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PublicationMOTIVATional intErviewing to Improve Self-Care in Heart Failure Patients (MOTIVATE-HF): Study Protocol of a Three-Arm Multicenter Randomized Controlled Trial(2017-04-01) Vellone, Ercole; Paturzo, Marco; D'Agostino, Fabio; Petruzzo, Antonio; Masci, Stefano; Ausili, Davide; Rebora, Paola; Alvaro, Rosaria; Riegel, BarbaraAims Heart Failure (HF) self-care improves patient outcomes but trials designed to improve HF self-care have shown inconsistent results. Interventions may be more effective in improving self-care if they mobilize support from providers, promote self-efficacy, increase understanding of HF, increase the family involvement, and are individualized. All of these elements are emphasized in motivational interviewing (MI); few trials have been conducted using MI in HF patients and rarely have caregivers been involved in MI interventions. The aim of this study will be to evaluate if MI improves self-care maintenance in HF patients, and to determine if MI improves the following secondary outcomes: a) in HF patients: self-care management, self-care confidence, symptom perception, quality of life, anxiety/depression, cognition, sleep quality, mutuality with caregiver, hospitalizations, use of emergency services, and mortality; b) in caregivers: caregiver contribution to self-care, quality of life, anxiety/depression, sleep, mutuality with patient, preparedness, and social support. Methods A three-arm randomized controlled trial will be conducted in a sample of 240 HF patients and caregivers. Patients and caregivers will be randomized to the following arms: 1) MI intervention to patients only; 2) MI intervention to patients and caregivers; 3) standard of care to patients and caregivers. The primary outcome will be measured in patients 3 months after enrollment. Primary and secondary outcomes also will be evaluated 6, 9 and 12 months after enrollment. Conclusion This study will contribute to understand if MI provided to patients and caregivers can improve self-care. Because HF is rising in prevalence, findings can be useful to reduce the burden of the disease. PublicationSocial 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. PublicationWho 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. PublicationQualitative 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. PublicationUsing Growth Mixture Modeling to Identify Classes of Sodium Adherence in Adults with Heart Failure(2014-05-01) Masterson-Creber, Ruth; Lee, Christopher S; Lennie, Terry A; Topaz, Maxim; Riegel, BarbaraBACKGROUND: The prevention of fluid retention is important to reduce hospitalizations in patients with heart failure (HF). Following a low-sodium diet helps to reduce fluid retention. OBJECTIVE: The primary objective of this study was to use growth mixture modeling to identify distinct classes of sodium adherence-characterized by shared growth trajectories of objectively measured dietary sodium. The secondary objective was to identify patient-level determinants of the nonadherent trajectory. METHODS: This was a secondary analysis of data collected from a prospective longitudinal study of 279 community-dwelling adults with previously or currently symptomatic HF. Growth mixture modeling was used to identify distinct trajectories of change in 24-hour urinary sodium excretion measured at 3 time points over 6 months. Logistic modeling was used to predict membership in observed trajectories. RESULTS: The sample was predominantly male (64%), had a mean age of 62 years, was functionally compromised (59% New York Heart Association class III), and had nonischemic HF etiology. Two distinct trajectories of sodium intake were identified and labeled adherent (66%) and nonadherent (34%) to low-sodium diet recommendations. Three predictors of the nonadherent trajectory were identified, confirming our previous mixed-effect analysis. Compared with being normal weight (body mass index/m2), being overweight and obese was associated with a 4-fold incremental increase in the likelihood of being in the nonadherent trajectory (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.66-12.91; P < .002). Being younger than 65 years (OR, 4.66; 95% CI, 1.04-20.81; P = .044) or having diabetes (OR, 4.15; 95% CI, 1.29-13.40; P = .016) were both associated with more than 4 times the odds of being in the nonadherent urine sodium trajectory compared with being older than 65 years or not having diabetes, respectively. CONCLUSIONS: Two distinct trajectories of sodium intake were identified in patients with HF. The nonadherent trajectory was characterized by an elevated pattern of dietary sodium intake shown by others to be associated with adverse outcomes in HF. Predictors of the nonadherent trajectory included higher body mass index, younger age, and diabetes. PublicationMotivational Interviewing to Improve Self-Care for Patients with Chronic Heart Failure: MITI-HF Randomized Controlled Trial(2016-02-01) Masterson-Creber, Ruth; Patey, Megan; Lee, Christopher S; Kuan, Amy; Jurgens, Corrine Y; Riegel, BarbaraOBJECTIVE: The purpose of this study was to test the efficacy of a tailored motivational interviewing (MI) intervention versus usual care for improving HF self-care behaviors, physical HF symptoms and quality of life. METHODS: This is a single-center, randomized controlled trial. Participants were enrolled in the hospital. Immediately after discharge, those in the intervention group received a single home visit and 3-4 follow-up phone calls by a nurse over 90 days. RESULTS: A total of 67 participants completed the study (mean age 62±12.8 years), of which 54% were African American, 30% were female, 84% had class III/IV symptoms, and 63% were educated at a high school level or less. There were no differences between the groups in self-care maintenance, self-care confidence, physical HF symptoms, or quality of life at 90 days. CONCLUSION: Patients who received the MI intervention had significant and clinically meaningful improvements in HF self-care maintenance over 90 days that exceeded that of usual care. PRACTICE IMPLICATIONS: These data support the use of a nurse-led MI intervention for improving HF self-care. Identifying methods to improve HF self-care may lead to improved clinical outcomes. PublicationA 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. PublicationMarital 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. PublicationDoes 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. PublicationRelationship Between Self-Care and Health-Related Quality of Life in Older Adults with Moderate to Advanced Heart Failure(2012-01-01) Buck, Harleah G; Lee, Christopher S; Moser, Debra K; Albert, Nancy M; Lennie, Terry A; Bentley, Brooke; Worrall-Carter, Linda; Riegel, BarbaraBackground: Heart failure (HF) patients who follow the treatment regimen and attend to symptoms before they escalate are assumed to have better health-related quality of life (HRQOL) than those with poor self-care, but there are few data available to support or refute this assumption. Objective: The objective of the study was to describe the relationship between HF self-care and HRQOL in older (≥65 years old) adults with moderate to advanced HF. Methods: Self-care was measured using the 3 scales (maintenance, management, and confidence) of the Self-care of Heart Failure Index. Scores range from 0 to 100, with higher numbers indicating better self-care. Health-related quality of life was measured with the Minnesota Living With Heart Failure Questionnaire, a 2-subscale (physical and emotional) instrument. Lower numbers on the Minnesota Living With Heart Failure Questionnaire indicate better HRQOL. Pearson correlations, independent-samples t-tests, and linear and logistic regression modeling were used in the analysis. Results: In 207 adults (72.9 [SD, 6.3] years), New York Heart Association class III (82%) or IV, significant linear associations were observed between self-care confidence and total (r = −0.211; P = .002), physical (r = −0.189; P = .006), and emotional HRQOL (r = −0.201; P = .004). Patients reporting better (below median) HRQOL had higher confidence scores compared with patients reporting above-median HRQOL scores (58.8 [19.2] vs 52.8 [19.6]; P = .028). Confidence was an independent determinant of total (βs = −3.191; P = .002), physical (βs = −2.346; P = .002), and emotional (βs = −3.182; P = .002) HRQOL controlling for other Self-care of Heart Failure Index scores, age, gender, and New York Heart Association class. Each 1-point increase in confidence was associated with a decrease in the likelihood that patients had worse (above median) HRQOL scores (odds ratio, 0.980 [95% confidence interval, 0.963–0.998]) with the same controls. No significant associations were found between self-care maintenance or management and HRQOL. Conclusions: The degree of individual confidence in HF self-care is related to HRQOL, but self-reports of specific maintenance and management behaviors are not. Interventions that improve self-care confidence may be particularly important in older adults with moderate to advanced HF.