Riegel, Barbara
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Publication Qualitative Analysis of Naturalistic Decision Making in Adults with Chronic Heart Failure(2013-03-01) Riegel, Barbara; Dickson, Victoria V; Topaz, MaximBackground: Self-care of heart failure has been described as a naturalistic decision-making process, but the data available to defend this description are anecdotal. Objectives: The aim of this study was to explore the process used by adults with chronic heart failure to make decisions about their symptoms. Methods: This was a secondary analysis of data obtained from four mixed methods studies. The full data set held qualitative data on 120 adults over the age of 18 years. For this analysis, maximum variation sampling was used to purposively select a subset of 36 of the qualitative interviews to reanalyze. Results: In this sample, equally distributed by gender, 56% Caucasian, between 40 and 98 years, the overarching theme was that decisions about self-care reflect a naturalistic decision-making process with components of situation awareness with mental simulation of a plausible course of action and an evaluation of the outcome of the action. In addition to situation awareness and mental simulation, three key factors were identified as influencing self-care decision making: (a) experience; (b) decision characteristics such as uncertainty, ambiguity, high stakes, urgency, illness, and involvement of others in the decision-making process; and (c) personal goals. Discussion: These results support naturalistic decision making as the process used by this sample of adults with heart failure to make decisions about self-care.Publication Palliative Care: Is Now the Time?(2018-01-02) Riegel, Barbara; Kimmel, Stephen EPalliative care is an approach that focuses on optimizing quality of life for patients and families affected by serious illness, regardless of prognosis. It comprises pain and symptom management; psychological, spiritual, and social support; assistance with treatment decision-making; and complex care coordination. Mounting evidence indicates that palliative care reduces symptom burden, improves mood, decreases healthcare utilization, and improves quality of life for both patients with end-stage heart disease and their caregivers. Indeed, there is a consensus among major clinical guidelines of the importance of early integration of palliative care as an essential component of high quality care for patients with heart failure, a growing use of palliative care in patients with end-stage heart disease, and a clear desire of patients for such care.Publication Who Listens to Our Advice? A Secondary Analysis of Data From a Clinical Trial Testing an Intervention Designed to Decrease Delay in Seeking Treatment for Acute Coronary Syndrome(2011-11-01) Riegel, Barbara; Elmi, Angelo; Moser, Debra K; McKinley, Sharon; Meischke, Hendricka; Doering, Lynn V; Davidson, Patricia; Pelter, Michele; Baker, Heather; Dracup, KathleenObjective Prolonged prehospital delay in persons experiencing acute coronary syndrome (ACS) remains a problem. Understanding which patients respond best to particular interventions designed to decrease delay time would provide mechanistic insights into the process by which interventions work. Methods In the PROMOTION trial, 3522 at-risk patients were enrolled from 5 sites in the United States (56.4%), Australia and New Zealand; 490 (N = 272 intervention, N = 218 control) had an acute event within 2 years. Focusing on these 490, we (1) identified predictors of a rapid response to symptoms, (2) identified intervention group subjects with a change in these predictors over 3 months of follow-up, and (3) compared intervention group participants with and without the favorable response pattern. Hypothesized predictors of rapid response were increased perceived control and decreased anxiety. Knowledge, attitudes, and beliefs were hypothesized to differ between responders and non-responders. Results Contrary to hypothesis, responders had low anxiety and low perceived control. Only 73 (26.8%) subjects showed this pattern 3 months following the intervention. No differences in ACS knowledge, attitudes, or beliefs were found. Conclusion The results of this study challenge existing beliefs. Practice implications New intervention approaches that focus on a realistic decrease in anxiety and perceived control are needed.Publication Modifiable Factors Associated With Sleep Dysfunction in Adults With Heart Failure(2012-12-01) Riegel, BarbaraBackground: Sleep dysfunction contributes to poor quality of life in adults with heart failure (HF). The purpose of this study was to identify factors associated with sleep dysfunction that may be modifiable. Methods: Data were collected from 266 subjects enrolled from three sites in the U.S. Sleep dysfunction was measured over the past month with the Pittsburgh Sleep Quality Index, using a score > 10 to indicate sleep dysfunction. Potentially modifiable clinical, behavioral, and psychological factors thought to be associated with sleep dysfunction were analyzed with hierarchical logistic regression analysis. Results: When covariates of age, gender, race, data collection site, and New York Heart Association (NYHA) functional class were entered on the first step, only NYHA was a significant correlate of sleep dysfunction. When the clinical, behavioral, and psychological factors were entered, correlates of sleep dysfunction were the number of drugs known to cause daytime somnolence (OR = 2.08), depression (OR = 1.83), worse overall perceived health (OR = 1.64), and better sleep hygiene (OR = 1.40). Although most (54%) subjects had sleep disordered breathing (SDB), SDB was not a significant predictor of sleep dysfunction. Discussion: Factors associated with sleep dysfunction in HF include medications with sleepiness as a side-effect, depression, poorer health perceptions, and better sleep hygiene. Sleep dysfunction may motivate HF patients to address sleep hygiene. Eliminating medications with sleepiness as a side-effect, treating depression and perceptions of poor health may improve sleep quality in HF patients.Publication "I Forgot" — Memory and Medication Adherence in Heart Failure(2016-11-28) Riegel, BarbaraPublication 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 Using Brief Motivational Interviewing to Address the Complex Needs of a Challenging Patient With Heart Failure(2014-01-01) Stawnychy, Michael; Creber, Ruth Masterson; Riegel, BarbaraBackground: Hospitals and healthcare providers are looking for methods to reduce hospitalization rates and improve patient outcomes for patients with heart failure (HF). Using behavioral approaches to increase patients’ confidence in their abilities to perform self-care is 1 such approach. Motivational interviewing is an empirically validated modality that has shown promise in improving motivation to change and confidence in the ability to do so. Objective: This case represents a number of themes common in the management of care for a HF patient and explores a 4-session brief motivational interviewing approach to address these themes. The manner in which patient frustration is linked to hospitalization is discussed along with possible ways to address problems in self-care behaviors. Conclusions: With the use of this brief motivational interviewing approach, the patient reported an increase in her motivation and ability to change and developed a postdischarge plan for incorporating self-care behaviors in her daily routine. Clinical Implications: Motivational interviewing may be an effective method of increasing the self-care behaviors of patients with HF.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 Social Support and Self-Care of Patients with Heart Failure(2008-02-20) Sayers, Steven L; Riegel, Barbara; Pawlowski, Stephanie; Coyne, James C; Samaha, Frederick FBackground Social support can influence treatment adherence of patients with chronic illnesses, which may explain the positive effects of social support on heart failure (HF) outcomes. Purpose To investigate the effects of social support among patients with HF, we examined whether aspects of social support were associated with self-care, including medication adherence, dietary adherence, and HF symptom monitoring functions. Methods We recruited 74 patients with HF from cardiology clinics of a Veterans Affairs Medical Center and a university-affiliated hospital, and tested the relationships between social support and the patients' self-care. Results Consistent with previous research in older adults, family members, especially spouses, were often involved in the medical care of patients with chronic HF and provided a range of levels of support to patients. Self-care was generally poor, as measured across several self-care domains. Perceived social support was moderately associated with relatively better self-reported medication and dietary adherence, and other aspects of self-care such as daily weighing. Conclusions These findings suggest that a relatively higher level of self-care is an important correlate of social support and may explain how social support influences HF outcomes. This study also suggests that family members should play a greater part in clinical care focused on improving self-care.