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Publication Introduction of the Tools for Economic Analysis of Patient Management Interventions in Heart Failure Costing Tool: A User-Friendly Spreadsheet Program to Estimate Costs of Providing Patient-Centered Interventions(2011-12-06) Reed, Shelby D; Li, Yanhong; Kamble, Shital; Polsky, Daniel; Graham, Felicia L; Bowers, Margaret T; Samsa, Gregory P; Paul, Sara; Schulman, Kevin A; Whellan, David J; Riegel, BarbaraBackground—Patient-centered health care interventions, such as heart failure disease management programs, are under increasing pressure to demonstrate good value. Variability in costing methods and assumptions in economic evaluations of such interventions limit the comparability of cost estimates across studies. Valid cost estimation is critical to conducting economic evaluations and for program budgeting and reimbursement negotiations. Methods and Results—Using sound economic principles, we developed the Tools for Economic Analysis of Patient Management Interventions in Heart Failure (TEAM-HF) Costing Tool, a spreadsheet program that can be used by researchers and health care managers to systematically generate cost estimates for economic evaluations and to inform budgetary decisions. The tool guides users on data collection and cost assignment for associated personnel, facilities, equipment, supplies, patient incentives, miscellaneous items, and start-up activities. The tool generates estimates of total program costs, cost per patient, and cost per week and presents results using both standardized and customized unit costs for side-by-side comparisons. Results from pilot testing indicated that the tool was well-formatted, easy to use, and followed a logical order. Cost estimates of a 12-week exercise training program in patients with heart failure were generated with the costing tool and were found to be consistent with estimates published in a recent study. Conclusions—The TEAM-HF Costing Tool could prove to be a valuable resource for researchers and health care managers to generate comprehensive cost estimates of patient-centered interventions in heart failure or other conditions for conducting high-quality economic evaluations and making well-informed health care management decisions.Publication Establishing a Pragmatic Framework to Optimise Health Outcomes in Heart Failure and Multimorbidity (ARISE-HF): A Multidisciplinary Position Statement(2016-06-01) Stewart, Simon; Riegel, Barbara; Boyd, Cynthia; Ahamed, Yasmin; Thompson, David R; Burrell, Louise M; Carrington, Melinda J; Coats, Andrew; Granger, Bradi B; Hides, Julie; Weintraub, William S; Moser, Debra K; Dickson, Victoria Vaughan; McDermott, Cressida J; Keates, Ashley K; Rich, Michael WBackground Multimorbidity in heart failure (HF), defined as HF of any aetiology and multiple concurrent conditions that require active management, represents an emerging problem within the ageing HF patient population worldwide. Methods To inform this position paper, we performed: 1) an initial review of the literature identifying the ten most common conditions, other than hypertension and ischaemic heart disease, complicating the management of HF (anaemia, arrhythmias, cognitive dysfunction, depression, diabetes, musculoskeletal disorders, renal dysfunction, respiratory disease, sleep disorders and thyroid disease) and then 2) a review of the published literature describing the association between HF with each of the ten conditions. From these data we describe a clinical framework, comprising five key steps, to potentially improve historically poor health outcomes in this patient population. Results We identified five key steps (ARISE-HF) that could potentially improve clinical outcomes if applied in a systematic manner: 1) Acknowledge multimorbidity as a clinical syndrome that is associated with poor health outcomes, 2) Routinely profile (using a standardised protocol — adapted to the local health care system) all patients hospitalised with HF to determine the extent of concurrent multimorbidity, 3) Identify individualised priorities and person-centred goals based on the extent and nature of multimorbidity, 4) Support individualised, home-based, multidisciplinary, case management to supplement standard HF management, and 5) Evaluate health outcomes well beyond acute hospitalisation and encompass all-cause events and a person-centred perspective in affected individuals. Conclusions We propose ARISE-HF as a framework for improving typically poor health outcomes in those affected by multimorbidity in HF.Publication A Model to Advance Nursing Science in Trauma Practice and Injury Outcomes Research(2011-01-01) Richmond, Therese S; Aitken, Leanne MAims: This discussion paper reports development of a model to advance nursing science and practice in trauma care based on an analysis of the literature and expert opinion. Background: The continuum of clinical care provided to trauma patients extends from the time of injury through to long-term recovery and final outcomes. Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum. Data Sources: Literature was obtained by searching CINAHL, PubMed and OvidMedline databases for 1990 – 2010. Search terms included trauma, nursing, scope of practice and role, with results restricted to those published in English. Manual searches of relevant journals and websites were undertaken. Discussion: Core concepts in this trauma outcomes model include environment, person/family, structured care settings, long term outcomes and nursing interventions. The relationships between each of these concepts extend across all phases of care. Intermediate outcomes are achieved in each phase of care and influence and have congruence with long term outcomes. Implications for Policy and Practice: This model is intended to provide a framework to assist trauma nurses and researchers to consider the injured person in the context of the social, economic, cultural and physical environment from which they come and the long term goals that each person has during recovery. The entire model requires testing in research and assessment of its practical contribution to practice. Conclusion: Planning and integrating care across the trauma continuum, as well as recognition of the role of the injured person’s background, family and resources, will lead to improved long term outcomes.Publication Predictors of Medication Nonadherence Differ among Black and White Patients with Heart Failure(2015-05-11) Dickson, Victoria Vaughan; Knafl, George J; Riegel, BarbaraHeart failure (HF) is a global public health problem, and outcomes remain poor, especially among ethnic minority populations. Medication adherence can improve heart failure outcomes but is notoriously low. The purpose of this secondary analysis of data from a prospective cohort comparison study of adults with heart failure was to explore differences in predictors of medication nonadherence by racial group (Black vs. White) in 212 adults with heart failure. Adaptive modeling analytic methods were used to model HF patient medication nonadherence separately for Black (31.7%) and White (68.3%) participants in order to investigate differences between these two racial groups. Of the 63 Black participants, 33.3% had low medication adherence, compared to 27.5% of the 149 White participants. Among Blacks, 16 risk factors were related to adherence in bivariate analyses; four of these (more comorbidities, lower serum sodium, higher systolic blood pressure, and use of fewer activities compensating for forgetfulness) jointly predicted nonadherence. In the multiple risk factor model, the number of risk factors in Black patients ranged from 0 to 4, and 76.2% had at least one risk factor. The estimated odds ratio for medication nonadherence was increased 9.34 times with each additional risk factor. Among White participants, five risk factors were related to adherence in bivariate analyses; one of these (older age) explained the individual effects of the other four. Because Blacks with HF have different and more risk factors than Whites for low medication adherence, interventions are needed that address unique risk factors among Black patients with HF.Publication Identification of Symptom Clusters among Patients with Heart Failure: An International Observational Study(2014-10-01) Moser, Debra K; Lee, Kyoung Suk; Wu, Jia-Rong; Mudd-Martin, Gia; Jaarsma, Tiny; Huang, Tsuey-Yuan; Fan, Xui-Zhen; Strömberg, Anna; Lennie, Terry A; Riegel, BarbaraBACKGROUND: Virtually all patients with heart failure experience multiple symptoms simultaneously, yet clinicians and researchers usually consider symptoms in isolation. Recognizing and responding early to escalating symptoms is essential to preventing hospitalizations in heart failure, yet patients have considerable difficulty recognizing symptoms. Identification of symptom clusters could improve symptom recognition, but cultural differences may be present that must be considered. OBJECTIVES: To identify and compare symptom clusters in heart failure patients from the United States, Europe and Asia. DESIGN: Cross-sectional, observational study. SETTINGS: In- and out-patient settings in three regions of the world: Asia (i.e., China and Taiwan); Europe (i.e., the Netherlands and Sweden); and the United States. PARTICIPANTS: A total of 720 patients with confirmed heart failure. Propensity scoring using New York Heart Association Classification was used to match participants from each of the three regions. METHODS: Symptoms were identified using the Minnesota Living with Heart Failure Questionnaire. To identify symptom clusters we used cluster analysis with the hierarchical cluster agglomerative approach. We used the Euclidean distance to measure the similarity of variables. Proximity between groups of variables was measured using Ward's method. The resulting clusters were displayed with dendrograms, which show the proximity of variables to each other on the basis of semi-partial R-squared scores. RESULTS: There was a core group of symptoms that formed two comparable clusters across the countries. Dyspnea, difficulty in walking or climbing, fatigue/increased need to rest, and fatigue/low energy were grouped into a cluster, which was labeled as a physical capacity symptom cluster. Worrying, feeling depressed, and cognitive problems were grouped into a cluster, which was labeled as an emotional/cognitive symptom cluster. The symptoms of edema and trouble sleeping were variable among the countries and fell into different clusters. CONCLUSION: Despite the diversity in cultures studied, we found that symptoms clustered similarly among the cultural groups. Identification of similar symptoms clusters among patients with heart failure may improve symptom recognition in both patients and healthcare providers.Publication Motivational Interviewing Tailored Interventions for Heart Failure (MITI-HF): Study Design and Methods(2015-03-01) Masterson-Creber, Ruth; Patey, Megan; Dickson, Victoria Vaughan; DeCesaris, Marissa; Riegel, BarbaraOBJECTIVE: Lack of engagement in self-care is common among patients needing to follow a complex treatment regimen, especially patients with heart failure who are affected by comorbidity, disability and side effects of poly-pharmacy. The purpose of Motivational Interviewing Tailored Interventions for Heart Failure (MITI-HF) is to test the feasibility and comparative efficacy of an MI intervention on self-care, acute heart failure physical symptoms and quality of life. METHODS: We are conducting a brief, nurse-led motivational interviewing randomized controlled trial to address behavioral and motivational issues related to heart failure self-care. Participants in the intervention group receive home and phone-based motivational interviewing sessions over 90-days and those in the control group receive care as usual. Participants in both groups receive patient education materials. The primary study outcome is change in self-care maintenance from baseline to 90-days. CONCLUSION: This article presents the study design, methods, plans for statistical analysis and descriptive characteristics of the study sample for MITI-HF. Study findings will contribute to the literature on the efficacy of motivational interviewing to promote heart failure self-care. PRACTICAL IMPLICATIONS: We anticipate that using an MI approach can help patients with heart failure focus on their internal motivation to change in a non-confrontational, patient-centered and collaborative way. It also affirms their ability to practice competent self-care relevant to their personal health goals.Publication The Relationship Between Community Violence Exposure and Mental Health Symptoms in Urban Adolescents(2008-12-01) McDonald, Catherine C; Richmond, Therese SUrban adolescents are exposed to a substantial amount of community violence which has the potential to influence psychological functioning. To examine the relationship between community violence exposure and mental health symptoms in urban adolescents, a literature review using MEDLINE, CINAHL, PubMed, PsycINFO, CSA Social Services and CSA Sociological Abstracts was conducted. Search terms included adolescent/adolescence, violence, urban, mental health, well-being, emotional distress, depression, anxiety, posttraumatic stress disorder and aggression. Twenty-six empirical research articles from 1997 to 2007 met inclusion criteria for review. Findings indicate an influence of community violence exposure on mental health symptoms, particularly posttraumatic stress and aggression. Mediators and moderators for community violence exposure and mental health symptoms help explain relationships. Limitations in the literature are the lack of consistency in measurement and analysis of community violence exposure, including assessment of proximity and time frame of exposure, and in analysis of victimization and witnessing of community violence. Knowledge about identification of urban adolescents exposed to chronic community violence and who experience mental health symptoms is critical to mental health nursing practice and research.Publication Excessive Daytime Sleepiness is Associated With Poor Medication Adherence in Adults With Heart Failure(2011-04-01) Riegel, Barbara; Moelter, Stephen T; Ratcliffe, Sarah J; Pressler, Susan J; Geest, Sabina De; Potashnik, Sheryl; Fleck, Desiree; Sha, Daohang; Sayers, Steven L; Weintraub, William S; Weaver, Terri E; Goldberg, Lee RBackground A relationship between excessive daytime sleepiness (EDS) and poor treatment adherence has been suspected but not confirmed. We hypothesized that medication adherence would be poorer in adults with heart failure (HF) and EDS and that cognitive status would be the mechanism of effect. Methods and Results A sample of 280 adults with chronic HF were enrolled into a prospective cohort comparison study. We identified a cohort with EDS and a control group without EDS and further divided both groups into those with and without mild cognitive decline. Data on medication adherence were obtained at baseline and 3 and 6 months by using the Basel Assessment of Adherence Scale. Regression analysis was used to clarify the contribution of EDS and cognition to medication adherence and to assess relationships over 6 months after adjusting for age, enrollment site, gender, race, functional class, depression, and premorbid intellect. At baseline, 62% of subjects were nonadherent to their medication regime. Nonadherence was significantly more common in those with EDS, regardless of cognitive status (P = .035). The odds of nonadherence increased by 11% for each unit increase in EDS (adjusted odds ratio 1.11; 95% confidence interval 1.05–1.19; P = .001). In longitudinal models, there was a 10% increase in the odds of nonadherence for each unit increase in EDS (P = .008). The only cognition measure significantly associated with medication adherence was attention (P = .047). Conclusions Adults with HF and EDS are more likely to have problems adhering to their medication regimen than those without EDS, regardless of their cognitive status. Identifying and correcting factors that interfere with sleep may improve medication adherence.Publication Outcome From Serious Injury in Older Adults(2006-01-01) Jacoby, Sara F; Ackerson, Theimann H; Richmond, Therese SPurpose: The purpose of this paper is to analyze the research published in peer-reviewed journals between 1996 and 2005 that examine factors affecting the physical outcomes of older adults after serious traumatic injury. Organizing Construct: 27 primary research studies published in the last 10 years describe in-hospital and long-term outcomes of serious injury among older adults. Research specific to isolated hip injury, traumatic brain injury and burn trauma was excluded. Methods: An integrative review of research published between January 1996 and January 2005 was carried out to examine the relationship between older age and outcome from severe injury. MEDLINE, BIOSIS previews, CINAHL and PsycINFO databases were searched using the MeSH terms: injury, serious injury, trauma and multiple trauma, and crossed with type, severity, medical/surgical management, complication, outcome, mortality, morbidity, survival, disability, quality of life, functional status, functional recovery, function, and placement. Findings: Older adults experience higher short and long-term mortality when compared to younger adults. The relationship between older age and poorer outcome persists when adjusting for injury severity, number of injuries, comorbidities, and complications. At the same time, injury severity, number of injuries, complications, and gender each independently correlate to increased mortality among older adults. The body of research is limited by over-reliance on retrospective data and heterogeneity in definitional criteria for the older adult population. Conclusions: Additional research is needed to clarify the contributory effect of variables such as psychosocial sequelae and physiologic resilience on injury outcome. The field of geriatric trauma would benefit from further population-based prospective investigation of the determinants of injury outcome in older adults in order to guide interventions and acute care treatment.Publication Seriously Injured Urban Black Men’s Perceptions of Clinical Research Participation(2016-12-01) Ulrich, Connie M; Bruce, Marta M; Richmond, Therese S; Kassam-Adams, NancyPurpose: Black men are uniquely vulnerable in American society and our health care system: they bear a disproportionate burden of injury, yet are underrepresented in clinical research. This study aimed to explore the reasons why urban Black men with serious injuries chose to participate in clinical research and their concerns about research participation. Methods: This qualitative study was conducted within the context of a larger study focused on psychological effects of serious injury in urban Black men; 83 Black men with serious injuries were recruited while hospitalized in an urban trauma center. Informed consent was obtained. Semi-structured interviews were conducted in participants’ homes three months after discharge from the hospital and were audiotaped, transcribed, and de-identified. Thematic content analysis was used to identify themes about perceptions of participating in clinical research. Results: The mean age of our sample was 38.2 years, and the mean injury severity score was 10.7 (SD 9.6). The majority (53.2 %) of injuries was due to interpersonal violence, and 47 % were due to unintentional mechanisms. Eight reasons for research participation emerged from the data: human connection, altruism/community, self-improvement, compensation, gaining knowledge, curiosity/interest, low risk, and reciprocity. Conclusions: A major finding was that injured urban Black men participated in clinical research for the opportunity for human and therapeutic connection. Despite some expressions of mistrust, participants were willing to participate for altruistic reasons rooted in community priorities, and as part of their recovery process post-injury.