Antonello Cocchieri

Validity and Reliability of the Caregiver Contribution to Self-care of Heart Failure Index

Background:Caregivers make an important contribution to the self-care of patients with heart failure (HF), but few instruments are available to measure this contribution. Objective:The objective of this study was to test the psychometric properties of the Caregiver Contribution to Self-care of Heart Failure Index (CC-SCHFI), an instrument derived from the Self-care of Heart Failure Index version 6.2. The CC-SCHFI measures the contribution of caregivers to the self-care maintenance and self-care management of HF patients, as well as their confidence in their ability to contribute to the patients’ HF self-care. Methods:A cross-sectional design was used to study 291 Italian caregivers whose HF patients were cared for in 17 cardiovascular centers across Italy. Caregivers completed the CC-SCHFI and a sociodemographic questionnaire. Caregivers were retested on the CC-SCHFI 2 weeks later to assess test-retest reliability. Results:Most caregivers were women (66%) with a mean age of 59 years. First- and second-order confirmatory factor analysis (CFA) for each CC-SCHFI scale showed good model fit: &khgr;2 = 37.22, P = .08, Comparative Fit Index (CFI) = 0.97, Non-Normed Fit Index (NNFI) = 0.96 for caregiver contribution to self-care maintenance (second-order CFA); &khgr;2 = 14.05, P = .12, CFI = 0.96, NNFI = 0.93 for caregiver contribution to self-care management (first-order CFA); and &khgr;2 = 10.63, P = .15, CFI = 0.99, NNFI = 0.98 for caregiver confidence in contributing to self-care (second-order CFA). The CC-SCHFI was able to discriminate statistical and clinical differences between 2 groups of caregivers who had received or not received HF self-care education. Internal consistency reliability measured by factor score determinacy was more than .80 for all factors and scales except for 1 factor in the caregiver contribution to self-care management scale (.65). Test-retest reliability computed by intraclass correlation coefficient was high (>0.90) for most factors and scales. Conclusion:The CC-SCHFI showed good psychometric properties of validity and reliability and can be used to measure the contribution of caregiver to HF patient self-care.

Psychometric testing of the self‐care of heart failure index version 6.2

The Self-Care of Heart Failure Index Version 6.2 (SCHFI v.6.2) is widely used, but its psychometric profile is still questioned. In a sample of 659 heart failure patients from Italy, we performed confirmatory factor analysis (CFA) to test the original construct of the SCHFI v.6.2 scales (Self-Care Maintenance, Self-Care Management, and Self-Care Confidence), with limited success. We then used exploratory factor analysis to determine the presence of separate scale dimensions, followed by CFA in a separate sub-sample. Construct validity of individual scales showed excellent fit indices: CFI = .92, RMSEA = .05 for the Self-Care Maintenance Scale; CFI = .95, RMSEA = .07 for the Self-Care Management Scale; CFI = .99, RMSEA = .02 for the Self-Care Confidence scale. Contrasting groups validity, internal consistency, and test-retest reliability were supported as well. This evidence provides a new understanding of the structure of the SCHFI v.6.2 and supports its use in clinical practice and research.

Describing self-care in Italian adults with heart failure and identifying determinants of poor self-care

Background: Self-care improves outcomes in patients with heart failure; however, no studies have been conducted on this topic in Italy. Aims: We aimed to describe self-care in Italian adults with heart failure and to identify sociodemographic and clinical determinants of self-care. Methods: A cross-sectional design was used to study 1192 heart failure patients enrolled across Italy. We measured self-care using the Self-Care of Heart Failure Index version 6.2, which measures self-care maintenance, management and confidence. Sociodemographic and clinical data were tested as potential determinants of self-care. Results: The mean age of the sample was 72 (SD = 11) years; 58% were male. In the three areas of self-care, scores ranged from 53.18 to 55.26 and few people were adequate in self-care (14.5% to 24.4% of the sample). Self-care behaviours particularly low in this population were symptom monitoring, exercise, use of reminders to take medicines and symptom recognition. Confidence in the ability to keep oneself free of symptoms and relieve symptoms was low. Taking fewer medications, poor cognition, older age, having a caregiver, being male and having heart failure for a shorter time predicted poor self-care maintenance. Poor cognition, not being employed, being male, and having worse New York Heart Association class predicted poor self-care management. Poor cognition, taking fewer mediations, older age, and male gender predicted poor self-care confidence. Conclusion: Self-care is poor in Italian heart failure patients. Determinants of poor self-care identified in this study can help to target patients’ education. Male gender and poor cognition were consistently associated with poor self-care maintenance, management and confidence.

Effects of self-care on quality of life in adults with heart failure and their spousal caregivers: testing dyadic dynamics using the actor-partner interdependence model.

Emotions are contagious in couples. The purpose of this study was to analyze the manner in which adults with chronic heart failure (HF) and their informal caregivers influence each other’s self-care behavior and quality of life (QOL). A sample of 138 HF patients and spouses was enrolled from ambulatory centers across Italy. The Actor–Partner Interdependence Model (APIM) was used to analyze dyadic data obtained with the Self-Care of Heart Failure Index (SCHFI), the Caregivers Contribution to the SCHFI, and the Short Form 12. Both actor and partner effects were found. Higher self-care was related to lower physical QOL in patients and caregivers. Higher self-care maintenance in patients was associated with better mental QOL in caregivers. In caregivers, confidence in the ability to support patients in self-care was associated with improved caregivers’ mental QOL, but worsened physical QOL in patients. Interventions that build the caregivers’ confidence are needed.

Patterns and predictors of patient and caregiver engagement in heart failure care: A multi-level dyadic study

BACKGROUND Heart failure is a burdensome clinical syndrome, and patients and their caregivers are responsible for the vast majority of heart failure care. OBJECTIVES This study aimed to characterize naturally occurring archetypes of patient-caregiver dyads with respect to patient and caregiver contributions to heart failure self-care, and to identify patient-, caregiver- and dyadic-level determinants thereof. DESIGN Dyadic analysis of cross-sectional data on patients and their caregivers. SETTING Outpatient heart failure clinics in 28 Italian provinces. PARTICIPANTS 509 Italian heart failure patients and their primary caregivers. METHODS Multilevel and mixture modeling were used to generate dyadic averages and incongruence in patient and caregiver contributions to heart failure self-care and identify common dyadic archetypes, respectively. RESULTS Three distinct archetypes were observed. 22.4% of dyads were labeled as novice and complementary because patients and caregivers contributed to different aspects of heart failure self-care that was generally poor; these dyads were predominantly older adults with less severe heart failure and their adult child caregivers. 56.4% of dyads were labeled as inconsistent and compensatory because caregivers reported greater contributions to the areas of self-care most insufficient on the part of the patients; patients in these dyads had the highest prevalence of hospitalizations for heart failure in the past year and the fewest limitations to performing activities of daily living independently. Finally, 21.2% of dyads were labeled as expert and collaborative because of high contributions to all aspects of heart failure self-care, the best relationship quality and lowest caregiver strain compared with the other archetypes; patients in this archetype were likely the sickest because they also had the worst heart failure-related quality of life. CONCLUSION Three distinct archetypes of dyadic contributions to heart failure care were observed that represent a gradient in the level of contributions to self-care, in addition to different approaches to working together to manage heart failure. Interventions and clinical programs that involve heart failure dyads should tailor strategies to take into consideration these distinct archetypes and their attributes.

A Dyadic Approach to Managing Heart Failure With Confidence

Background: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.

The European Heart Failure Self-care Behaviour Scale: New insights into factorial structure, reliability, precision and scoring procedure

OBJECTIVE To evaluate a new factorial structure of the European Heart Failure Self-care Behaviour Scale 9-item version (EHFScBS-9), and to test its reliability, floor and ceiling effect, and precision. To propose a new 0-100 score with a higher score meaning better self-care. METHODS A sample of 1192 Heart Failure (HF) patients (mean age 72 years, 58% male) was enrolled. Psychometric properties of the EHFScBS-9 were tested with confirmative factor analysis, factor score determinacy, determining the floor and ceiling effect, and evaluating the precision with the standard error of measurement (SEM) and the smallest real difference (SRD). RESULTS We identified three well-fitting factors: consulting behaviour, autonomy-based adherence, and provider-based adherence (comparative fit index=0.96). Reliability ranged from 0.77 to 0.95. The EHFScBS-9 showed no floor and ceiling effect except for the provider-based adherence which had an expected ceiling effect. The SEM and the SRD indicated good precision of the EHFScBS-9. CONCLUSION The new factorial structure of the EHFScBS-9 showed supportive psychometric properties. PRACTICE IMPLICATIONS The EHFScBS-9 can be used to compute a total and specific scores for each identified factor. This may allow more detailed assessment and tailored interventions to improve self-care. The new score makes interpretation of the EHFScBS-9 easier.

Patterns of self-care and clinical events in a cohort of adults with heart failure: 1 year follow-up

Background: Heart failure (HF) self‐care is important in reducing clinical events (all‐cause mortality, emergency room visits and hospitalizations). HF self‐care behaviors are multidimensional and include maintenance (i.e. daily adherence behaviors), management (i.e. symptom response behaviors) and consulting behaviors (i.e. contacting a provider when appropriate). Across these dimensions, patterns of successful patient engagement in self‐care have been observed (e.g. successful in one dimension but not in others), but no previous studies have linked patterns of HF self‐care to clinical events. Objectives: To identify patterns of self‐care behaviors in HF patients and their association with clinical events. Methods: This was a prospective, non‐experimental, cohort study. Community‐dwelling HF patients (n = 459) were enrolled across Italy, and clinical events were collected one year after enrollment. We measured dimensions of self‐care behavior with the Self‐Care of HF Index (maintenance, management, and confidence) and the European HF Self‐care Behavior Scale (consulting behaviors). We used latent class mixture modeling to identify patterns of HF self‐care across dimensions, and Cox proportional hazards modeling to quantify event‐free survival over 12 months of follow‐up. Results: Patients (mean age 71.8 ± 12.1 years) were mostly males (54.9%). Three patterns of self‐care behavior were identified; we labeled each by their most prominent dimensional characteristic: poor symptom response, good symptom response, and maintenance‐focused behaviors. Patients with good symptom response behaviors had fewer clinical events compared with those who had poor symptom response behaviors (adjusted hazard ratio = 0.66 [0.46–0.96], p = 0.03). Patients with poor symptom response behaviors had the most frequent clinical events. Patients with poor symptom response and those with maintenance‐focused behaviors had a similar frequency of clinical events. Conclusions: Self‐care is significantly associated with clinical events. Routine assessment, mitigation of barriers, and interventions targeting self‐care are needed to reduce clinical events in HF patients.

Hospital Discharge: Results From an Italian Multicenter Prospective Study Using Blaylock Risk Assessment Screening Score

PURPOSE To analyze the predictive validity and reliability of the Blaylock Risk Assessment Screening Score (BRASS) Index in a large group of patients. METHODS Prospective multicenter observational study was conducted in six Italian hospitals. Data were collected in three phases. FINDINGS Seven hundred eleven patients were recruited. The mean length of hospitalization for low-risk patients was significantly shorter than those in the medium and high-risk groups. Patients with a BRASS Index lower than 10, unlike those with a higher BRASS Index, were mainly discharged home. CONCLUSIONS Our results indicate that the BRASS Index is useful to identify patients at risk for prolonged hospitalization. CLINICAL RELEVANCE The use of a validated BRASS instrument can be useful to screen the patients, improving individual discharge planning.

Implementing the family-centered care model, parents’ satisfaction and experiences in neonatology

Background The quality of family-centered care (FCC) in Neonatal Intensive Care Unit (NICU) is often assessed through Parental satisfaction (PS). Empathic-N, a validated questionnaire to evaluate PS in NICU, was recently developed in the Netherlands [1].To our knowledge similar instruments have not yet been used in Italy. The aim of this project is to translate the 57-item Empathic-N questionnaire and to develop and adapted Italian version for postNICU (Empathic-SN) taking the Italian cultural adaptation into account, and to test their psychometric validity.