Medication Adherence is a Mediator of the Relationship Between Ethnicity and Event-Free Survival in Patients With Heart Failure

BackgroundRehospitalization rates are higher in African American than Caucasian patients with heart failure (HF). The reasons for the disparity in outcomes between African Americans and Caucasians may relate to differences in medication adherence. To determine whether medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with HF.Methods and ResultsMedication adherence was monitored longitudinally in 135 HF patients using the Medication Event Monitoring System. Events (emergency department visits for HF exacerbation, HF and cardiac rehospitalization, and all-cause mortality) were obtained by interview and hospital data base review. A series of regression models and survival analyses was conducted to determine whether medication adherence mediated the relationship between ethnicity and event-free survival. Event-free survival was significantly worse in African Americans than Caucasians. Ethnicity was a predictor of medication adherence (P = .011). African Americans were 2.57 times more likely to experience an event than Caucasians (P = .026). Ethnicity was not a predictor of event-free survival after entering medication adherence in the model (P = .06).ConclusionsMedication adherence was a mediator of the relationship between ethnicity and event-free survival in this sample. Interventions designed to reduce barriers to medication adherence may decrease the disparity in outcomes.     

Association of Medication Adherence with Workplace Productivity and Health-Related Quality of Life in Patients with Asthma

Objective. Examine the association of medication adherence with workplace productivity and health-related quality of life (HRQL) in asthma patients. Methods. Adult patients with asthma in a state health insurance program identified from medical claims (July 2001-June 2003) were mailed a three-part survey to measure HRQL (St. George's Respiratory Questionnaire), workplace productivity (Workplace Productivity Short Inventory), and self-reported medication adherence (Morisky Scale). Results. The symptoms domain had the worst HRQL scores, followed by the activity and impacts domains; 39% of the participants reported themselves as “high” adherent, whereas 19% were “medium,” and 42% were “low” adherent. Asthma resulted in productivity losses of $597 ± $1,024 (absenteeism) and $658 ± $1,808 (presenteeism) per enrollee per year. Conclusions. Asthma was associated with HRQL detriments and workplace productivity losses.     

Association of Medication Adherence with Workplace Productivity and Health-Related Quality of Life in Patients with Asthma

Objective. Examine the association of medication adherence with workplace productivity and health-related quality of life (HRQL) in asthma patients. Methods. Adult patients with asthma in a state health insurance program identified from medical claims (July 2001–June 2003) were mailed a three-part survey to measure HRQL (St. George's Respiratory Questionnaire), workplace productivity (Workplace Productivity Short Inventory), and self-reported medication adherence (Morisky Scale). Results. The symptoms domain had the worst HRQL scores, followed by the activity and impacts domains; 39% of the participants reported themselves as “high” adherent, whereas 19% were “medium,” and 42% were “low” adherent. Asthma resulted in productivity losses of $597 ± $1,024 (absenteeism) and $658 ± $1,808 (presenteeism) per enrollee per year. Conclusions. Asthma was associated with HRQL detriments and workplace productivity losses.     

Depressive Symptoms Affect the Relationship of N-Terminal Pro B-Type Natriuretic Peptide to Cardiac Event-Free Survival in Patients With Heart Failure

BackgroundBoth N-terminal pro B-type natriuretic peptide (NT-pro BNP) and depressive symptoms independently predict cardiac events in heart failure (HF) patients. However, the relationship among NT-pro BNP, depressive symptoms, and cardiac event is unknown.Methods and ResultsBlood was drawn to measure NT-pro BNP and depressive symptoms were measured by the Patient Health Questionnaire 9 (PHQ-9) among 210 patients with HF. Data about cardiac event-free survival were collected for the average follow-up period of 397 days. Cox proportional hazards regression with survival curves were used to determine the relationship of NT-pro BNP and depressive symptoms to cardiac event-free survival. Higher NT-pro-BNP confers greater risk of cardiac events among those with depressive symptoms than those without depressive symptoms (P for the interaction = .029). Patients with NT-pro BNP >581 pg/mL and total PHQ-9 score ≥10 had a 5.5 times higher risk for cardiac events compared with patients with NT-pro BNP ≤581 pg/mL and total PHQ-9 score < 10 (P = .001).ConclusionsThe prognostic association of NT-pro BNP with cardiac event-free survival in patients with HF differed by the presence of depressive symptoms. Monitoring and treatment of depressive symptoms may be important for improving cardiac event-free survival in patients with HF.     

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

BackgroundCaregivers of patients with heart failure (HF) report depressive symptoms and poor quality of life (QOL) related to caregiving and poor family functioning, placing them at risk for poor health.ObjectivesThe purpose of this study was to examine the effect of depressive symptoms on the relationship between family functioning and quality of life in the HF caregiver.MethodsA sample of 92 HF caregivers were enrolled from an ambulatory clinic at a large academic medical center. A mediation analysis was used to analyze data obtained from the Family Assessment Device (FAD), the Patient Health Questionaire-9 (PHQ-9), and the Short Form-12 Health Survey Version 2 (SF-12v2).ResultsDepressive symptoms were found to be a significant mediator in the relationship between family functioning and caregiver quality of life.ConclusionsThe results of this study suggest that interventions targeting caregiver depression and family functioning could be effective in enhancing HF caregivers’ physical and mental QOL.     

Relationship Between Literacy, Knowledge, Self-Care Behaviors, and Heart Failure-Related Quality of Life Among Patients With Heart Failure

BACKGROUND

We sought to examine the relationship between literacy and heart failure-related quality of life (HFQOL), and to explore whether literacy-related differences in knowledge, self-efficacy and/or self-care behavior explained the relationship.

METHODS

We recruited patients with symptomatic heart failure (HF) from four academic medical centers. Patients completed the short version of the Test of Functional Health Literacy in Adults (TOFHLA) and questions on HF-related knowledge, HF-related self-efficacy, and self-care behaviors. We assessed HFQOL with the Heart Failure Symptom Scale (HFSS) (range 0?C100), with higher scores denoting better quality of life. We used bivariate (t-tests and chi-square) and multivariate linear regression analyses to estimate the associations between literacy and HF knowledge, self-efficacy, self-care behaviors, and HFQOL, controlling for demographic characteristics. Structural equation modeling was conducted to assess whether general HF knowledge, salt knowledge, self-care behaviors, and self-efficacy mediated the relationship between literacy and HFQOL.

RESULTS

We enrolled 605 patients with mean age of 60.7 years; 52% were male; 38% were African-American and 16% Latino; 26% had less than a high school education; and 67% had annual incomes under $25,000. Overall, 37% had low literacy (marginal or inadequate on TOFHLA). Patients with adequate literacy had higher general HF knowledge than those with low literacy (mean 6.6 vs. 5.5, adjusted difference 0.63, p?p?p?p?CONCLUSION Low literacy was associated with worse HFQOL and lower HF-related knowledge, self-efficacy, and self-care behaviors, but differences in knowledge, self-efficacy and self-care did not explain the relationship between low literacy and worse HFQOL.     

The Relationship Between Type and Quality of Social Support and HIV Medication Adherence

Abstract

In the last 10 years HIV has become a disease that can be effectively managed using antiretroviral medications. However, many factors affect adherence, including demographics, income, housing, mental health issues, and access to health care, as well as types and quality of social support. This paper summarizes results regarding specific sources of social support that are part of a larger, randomized study of medication adherence among people with HIV/AIDS. Results summarize findings from 98 program participants and include information regarding support from partners, family and health care providers, as well as the impact of support from these sources on medication adherence. Among participants in this study, those with higher levels of social support from partners demonstrated higher rates of medication adherence. Those who received more social support from their families, however, reported significantly lower adherence rates. These results suggest that efforts to improve medication adherence need to address the diverse types of social support networks of people diagnosed with HIV/AIDS.     

Prevalence of Restless Legs Syndrome and Its Effects on Sleep and Health-Related Quality of Life in Patients With Heart Failure

BackgroundRestless legs syndrome (RLS) is a neurological disorder characterized by leg restlessness and dysesthesia. Although the relationship between RLS and heart failure (HF) has been reported, the prevalence and clinical significance of RLS in patients with HF remain to be elucidated.Methods and ResultsWe enrolled consecutive patients with HF who were admitted to our institutions. RLS was diagnosed using the International Restless Legs Syndrome Study Group criteria. Subjective sleepiness, sleep quality, and quality of life (QoL) were assessed using the Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and 8-item Short Form (SF-8), respectively. Among the 133 patients, 18 (13.6%) had RLS and were younger than those without RLS (62.4±13.4 vs 70.0±12.2, P = .017). The RLS group had significantly disrupted sleep quality and QoL, with greater PSQI score (8.0±3.2 vs 5.9±3.3, P = .015) and lower SF-8 physical component summary (PCS) score (35.6±6.5 vs 40.7±9.5, P = .031), despite similar ESS and SF-8 mental component summary scores. In the multivariable regression analysis, RLS was associated with greater PSQI (β=0.211; P = .014) and lower PCS score (β=?0.177; P = .045).ConclusionIn the patients with HF, RLS was prevalent, and sleep quality and QoL may be disrupted by RLS.     

血浆脑钠肽水平与心力衰竭病人心功能的关系

目的研究心力衰竭病人血浆脑钠肽(BNP)水平与心力衰竭严重程度、左室功能等因素的关系.方法采用化学发光免疫分析法测定80例心力衰竭病人BNP水平,用心脏彩色多普勒超声仪测定其左室功能.结果 BNP水平随着心功能纽约分级(NYHA)程度的加重而显著增加,其与左室射血分数(LVEF)呈负相关(r=-0.407,P＜0.01),与LVEDD、LVMI呈正相关,相关系数分别为r=0.351(P＜0.01)、r=0.369(P＜0.05).结论心力衰竭病人血浆BNP水平随着心力衰竭严重程度的增加而升高,并能较好地反映左室功能状态.     

Mind the Gap: Mismatches Between Clinicians and Patients in Heart Failure Medication Management

Purpose

Previous studies on the ‘treatment gap’ in patients with heart failure (HF) have focused either on prescribing or patients’ adherence to prescribed treatment. This study sought to determine whether or not recent initiatives to close the gap have also minimised any mismatches between physicians’ expectation of their patients’ medications, medications in the patients’ possession and their actual medication use.

Methods

A cross-sectional observational survey was conducted from December 2015 to June 2016 in The Alfred Hospital HF clinic in Melbourne, Australia. Patients were invited to participate if they had chronic HF (NYHA class II to IV), were aged ≥?60 years, had no history of HF related hospitalisation within the past 6 months and were prescribed at least two HF medications.

Results

Of 123 eligible patients, 102 were recruited into the study. Beta-blockers, mineralocorticoid receptor antagonists, loop diuretics and statins were associated with the highest rates of mismatches of drugs and doses, ranging from 10 to 17%. Discrepancy of total daily doses was the most common type of mismatch. Overall, only 23.5% of the patients were taking the right drugs at the right doses as expected by their cardiologists/HF specialists.

Conclusions

Despite improved prescribers’ adherence to guideline-directed medical therapy, there remain considerable mismatches between prescribers’ expectation of patients’ HF medications, medications in patients’ possession and their actual medication use. Initiatives to improve this situation are urgently needed.

     

Association Between Disease-specific Health-related Quality of Life and All-cause Mortality in Patients with Heart Failure: A Meta-analysis

The association between disease-specific health quality of life (QoL) and adverse outcomes remains controversial in patients with heart failure (HF). This meta-analysis aimed to evaluate the association of QoL measured by the Minnesota Living with Heart Failure Questionnaire (MLHFQ) or Kansas City Cardiomyopathy Questionnaire (KCCQ) with all-cause mortality in patients with HF. PubMed and Embase databases were comprehensively searched until December 30, 2022 to identify studies investigating the utility of QoL measured by the MLHFQ or KCCQ in predicting all-cause mortality patients with HF. Twenty-five studies reported on 24 articles enrolling 42,414 HF patients were identified. A comparison of the top with the bottom MLHFQ score, the pooled adjusted hazard ratios (HR) of all-cause mortality was 1.56 (95% confidence intervals [CI] 1.26-1.94). When analyzed the MLHFQ as continuous variable, each 10-point MLHFQ score increase conferred a 12% (95% CI 6%-18%) higher risk of all-cause mortality, which was consistently significant for physical component (HR 1.19; 95% CI 1.09-1.30) and mental component (HR 1.21; 95% CI 1.05-1.40). A comparison of the bottom with the top KCCQ score, the pooled adjusted HR was 2.34 (95% CI 2.10–2.60) for all-cause mortality. Furthermore, each 10-point KCCQ score decrease was associated with a 12% (95% CI 7%-16%) higher risk of all-cause mortality. Worse health-related QoL defined by the higher MLHFQ or lower KCCQ score was associated with an increased risk of all-cause mortality in patients with HF. Assessment of disease-specific health QoL at baseline may provide important prognostic information in these patients.     

Improvement in Health-related Quality of Life After Hospitalization Predicts Event-free Survival in Patients With Advanced Heart Failure

BackgroundHealth-related quality of life (HRQOL) is a major clinical outcome for heart failure (HF) patients. We aimed to determine the frequency, durability, and prognostic significance of improved HRQOL after hospitalization for decompensated HF.Methods and ResultsWe analyzed HRQOL, measured serially using the Minnesota Living with Heart Failure Questionnaire (MLHFQ), for 425 patients who survived to discharge in a multicenter randomized clinical trial of pulmonary artery catheter versus clinical assessment to guide therapy for patients with advanced HF. All patients enrolled had 1 or more prior HF hospitalizations or chronic high diuretic doses and 1 or more symptom and 1 sign of fluid overload at admission. Improvement, defined as a decrease of more than 5 points in MLHFQ total score, occurred in 68% of patients by 1 month and stabilized. The degree of 1-month improvement differed (P < .0001 group × time interaction) between 6-month survivors and non-survivors. In a Cox regression model, after adjustment for traditional risk factors for HF morbidity and mortality, improvement in HRQOL by 1 month compared to worsening at 1 month or no change predicted time to subsequent event-free survival (P = .013).ConclusionsIn patients hospitalized with severe HF decompensation, HRQOL is seriously impaired but improves substantially within 1 month for most patients and remains improved for 6 months. Patients for whom HRQOL does not improve by 1 month after hospital admission merit specific attention both to improve HRQOL and to address high risk for poor event-free survival.     

Relation Between Gender, Etiology and Survival in Patients With Symptomatic Heart Failure

Objectives. This study investigated the relation between gender, etiology and survival in patients with symptomatic heart failure.

Background. Previous work provides conflicting results concerning the relation between gender, clinical characteristics and survival in patients with heart failure.

Methods. We examined the relation of these factors in 557 patients (380 men, 177 women) who had symptomatic heart failure, predominantly nonischemic in origin (68%) and typically associated with severe left ventricular dysfunction.

Results. Follow-up data were available in 99% of patients (mean follow-up period 2.4 years, range 1 day to 10 years) after study entry, and 201 patients reached the primary study end point of all-cause mortality. By life-table analysis, women were significantly less likely to reach this primary end point than men (p < 0.001). A significant association was found between female gender and better survival (p < 0.001), which depended on the primary etiology of heart failure (p = 0.008 for the gender–etiology interaction) but not on baseline ventricular function. Women survived longer than men when heart failure was due to nonischemic causes (men vs. women: relative risk [RR] 2.36, 95% confidence interval [CI] 1.59 to 3.51, p < 0.001). In contrast, outcome appeared similar when heart failure was due to ischemic heart disease (men vs. women: RR 0.85, 95% CI 0.45 to 1.61, p = 0.651).

Conclusions. Women with heart failure due to nonischemic causes had significantly better survival than men with or without coronary disease as their primary cause of heart failure.

(J Am Coll Cardiol 1996;28:1781–8)>     

Role of Heart Rate as a Marker and Mediator of Poor Outcome for Patients with Heart Failure

Tachycardia has been associated with worse outcomes for patients with heart failure and is also thought to have a direct adverse impact on the myocardium. This report highlights the current evidence for heart rate as both a risk factor and mediator for poor outcome for patients with heart failure. We summarize the large number of studies evaluating heart rate in patients with systolic dysfunction and newer studies that examine patients with preserved systolic function. The effect on outcomes in heart failure of medications known to slow the heart rate such as β-blockers and the more recently developed drug ivabradine are discussed. The data clearly show that a high heart rate is a marker of increased mortality. There is also a strong suggestion that a higher heart rate directly worsens outcome and that this can be mitigated by heart rate–reducing medications.     

Understanding the Relationship Between Readmission and Quality of Hospital Care in Heart Failure

Hospital readmission rates for heart failure (HF) are increasingly seen as a quality metric and are being used to define reimbursement rates and penalize underperforming hospitals. As disease patterns shift from single acute episodes of illness to more chronic and degenerative diseases, healthcare systems across the country are grappling with the challenge of providing quality care while simultaneously controlling both readmission rates and spending. Using HF as a prototypical example of chronic illness, this review begins by describing the historical underpinnings of readmission rates and how they have become a mainstream metric of healthcare quality. It then examines the controversial relationship between hospital quality and readmission rates. The paper examines several strategies to decrease readmission rates, including discharge planning and readmission reduction programs, as well as the relationship between readmission rates and mortality rates. The principal drivers of readmissions are discussed and the impact of new readmission-based financial policy is explored as well.     

Longitudinal Health-Related Quality of Life Assessment in Children with Congenital Heart Disease

Objective: Health-related quality of life (HRQoL) has become animportant outcome measure for patients with congenital heart disease (CHD).The aim of this study was to evaluate the natural course of HRQoL from longitudinal assessment in children with CHD. Patients and Methods: From July2014 to February 2020 this longitudinal study recruited 317 children with CHD(113 girls, 35.6%) aged 6 to 18 years (11.6 ± 2.9 years). HRQoL was assessedwith the generic, self-reported and age-adapted KINDL^® questionnaire. Duringa mean follow-up period of 2.2 ± 1.3 years, 195 patients had one HRQoL reassessment, 70 two, 40 three and 12 patients four or more re-assessment, respective. Results: Overall HRQoL at baseline was 78.7 ± 9.3. During follow-up therewere no changes in HRQoL over time (0.03 [–0.01–0.07]; p = 0.195). In a linearmixed model neither CHD severity, the diagnostic subgroup, age, BMI, surgicalhistory nor gender could be linked to a change in HRQoL during the follow-uptime. Only children with higher age baseline (–0.48 [–0.85––0.11]; p = 0.010)had lower HRQoL. Same trend was seen for BMI (–0.19 [–0.41–0.03]; p =0.099). Conclusion: Older children with CHD have significantly worse HRQoL,but they evolve similarly to younger children over time. Since no demographic orclinical variable could be linked to the course of HRQoL, it seems that individualHRQoL courses are not predictable and routine HRQoL evaluations seem to benecessary for acute decision making in clinical practice.