, p < 0.001), behaviour plan (β_group*time = 0.72, p < 0.001), and self-efficacy (β_group*time = 1.85, p < 0.001). Education was significantly associated with behaviour belief (β = 0.18, p < 0.05). Chronic comorbidity was significantly associated with behaviour plan (β=−0.26, p < 0.05).ConclusionCompared with single health education, the HAPA-based multicomponent interventions significantly improved the self-management precursor of older adults with TB.Practice implicationsThis HAPA-based multicomponent intervention strategy may be a promising self-management mode for the routine health care of TB patients.     

Patient education for children with interstitial lung diseases and their caregivers: A pilot study

ObjectivePatient education in children with rare chronic diseases like children’s interstitial lung disease (chILD) remains a challenge.AimsTo develop and evaluate a component-based educational program for individual counselling and to improve patients’ and caregivers’ self-efficacy and treatment satisfaction. Furthermore, to create chILD-specific educational material and assess physicians’ satisfaction with the intervention as well as patients’ health-related quality of life (HrQoL).MethodsThe study was conducted in two German centers for pediatric pulmonology, as a single-group intervention with pre-post-follow-up design.ResultsParticipants (N = 107, age: M = 7.67, SD = 5.90) showed significant improvement of self-efficacy (self-report: t = 2.89, p < 0.01; proxy-report: t = 3.03, p < 0.01), and satisfaction (patients: t = 3.56, p = 0.001; parents t = 6.38, p < 0.001) with the medical consultations. There were no pre-post differences in HrQoL. Participants were highly satisfied with the material and the physicians with the program.ConclusionsThe chILD education-program is a promising strategy to improve patients’ and their parents’ self-efficacy and treatment-satisfaction. Specific effects of the intervention need to be determined in a randomized controlled trial.Practice implicationHealthcare providers managing pediatric patients with chILD, may choose to use a patient education-program specifically tailored to the needs of chILD patients and their families, such as the program described here, which is the first of its kind.     

Executive function moderates the relationship between depressive symptoms and resting heart rate variability in heart failure

Heart failure (HF) is associated with high rates of depression. In turn, depression is associated with reduced heart rate variability (HRV), a marker of parasympathetic dysfunction and poorer cardiac outcomes. Cognitive impairment—especially executive dysfunction—is also highly prevalent in HF, but it is unknown whether executive function (EF) impacts the depression-HRV relationship. The primary objective of this paper is to examine whether EF moderates the relationship between depression and HRV in HF. Participants were 109 HF patients. Depressive symptoms were measured using the Beck Depression Inventory-II. EF was assessed using a composite of age-adjusted T scores on the Frontal Assessment Battery, Trail Making Test B, and Stroop Color Word subtest. Parasympathetic function was assessed using resting high frequency HRV (HF-HRV). Multiple hierarchical regression was used to conduct BDI × EF moderation analyses. BDI scores were associated with reduced resting HF-HRV (p < .05). No main effects were detected between EF and resting HF-HRV (p > .05). However, EF moderated the relationship between BDI scores and resting HF-HRV (β = 0.59, p < .01). Simple slope analyses revealed that among participants with poorer EF, higher BDI scores were associated with lower resting HF-HRV (p < .001). Structural brain changes common in HF may contribute to lower EF, increased depression, and poorer autonomic functioning. Alternatively, the results may indicate that individuals with intact EF engage in self-care strategies that negate the detrimental impact of depression on autonomic function. Additional work is needed to clarify these possibilities and the potential benefits of treating depression in HF patients with different cognitive abilities.     

Efficacy of a social support and problem-solving intervention on heart failure self-care: A pilot study

Objective

The purpose of this study was to examine the preliminary effects of a coping partnership intervention comprised of social support and problem-solving on HF self-care maintenance, management, and confidence.

Prevalence of pathogenic germline cancer risk variants in high-risk urothelial carcinoma

PurposeTo date, there has not been a large, systematic evaluation of the prevalence of germline risk variants in urothelial carcinoma (UC).MethodsWe evaluated the frequency of germline pathogenic and likely pathogenic variants in 1038 patients with high-risk UC who underwent targeted clinical germline testing. Case–control enrichment analysis was performed to screen for pathogenic variant enrichment in 17 DNA repair genes in 1038 UC patients relative to cancer-free individuals.ResultsAmong 1038 patients with UC, the cumulative frequency of patients with pathogenic variants was 24%; 18.6% of patients harbored ≥1 actionable germline variant with preventive or therapeutic utility. MSH2 (34/969, 3.5%) and BRCA1/2 (38/867, 4.4%) germline variants had the highest frequency. Germline variants in DNA damage repair genes accounted for 78% of pathogenic germline variants. Compared to the cancer-free cohort, UC patients had significant variant enrichment in MSH2 (odds ratio [OR]: 15.4, 95% confidence interval [CI]: 7.1–32.7, p < 0.0001), MLH1 (OR: 15.9, 95% CI: 4.4–67.7, p < 0.0001), BRCA2 (OR: 5.7, 95% CI: 3.2–9.6, p < 0.0001), and ATM (OR: 3.8, 95% CI: 1.8–8.3, p = 0.02).ConclusionIn this study, 24% of UC patients harbored pathogenic germline variants and 18.6% had clinically actionable variants. MLH1 and MSH2 were validated as UC risk genes while ATM and BRCA2 were highlighted as potential UC predisposition genes. This work emphasizes the utility of germline testing in selected high-risk UC cohorts.     

Plasma adiponectin concentration and its association with metabolic syndrome in patients with heart failure

Purpose

Plasma adiponectin concentrations are inversely related with metabolic syndrome (MetS), and MetS is associated with increased risk for heart failure (HF). However, the relationship between adiponectin and MetS in HF remains undetermined. Therefore, we tested whether MetS was associated with the degree of plasma adiponectin concentrations in HF patients.

Materials and Methods

One hundred twenty eight ambulatory HF patients with left ventricular ejection fraction of <50% (80 males, 61.8±11.9 years old) were enrolled for this cross-sectional study. Echocardiographic measurements were performed, and plasma concentrations of adiponectin, lipoproteins, apolipoproteins (apoB, apoA1) and high sensitive C-reactive protein (hsCRP) were measured.

Results

Adiponectin concentrations in HF patients with MetS (n=43) were significantly lower than those without MetS (n=85) (9.7±7.0 vs. 15.8±10.9 µg/mL, p=0.001). Higher concentrations of apoB (p=0.017), apoB/A1 ratio (p<0.001), blood urea nitrogen (p=0.034), creatinine (p=0.003), and fasting insulin (p=0.004) were observed in HF patients with MetS compared with those without MetS. In HF patients with MetS, adiponectin concentrations were negatively correlated with hsCRP (r=-0.388, p=0.015) and positively correlated with the ratio of early mitral inflow velocity to early diastolic mitral annular velocity, E/E'' (r=0.399, p=0.015). There was a significant trend towards decreased adiponectin concentrations with an increasing number of components of MetS (p for trend=0.012).

Conclusion

Our study demonstrated that adiponectin concentrations decreased in HF patients with MetS, and that relationship between adiponectin, inflammation and abnormal diastolic function, possibly leading to the progression of HF.     

Increasing genomic literacy among adolescents

PurposeAdolescents increasingly need to be “genomics literate,” and may engage more with video educational formats than traditional written formats. We conducted a pilot study to assess and compare the impact of two modes of education about genome sequencing (GS) on adolescents’ genomic knowledge and genomic-related decisions.MethodsUsing an online survey, 43 adolescents ages 14–17 years were randomly assigned to watch a video or read a pamphlet about GS. Measures included pre- and postintervention assessment of genomic knowledge, perceived utility of these materials for decisions about participating in genetic research, interest in receiving GS results, and overall satisfaction with these materials. Analyses described results for all participants and compared results between intervention groups.ResultsSelf-reported genomic knowledge increased overall (p < 0.001). Postintervention knowledge about GS limitations was higher among video group than pamphlet group participants (p = 0.038). More video group than pamphlet group participants expressed satisfaction with the material’s understandability (45% vs. 29%) and suitability (91% vs. 76%). Interest in receiving personal GS results was significantly associated with being female (p = 0.01) and younger (14–15 years vs. 16–17 years) (p = 0.002).ConclusionA video format may be preferable for increasing genomic literacy among adolescents. Further research with adolescents is needed to better understand how gender and age may impact genomic decisions and preferences.     

Exploratory analysis of cold,heat, deficiency,or excess pattern distribution in women with dysmenorrhea

ObjectiveTo understand the impact and implications of cold, heat, deficiency, or excess pattern identification in relation to dysmenorrhea, comparing the prevalence of these patterns between women with and without dysmenorrhea is needed.MethodsWe gathered data from the Korea Constitutional Multicenter Bank. A total of 508 patients were recruited and provided with cold, heat, deficiency, or excess pattern and dysmenorrhea questionnaires. On the basis of their responses, they were divided into the dysmenorrhea group (moderate or severe dysmenorrheic pain; n = 90) and non-dysmenorrhea group (no dysmenorrheic pain; n = 155). We analyzed the characteristics of the groups and compared the cold, heat, deficiency, or excess pattern scores. Comparisons were performed using the independent t-test. We also performed multiple comparisons of each individual symptom between the groups to explore which symptoms appear with dysmenorrhea using the Bonferroni adjustment method.ResultsThere was a high positive correlation between deficiency pattern scores and excess pattern scores (p < 0.001). The cold, deficiency, and excess pattern scores were significantly higher in the dysmenorrhea group than in the non-dysmenorrhea group (p < 0.001). Twenty among the 76 pattern items showed significant differences between the groups (p < 0.001). Among all items, there was a large effect size only in sleep quality (mean difference 1.07, 95% confidence interval 0.75–1.39, p < 0.001).ConclusionsWomen with dysmenorrhea have higher cold, deficiency, and excess pattern scores than those without dysmenorrhea. The longitudinal observation of these symptoms needs to be evaluated using a clinical prospective study design in accordance with pattern differentiation in the future.     

Improving knowledge,attitudes and beliefs about acute coronary syndrome through an individualized educational intervention: A randomized controlled trial

Objective

To test the effectiveness of an individualized educational intervention on knowledge, attitudes and beliefs about acute coronary syndrome (ACS).

Methods

This multi-site, randomized controlled trial was conducted on 1947 patients with a diagnosis of ACS. Both groups received usual in-hospital education. Participants randomized to the intervention group received a 40-min one to one individualized education session, delivered using motivational interviewing techniques. The intervention was reinforced 1 month and 6 months later. Knowledge, attitudes and beliefs were measured using the ACS Response Index. A total of 1136 patients (control, n = 551; intervention, n = 585) completed the questionnaire at baseline, 3 and 12 months. Data were analyzed using repeated measures analysis of variance. Ethical approval was obtained.

Results

There was a significant effect of the intervention on mean knowledge (p < 0.001), attitude (p = 0.003) and belief (p < 0.001) scores at 3 and 12 months.

Conclusion

Ensuring patients retain information post education has always been difficult to attain. This study demonstrated that patient education using motivational interviewing techniques and an individualized approach has the potential to alter knowledge, attitudes and beliefs about ACS among a high risk population.

Practice implications

This relatively short, simple and effective educational intervention could be delivered by nurses in multiple settings.     

Effect of family nursing therapeutic conversations on health-related quality of life,self-care and depression among outpatients with heart failure: A randomized multi-centre trial

Objective

To evaluate the short-term (3 months) effects of family nursing therapeutic conversations (FNTC) on health-related quality of life, self-care and depression in outpatients with Heart failure (HF).

Evaluation of the effectiveness of the healthy heart tracker on heart failure self-care

ObjectiveWe evaluated the effectiveness of a newly designed patient education booklet, the Health Heart Tracker (HHT), in promoting Heart Failure Self-Care (HFSC) behaviors compared to usual patient discharge handouts.MethodsWe conducted a quasi-experimental, comparative two-group study using patients admitted for HF to four intermediate care units. The HHT was instituted on two units; patients on the other units served as control. We analyzed HFSC measured prior to HF discharge education and at two and six weeks post discharge using repeated measures ANOVA.ResultsEighty-four 84 patients completed the study. The sample was 72.6 (+ 12.9) years old, white (75%), educated, and retired (85.8%). All HFSC behaviors improved significantly over time, but there were no significant time by group interactions in HFSC maintenance, symptom perception, and confidence. A notable increase in HFSC management in the HHT group between baseline and 2 weeks was evident, but not sustained to 6 weeks.ConclusionsA focused, singular intervention in the form of a patient education booklet designed specifically to improve HFSC did not significantly improve self-care behaviors over time compared to a control group.Practice ImplicationsMore work is needed to determine optimal written resources for patients with HF.