Riegel, Barbara
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Publication Self-Care Among Patients with Inflammatory Bowel Disease: An Interview Study(2016-04-01) Wickman, Ulrica L; Yngman-Uhlin, Pia; Hjortswang, Henrik; Riegel, Barbara; Stjernman, Henrik; Frisman, Gunilla HInflammatory bowel disease (IBD) is a chronic disease of unknown etiology. The disease occurs early in life and the burden of symptoms is significant. Patients need to perform self-care to handle their symptoms, but knowledge about what kind of self-care patients do is limited and these individuals need to learn how to manage the symptoms that arise. The aim of this study was to explore self-care among patients with IBD. Twenty adult patients with IBD, 25–66 years of age, were interviewed. Data were analyzed by performing a qualitative content analysis. Four categories with 10 subcategories emerged from the analysis of the interviews. The self-care patients perform consists of symptom recognition (subcategories: physiological sensations and psychological sensations), handling of symptoms (subcategories: adapting the diet, using medical treatment, stress management, and using complementary alternative medicine), planning life (subcategories: planning for when to do activities and when to refrain from activities), and seeking new options (subcategories: seeking knowledge and personal contacts). Self-care consists of symptom recognition, handling life through planning, and accommodating the existing situation with the ultimate goal of maintaining well-being. Being one step ahead facilitates living with IBD. A decision to actively participate in care of a chronic illness is a prerequisite for self-care. Healthcare professionals must consider patients' potential for and desire for self-care when giving advice on self-care activities. Doing so may help people better cope with IBD.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 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.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 A Qualitative Meta-Analysis of Heart Failure Self-Care Practices among Individuals with Multiple Comorbid Conditions(2011-05-01) Dickson, Victoria V; Buck, Harleah G; Riegel, BarbaraBackground Most heart failure (HF) patients have other comorbid conditions. HF self-care requires medication and diet adherence, daily weight monitoring, and a thoughtful response to symptoms when they occur. Self-care is complicated when other chronic conditions have additional self-care requirements. The purpose of this study is to explore how comorbidity influences HF self-care. Methods Using qualitative descriptive meta-analysis techniques, transcripts from 3 mixed methods studies (n = 99) were reexamined to yield themes about perceptions about HF and self-care and to explore the influence on HF self-care. The Charlson Comorbidity Index identified comorbid conditions. Results The sample was 74% Caucasian, 66% male (mean age of 59.6 years ± 15 years). Fifty-three percent of the sample was New York Heart Association Class III. All had at least 1 other chronic condition. Narrative accounts revealed that adherence to diet, symptom monitoring, and differentiating symptoms from multiple conditions were the most challenging self-care skills. Emerging themes included 1) attitudes drive self-care prioritization and 2) fragmented self-care instruction leads to poor self-care integration and self-care skill deficits. Conclusions Individuals with multiple chronic conditions are vulnerable to poor self-care. Research testing coaching interventions that integrate self-care requirements and focus on developing skill in self-care across multiple chronic conditions is needed.Publication Does Cognitive Impairment Predict Poor Self-Care in Patients with Heart Failure?(2010-04-21) Cameron, Jan; Worrall-Carter, Linda; Page, Karen; Riegel, Barbara; Kai Lo, Sing; Stewart, SimonAims Cognitive impairment occurs often in patients with chronic heart failure (CHF) and may contribute to sub‐optimal self‐care. This study aimed to test the impact of cognitive impairment on self‐care. Methods and Results In 93 consecutive patients hospitalized with CHF, self‐care (Self‐Care of Heart Failure Index) was assessed. Multiple regression analysis was used to test a model of variables hypothesized to predict self‐care maintenance, management, and confidence. Variables in the model were mild cognitive impairment (MCI; Mini‐Mental State Exam and Montreal Cognitive Assessment), depressive symptoms (Cardiac Depression Scale), age, gender, social isolation, education level, new diagnosis, and co‐morbid illnesses. Sixty‐eight patients (75%) were coded as having MCI and had significantly lower self‐care management (η2= 0.07, P < 0.01) and self‐confidence scores (η2= 0.05, P < 0.05). In multivariate analysis, MCI, co‐morbidity index, and NYHA class III or IV explained 20% of the variance in self‐care management (P < 0.01); MCI made the largest contribution explaining 9% of the variance. Increasing age and symptoms of depression explained 13% of the variance in self‐care confidence scores (P < 0.01). Conclusion Cognitive impairment, a hidden co‐morbidity, may impede patients' ability to make appropriate self‐care decisions. Screening for MCI may alert health professionals to those at greater risk of failed self‐care.Publication Electronically Monitored Medication Adherence Predicts Hospitalization in Heart Failure Patients(2013-12-05) Riegel, Barbara; Knafl, George JBackground: Hospitalization contributes enormously to health care costs associated with heart failure. Many investigators have attempted to predict hospitalization in these patients. None of these models has been highly effective in prediction, suggesting that important risk factors remain unidentified. Purpose: To assess prospectively collected medication adherence, objectively measured by the Medication Event Monitoring System, as a predictor of hospitalization in heart failure patients. Materials and methods: We used recently developed adaptive modeling methods to describe patterns of medication adherence in a sample of heart failure patients, and tested the hypothesis that poor medication adherence as determined by adaptive methods was a significant predictor of hospitalization within 6 months. Results: Medication adherence was the best predictor of hospitalization. Besides two dimensions of poor adherence (adherence pattern type and low percentage of prescribed doses taken), four other single factors predicted hospitalization: low hemoglobin, depressed ejection fraction, New York Heart Association class IV, and 12 or more medications taken daily. Seven interactions increased the predictive capability of the model: 1) pattern of poor adherence type and lower score on the Letter–Number Sequencing test, a measure of short-term memory; 2) higher number of comorbid conditions and higher number of daily medications; 3) higher blood urea nitrogen and lower percentage of prescribed doses taken; 4) lower hemoglobin and much worse perceived health compared to last year; 5) older age and lower score on the Telephone Interview of Cognitive Status; 6) higher body mass index and lower hemoglobin; and 7) lower ejection fraction and higher fatigue. Patients with none of these seven interactions had a hospitalization rate of 9.7%. For those with five of these interaction risk factors, 100% were hospitalized. The C-index (the area under the receiver-operating characteristics [ROC] curve) for the model based on the seven interactions was 0.83, indicating excellent discrimination. Conclusion: Medication adherence adds important new information to the list of variables previously shown to predict hospitalization in adults with heart failure.Publication Ethnic Differences in Quality of Life in Persons with Heart Failure(2008-02-01) Riegel, Barbara; Moser, Debra K; Rayens, Mary Kay; Carlson, Beverly; Pressler, Susan J; Shively, Martha; Albert, Nancy M; Armola, Rochelle R; Evangelista, Lorraine; Westlake, Cheryl; Sethares, KristenBackground Chronic illness burdens some groups more than others. In studies of ethnic/racial groups with chronic illness, some investigators have found differences in health-related quality of life (HRQL), whereas others have not. Few such comparisons have been performed in persons with heart failure. The purpose of this study was to compare HRQL in non-Hispanic white, black, and Hispanic adults with heart failure. Methods Data for this longitudinal comparative study were obtained from eight sites in the Southwest, Southeast, Northwest, Northeast, and Midwest United States. Enrollment and 3- and 6-month data on 1212 patients were used in this analysis. Propensity scores were used to adjust for sociodemographic and clinical differences among the ethnic/racial groups. Health-related quality of life was measured using the Minnesota Living with Heart Failure Questionnaire. Results Significant ethnic/racial effects were demonstrated, with more favorable Minnesota Living with Heart Failure Questionnaire total scores post-baseline for Hispanic patients compared with both black and white patients, even after adjusting for baseline scores, age, gender, education, severity of illness, and care setting (acute vs. chronic), and estimating the treatment effect (intervention vs. usual care). The models based on the physical and emotional subscale scores were similar, with post hoc comparisons indicating more positive outcomes for Hispanic patients than non-Hispanic white patients. Conclusion Cultural differences in the interpretation of and response to chronic illness may explain why HRQL improves more over time in Hispanic patients with heart failure compared with white and black patients.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 A Dyadic Approach to Managing Heart Failure with Confidence(2015-07-01) Lyons, Karen S; Vellone, Ercole; Lee, Christopher S; Cocchieri, Antonello; Bidwell, Julie T; D'Agostino, Fabio; Hiatt, Shirin O; Alvaro, Rosaria; Juarez, Raul; Riegel, BarbaraBackground: The majority of heart failure (HF) self-care research remains focused on patients, despite the important involvement of family caregivers. Although self-care confidence has been found to play an important role in the effectiveness of HF self-care management on patient outcomes, no known research has examined self-care confidence within a dyadic context. Objective: The purpose of this study was to identify individual and dyadic determinants of self-care confidence in HF care dyads. Methods: Multilevel modeling, which controls for the interdependent nature of dyadic data, was used to examine 329 Italian HF dyads (caregivers were either spouses or adult children). Results: Both patients and caregivers reported lower-than-adequate levels of confidence, with caregivers reporting slightly higher confidence than patients. Patient and caregiver levels of confidence were significantly associated with greater patient-reported relationship quality and better caregiver mental health. Patient confidence in self-care was significantly associated with patient female gender, nonspousal care dyads, poor caregiver physical health, and low care strain. Caregiver confidence to contribute to self-care was significantly associated with poor emotional quality of life in patients and greater perceived social support by caregivers. Conclusions: Findings are supportive of the need for a dyadic perspective of HF self-care in practice and research as well as the importance of addressing the needs of both members of the dyad to maximize optimal outcomes for both.