Elizabeth Avery

Self-management Counseling in Patients With Heart Failure: The Heart Failure Adherence and Retention Randomized Behavioral Trial

CONTEXT Motivating patients with heart failure to adhere to medical advice has not translated into clinical benefit, but past trials have had methodological limitations. OBJECTIVE To determine the value of self-management counseling plus heart failure education, compared with heart failure education alone, for the primary end point of death or heart failure hospitalization. DESIGN, SETTING, AND PATIENTS The Heart Failure Adherence and Retention Trial (HART), a single-center, multiple-hospital, partially blinded behavioral efficacy randomized controlled trial involving 902 patients with mild to moderate heart failure and reduced or preserved systolic function, randomized from the Chicago metropolitan area between October 2001 and October 2004 and undergoing follow-up for 2 to 3 subsequent years. INTERVENTIONS All patients were offered 18 contacts and 18 heart failure educational tip sheets during the course of 1 year. Patients randomized to the education group received tip sheets in the mail and telephone calls to check comprehension. Patients randomized to the self-management group received tip sheets in groups and were taught self-management skills to implement the advice. MAIN OUTCOME MEASURE Death or heart failure hospitalization during a median of 2.56 years of follow-up. RESULTS Patients were representative of typical clinical populations (mean age, 63.6 years; 47% women, 40% racial/ethnic minority, 52% with annual family income less than

Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial

30,000, and 23% with preserved systolic function). The rate of the primary end point in the self-management group was no different from that in the education group (163 [40.1%)] vs 171 [41.2%], respectively; odds ratio, 0.95 [95% confidence interval, 0.72-1.26]). There were no significant differences on any secondary end points, including death, heart failure hospitalization, all-cause hospitalization, or quality of life. CONCLUSIONS Compared with an enhanced educational intervention alone, the addition of self-management counseling did not reduce death or heart failure hospitalization in patients with mild to moderate heart failure. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00018005.

Mexican American Trial of Community Health Workers: A Randomized Controlled Trial of a Community Health Worker Intervention for Mexican Americans With Type 2 Diabetes Mellitus

PURPOSE OF THE STUDY To identify needs encountered by older adult patients after hospital discharge and assess the impact of a telephone transitional care intervention on stress, health care utilization, readmissions, and mortality. DESIGN AND METHODS Older adult inpatients who met criteria for risk of post-discharge complications were randomized at discharge through the electronic medical record. Intervention group participants received the telephone-based Enhanced Discharge Planning Program intervention that included biopsychosocial assessment and an individualized plan following program protocols to address identified transitional care needs. All patients received a follow-up call at 30 days post discharge to assess psychosocial needs, patient and caregiver stress, and physician follow-up. RESULTS 83.3% of intervention group participants experienced significant barriers to care. For 73.3% of this group, problems did not emerge until after discharge. Intervention patients were more likely than usual care patients to have scheduled and completed physician visits by 30 days post discharge. There were no differences between groups on patient or caregiver stress or hospital readmission. IMPLICATIONS At-risk older adults may benefit from transitional care programs to ensure delivery of care as ordered and address unmet needs. Although patients who received the intervention were more likely to communicate and follow up with their physicians, the absence of impact on readmission suggests that more intensive efforts may be indicated to affect this outcome.

Adherence to Evidence‐Based Guidelines for Heart Failure in Physicians and Their Patients: Lessons From the Heart Failure Adherence Retention Trial (HART)

OBJECTIVES We assessed whether community health workers (CHWs) could improve glycemic control among Mexican Americans with diabetes. METHODS We recruited 144 Mexican Americans with type 2 diabetes between January 2006 and September 2008 into the single-blinded, randomized controlled Mexican American Trial of Community Health Workers (MATCH) and followed them for 2 years. Participants were assigned to either a CHW intervention, delivering self-management training through 36 home visits over 2 years, or a bilingual control newsletter delivering the same information on the same schedule. RESULTS Intervention participants showed significantly lower hemoglobin A1c levels than control participants at both year 1 Δ = -0.55; P = .021) and year 2 (Δ = -0.69; P = .005). We observed no effect on blood pressure control, glucose self-monitoring, or adherence to medications or diet. Intervention participants increased physical activity from a mean of 1.63 days per week at baseline to 2.64 days per week after 2 years. CONCLUSIONS A self-management intervention delivered by CHWs resulted in sustained improvements in glycemic control over 2 years among Mexican Americans with diabetes. MATCH adds to the growing body of evidence supporting the use of CHWs to reduce diabetes-related health disparities.

Cortisol and Depressive Symptoms in a Population-Based Cohort of Midlife Women

The Heart Failure Adherence and Retention Trial (HART) provided an opportunity to determine adherence to evidence-based guidelines (EBG) in patients with heart failure (HF). Ten hospitals were the source of 692 patients with HF (EF < 40%). Physicians of patients with HF were classified as adherent to EBG if the patient chart audit showed they were on a beta-blocker, ACE-inhibitor (ACE-I), or angiotensin receptor blocker (ARB). Patients were classified as adherent to EBG if MEMS pill caps were used appropriately more than 80% of the time. Sixty-three percent of physicians prescribed evidence-based medications that were adherent to clinical practice guidelines. New York Heart Association (NYHA) III patients were less likely to be adherent (P < 0.001), as were those with renal disease (P < 0.001) and asthmatics (P < 0.001). Nonadherent physicians were less likely to treat patients with beta-blockers (39% vs 98%, P < 0.001) and ACE-I or ARBs (71% vs 98% P < 0.001). Thirty-seven percent of patients prescribed evidence-based therapy failed to use the MEMS pill cap bottles appropriately and were more likely a minority or higher NYHA class. Adherence to evidence-based therapy is less than optimal in HF patients based on a combination of both physician and patient nonadherence.

Vitamin D is associated with atheroprotective high-density lipoprotein profile in postmenopausal women

Objective: To determine whether there is a relationship between depressive symptoms and cortisol assessed at first morning awakening, 6 PM, and 9 PM in a population-based sample of midlife women. If this relationship is not linear, we aim to test whether this relationship is nonlinear, only present in those with more severe depressive symptoms, better accounted for by diurnal slope, or only apparent under uncontaminated conditions. Methods: We investigated the cross-sectional association between cortisol and depressive symptoms, assessed by the Center for Epidemiological Studies Depression scale (CES-D) in 408 midlife women (45.7% African Americans, 54.3% white; mean age, 50.4 years) participating in the Chicago site of the Study of Womens Health Across the Nation. Results: Diurnal cortisol slope is significantly flatter for women with higher CES-D scores than for less depressed women (p < .05 for the interaction). This relationship remains significant even after adjusting for age, smoking status, race, education, income, menopausal status, hormone replacement therapy, body mass index, medications, and wake time, as well as possibly contaminating factors, including physical activity, smoking, eating, or caffeine or alcohol consumption before saliva collection. Results using depression assessed categorically (CES-D cutoff ≥16) were similar to those using continuous depression in both unadjusted and adjusted analyses (p = .005 for the interaction of CES-D by time). Conclusions: In this population-based sample of midlife women, greater depressive symptoms were associated with a significantly flatter diurnal cortisol slope than those with fewer symptoms, even after adjusting for covariates and possibly contaminating behaviors. BMI = body mass index; SWAN = Study of Womens Health Across the Nation; CES-D = Center for Epidemiologic Studies Depression scale; CRH = corticotropin-releasing hormone.

Relationships between menopausal and mood symptoms and EEG sleep measures in a multi-ethnic sample of middle-aged women: the SWAN sleep study.

BACKGROUND Low vitamin D has been associated with low levels of high-density lipoprotein (HDL) cholesterol, a marker of coronary risk. Whether atheroprotective HDL particle composition accounts for this association and whether fat affects this association is not known. OBJECTIVE To explore the association between HDL particle composition and 25-hydroxy vitamin D (25[OH]D) in post-menopausal women. METHODS Vitamin D levels and lipoprotein composition were assessed in fasting blood samples of apparently healthy women from a diverse Chicago community. Visceral (VAT) and subcutaneous (SAT) abdominal fat area were assessed using computed tomography. Total body fat mass was measured by dual-energy X-ray absorptiometry. RESULTS We enrolled 78 women (50% black; 50% white), age 48 to 64 years, all of whom were participants in a longitudinal study of fat patterning. They had a mean 25[OH]D of 31 ± 15 μg/L, HDL cholesterol 57±11 mg/dL, and large HDL particle subclass 8.6±3.4 μmol/L. In a multivariable-adjusted regression model, each 5 μg/L higher 25[OH]D predicted 0.57 μmol/L (95%CI 0.20-0.95) higher large HDL particles, independent of race, season, and total HDL particle concentration. This association was only partially confounded by total body fat mass (0.49, 95%CI 0.10-0.89), SAT (0.50, 95%CI 0.11-0.90), or VAT (0.37, 95%CI 0.01-0.74). Age did not significantly influence the strength of associations. CONCLUSIONS Higher 25[OH]D levels are associated with large HDL particles. This association is stronger than that of HDL cholesterol and only partially confounded by body fat. Theoretically, vitamin D may protect against cardiovascular risk by promoting formation of large HDL particles, affecting reverse cholesterol transport.

Factors associated with levels of adherence to inhaled corticosteroids in minority adolescents with asthma.

STUDY OBJECTIVES Examine associations of vasomotor and mood symptoms with visually scored and computer-generated measures of EEG sleep. DESIGN Cross-sectional analysis. SETTING Community-based in-home polysomnography (PSG). PARTICIPANTS 343 African American, Caucasian, and Chinese women; ages 48-58 years; pre-, peri- or post-menopausal; participating in the Study of Womens Health Across the Nation Sleep Study (SWAN Sleep Study). INTERVENTIONS None. MEASUREMENTS AND RESULTS Measures included PSG-assessed sleep duration, continuity, and architecture, delta sleep ratio (DSR) computed from automated counts of delta wave activity, daily diary-assessed vasomotor symptoms (VMS), questionnaires to collect mood (depression, anxiety) symptoms, medication, and lifestyle information, and menopausal status using bleeding criteria. Sleep outcomes were modeled using linear regression. Nocturnal VMS were associated with longer sleep time. Higher anxiety symptom scores were associated with longer sleep latency and lower sleep efficiency, but only in women reporting nocturnal VMS. Contrary to expectations, VMS and mood symptoms were unrelated to either DSR or REM latency. CONCLUSIONS Vasomotor symptoms moderated associations of anxiety with EEG sleep measures of sleep latency and sleep efficiency and was associated with longer sleep duration in this multi-ethnic sample of midlife women.

The Impact of Peer Support and mp3 Messaging on Adherence to Inhaled Corticosteroids in Minority Adolescents with Asthma: A Randomized, Controlled Trial

BACKGROUND Nonadherence to inhaled corticosteroids (ICS) is a significant risk factor for poor asthma outcomes in minority adolescents with persistent asthma. OBJECTIVE To identify factors associated with nonadherence to daily ICS in this target population. METHODS Adolescents 11 to 16 years old, self-identified as African American or Hispanic, diagnosed with persistent asthma and with an active prescription for daily ICS were invited to participate. Participant adherence to ICS was electronically measured during 14 days. Concurrently, participants completed the following assessments: demographic information, asthma history, asthma control, asthma exacerbations, media use, depression, asthma knowledge, ICS knowledge, and ICS self-efficacy. Of the 93 subjects, 68 had low (<48%) adherence and 25 had high (>48%) adherence. RESULTS Older age and low ICS knowledge each were associated with low (≤48%) adherence (P < .01 for the 2 variables). CONCLUSION Older age and low ICS knowledge each may be associated with poor adherence to ICS in minority adolescents with persistent asthma. Although older age often is associated with the assignment of increased responsibility for medication-taking behavior, it may not be associated with increased adherence. Continued and expanded efforts at promoting asthma education and specifically knowledge of ICS may increase adherence to ICS.

A Self-Management Intervention for African Americans With Comorbid Diabetes and Hypertension: A Pilot Randomized Controlled Trial

BACKGROUND Poor adherence to inhaled corticosteroids (ICS) is a critical risk factor contributing to asthma morbidity among low-income minority adolescents. OBJECTIVE This trial tested whether peer support group meetings and peer asthma messages delivered via mp3 players improved adherence to ICS. METHODS Low-income African American and/or Hispanic adolescents, ages 11-16 years old, with persistent asthma, and poor (≤ 48%) adherence to prescription ICS during the 3-week run-in were randomized to intervention or attention control groups (ATG) for the 10-week treatment. During treatment, the intervention arm subjects participated in weekly coping peer group support sessions and received mp3 peer-recorded asthma messages that promoted adherence. The ATG participated in weekly meetings with a research assistant and received an equivalent number of mp3 physician-recorded asthma messages. Adherence was measured by using self-report and the Doser CT, an electronic dose counter. The primary outcome was the difference in adherence at 10 weeks between the 2 arms. RESULTS Thirty-four subjects were randomized to each arm. At 10 weeks, no statistical difference in objectively measured adherence could be detected between the 2 arms when adjusting for baseline adherence (P = .929). Adherence declined in both groups over the course of the active treatment period. In both study arms, self-reported adherence by participants was significantly higher than their objectively measured adherence at week 10 (P < .0001). CONCLUSION Improving medication adherence in longitudinal studies is challenging. Peer support and mp3-delivered peer asthma messages may not be of sufficient dose to improve outcomes.