Riegel, Barbara
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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 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 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 Marital Status as an Independent Predictor of Event-Free Survival of Patients with Heart Failure(2009-01-01) Chung, Misook L; Lennie, Terry A; Riegel, Barbara; Wu, Jia-Rong; Dekker, Rebecca L; Moser, Debra KBackground: Depressive symptoms are a well-known predictor of mortality in patients with heart failure, and positive spousal support is associated with improved outcomes in these patients. However, in the context of depressive symptoms, the effect on survival of having a spouse is unknown. Objective: To determine the effect of marital status on event-free survival in patients with heart failure who did or did not have depressive symptoms. Methods: Depressive symptoms were assessed by using the Back Depression Inventory-II in patients with heart failure who were followed-up for up to 4 years to collect data on mortality and hospitalizations. Patients were grouped according to the presence and absence of depressive symptoms by using the standard cutoff score of 14 on the Beck Depression Inventory-II. Kaplan-Meier and Cox regression analyses were used to compare event-free survival for married and nonmarried patients who were stratified according to the presence or absence of depressive symptoms. Results: Of 166 patients, 56% were married, and 33% had depressive symptoms. Levels of depressive symptoms were similar between married and nonmarried patients (10.9 vs 12.1; P=.39). Married patients experienced longer event-free survival than did nonmarried patients (P=.01). Conclusions: Patients with a spouse had longer event-free survival than nonmarried patients did, even in the context of depressive symptoms.Publication Palliative Care in Heart Failure: Rationale, Evidence, and Future Priorities(2017-10-10) Kavalieratos, Dio; Gelfman, Laura P; Tycon, Laura E; Riegel, Barbara; Bekelman, David B; Ikejiani, Dara Z; Goldstein, Nathan; Kimmel, Stephen E; Bakitas, Marie A; Arnold, Robert MPatients with heart failure (HF) and their families experience stress and suffering from a variety of sources over the course of the HF experience. Palliative care is an interdisciplinary service and an overall approach to care that improves quality of life and alleviates suffering for those living with serious illness, regardless of prognosis. In this review, we synthesize the evidence from randomized clinical trials of palliative care interventions in HF. While the evidence base for palliative care in HF is promising, it is still in its infancy and requires additional high-quality, methodologically sound studies to clearly elucidate the role of palliative care for patients and families living with the burdens of HF. Yet, an increase in attention to primary palliative care (e.g., basic physical and emotional symptom management, advance care planning), provided by primary care and cardiology clinicians, may be a vehicle to address unmet palliative needs earlier and throughout the illness course.Publication Gender-Specific Characteristics of Individuals With Depressive Symptoms and Coronary Heart Disease(2011-06-01) Doering, Lynn V; McKinley, Sharon; Riegel, Barbara; Moser, Debra K; Meischke, Hendrika; Pelter, Michele M; Dracup, KathleenObjective In individuals with depressive symptoms and coronary heart disease (CHD), little is known about gender-specific characteristics that may inform treatments and outcomes. This study sought to identify characteristics that distinguish men from women with both conditions. Methods By cross-sectional design, 1951 adults with CHD and elevated depressive symptoms completed questionnaires to measure anxiety, hostility, perceived control, and knowledge, attitudes, and beliefs about CHD. Gender differences were evaluated by multivariable logistic regression. Results Women were more likely to be single (odds ratio [OR] 3.61, P < .001), to be unemployed (OR 2.52, P < .001), to be poorly educated (OR 2.52, P < .001), to be anxious (OR 1.14, P < .01), and to perceive lower control over health (OR 1.34, P < .01) than men. Conclusion Women with CHD and depressive symptoms have fewer resources, greater anxiety, and lower perceived control than men. In women, targeting modifiable factors, such as anxiety and perceived control, is warranted.Publication Role of Self-Care in the Patient with Heart Failure(2012-06-01) Moser, Debra K; Dickson, Victoria V; Jaarsma, Tiny; Lee, Christopher; Stromberg, Anna; Riegel, BarbaraOptimal outcomes and quality of life for patients with heart failure depend on engagement in effective self-care activities. Self-care is a complex set of activities and most clinicians are not adequately prepared to assist their patients to engage in effective self-care. In this paper, we provide an overview of self-care that includes definitions, the importance of self-care to outcomes, the physiologic basis for better outcomes with good self-care, cultural perspectives of self-care, and recommendations for the improvement of self-care. Promotion of effective self-care by all clinicians could substantially reduce the economic and personal burden of repeated rehospitalizations among patients with heart failure.