Jill Howie-Esquivel

Is ''Teach-Back'' Associated With Knowledge Retention and Hospital Readmission in Hospitalized Heart Failure Patients?

Background:Heart failure (HF) is a chronic and costly condition that affects approximately 5.8 million people in the United States, with an additional 670 000 diagnosed yearly. With high 30-day hospital readmission rates, the importance of determining effective means of preventing readmissions is imperative. Despite published guidelines emphasizing the importance of education in preventing readmissions, the most effective means of educating hospitalized patients with HF about their self-care remains unknown. Objective:The aim of this study was to determine if hospitalized HF patients educated with the teach-back method retain self-care educational information and whether it is associated with fewer hospital readmissions. Methods:A prospective cohort study design included 276 patients older than 65 years hospitalized with HF over a 13-month period. Patients were educated and evaluated using the teach-back method as part of usual care. Data on ability to recall educational information while hospitalized and during follow-up approximately 7 days after hospital discharge were collected. Readmissions were confirmed through follow-up telephone calls and review of medical records. Results:Patients correctly answered 3 of 4, or 75%, of self-care teach-back questions 84.4% of the time while hospitalized and 77.1% of the time during follow-up telephone call. Greater time spent teaching was significantly associated with correctly answered questions (P < .001). Patients who answered teach-back questions correctly while hospitalized and during follow-up had nonsignificant (P = .775 and .609) reductions in all-cause 30-day hospital readmission rates, but a trend toward significance (P = .15) was found in patients who had readmissions for HF. Conclusions:The teach-back method is an effective method used to educate and assess learning. Patients educated longer retained significantly more information than did patients with briefer teaching. Correctly answered HF-specific teach-back questions were not associated with reductions in 30-day hospital readmission rates. Future studies that include patients randomized to receive usual care or teach-back education to compare readmissions and knowledge acquisition would provide further comparison of teach-back effectiveness.

A text messaging intervention to promote medication adherence for patients with coronary heart disease: A randomized controlled trial

OBJECTIVE Pharmacologic treatment for secondary prevention of coronary heart disease (CHD) is critical to prevent adverse clinical outcomes. In a randomized controlled trial, we compared antiplatelet and statin adherence among patients with CHD who received: (1) text messages (TM) for medication reminders and education, (2) educational TM only, or (3) No TM. METHODS A mobile health intervention delivered customized TM for 30 days. We assessed and analyzed medication adherence with electronic monitoring devices [Medication Event Monitoring System (MEMS)] by one-way ANOVA and Welch tests, two-way TM response rates by t-tests, and self-reported adherence (Morisky Medication Adherence Scale) by Repeated Measures ANOVA. RESULTS Among 90 patients (76% male, mean age 59.2 years), MEMS revealed patients who received TM for antiplatelets had a higher percentage of correct doses taken (p=0.02), percentage number of doses taken (p=0.01), and percentage of prescribed doses taken on schedule (p=0.01). TM response rates were higher for antiplatelets than statins (p=0.005). Self-reported adherence revealed no significant differences among groups. CONCLUSION TM increased adherence to antiplatelet therapy demonstrated by MEMS and TM responses. PRACTICE IMPLICATIONS Feasibility and high satisfaction were established. Mobile health interventions show promise in promoting medication adherence.

Does sufficient evidence exist to support a causal association between vitamin D status and cardiovascular disease risk? An assessment using Hill's criteria for causality.

Serum 25-hydroxyvitamin D (25(OH)D) levels have been found to be inversely associated with both prevalent and incident cardiovascular disease (CVD) risk factors; dyslipidemia, hypertension and diabetes mellitus. This review looks for evidence of a causal association between low 25(OH)D levels and increased CVD risk. We evaluated journal articles in light of Hill’s criteria for causality in a biological system. The results of our assessment are as follows. Strength of association: many randomized controlled trials (RCTs), prospective and cross-sectional studies found statistically significant inverse associations between 25(OH)D levels and CVD risk factors. Consistency of observed association: most studies found statistically significant inverse associations between 25(OH)D levels and CVD risk factors in various populations, locations and circumstances. Temporality of association: many RCTs and prospective studies found statistically significant inverse associations between 25(OH)D levels and CVD risk factors. Biological gradient (dose-response curve): most studies assessing 25(OH)D levels and CVD risk found an inverse association exhibiting a linear biological gradient. Plausibility of biology: several plausible cellular-level causative mechanisms and biological pathways may lead from a low 25(OH)D level to increased risk for CVD with mediators, such as dyslipidemia, hypertension and diabetes mellitus. Experimental evidence: some well-designed RCTs found increased CVD risk factors with decreasing 25(OH)D levels. Analogy: the association between serum 25(OH)D levels and CVD risk is analogous to that between 25(OH)D levels and the risk of overall cancer, periodontal disease, multiple sclerosis and breast cancer. Conclusion: all relevant Hill criteria for a causal association in a biological system are satisfied to indicate a low 25(OH)D level as a CVD risk factor.

Biomarkers in acute cardiovascular disease.

Cardiovascular disease today remains a formidable foe affecting 1 in 3 Americans. The emergence of cardiac biochemical markers has provided clinicians unique insight into the state of the myocardium. In fact, cardiac biomarkers now represent an essential criterion in the definition of acute myocardial infarction. There has been impressive development of efficient and reliable assays to detect biomarkers in the serum. Together with patient history and electrocardiographic analysis, the invaluable information gained from serum cardiac biomarkers supports diagnosis, therapy selection, and determination of prognosis. Biomarkers such as troponin and creatine kinase MB have received well-deserved attention for their ability to detect myocardial ischemia. Clinicians today use cardiac markers to identify ischemia as well as alternate clinical states. B-type natriuretic peptide, for instance, reflects myocardial stretch as seen in heart failure exacerbations and may well have promising prognostic significance. The purpose of this review is to discuss current and emerging cardiac biomarkers in acutely ill patients. The advantages and disadvantages of biomarkers will also be presented in the context of their clinical uses. Present markers are highly sensitive and specific to myocardial injury; however they do not specifically identify the method of injury. An exciting potential exists for future biomarkers to demonstrate enhanced specificity and earlier detection of compromised myocardium.

Readmission Risk Factors after Hospital Discharge Among the Elderly

Hospital readmission rates among the elderly are attracting increasing attention. Readmission is costly, especially as proposed new guidelines could deny reimbursement for readmissions. Identifying key factors at discharge that can serve as prognostic indicators for readmission is an important step toward developing and targeting interventions to reduce hospital readmissions rates. Published literature has listed predominantly demographic, clinical, and health care utilization characteristics to describe the factors that put the elderly at risk. However, additional factors are proposed that include social, clinical, individual-level, environmental, and system-level factors. Multimodal interventions have been tested and some reduction in readmissions has been shown. Whether these additional factors might lead to a further reduction remains unclear. In addition to possible factors at discharge, factors identified after the patient has been discharged also must be identified and addressed. The patient safety literature characterizes factors that put the elderly at risk for adverse drug events, which function as antecedent factors for readmission and likely include the environmental and system-level factors. Synthesizing these factors from the readmission and patient safety literature provides the basis to develop a more comprehensive conceptual framework to identify research gaps aimed at reducing hospital readmissions among the elderly.

Improving heart failure symptom recognition: a diary analysis.

Background:Heart failure (HF) is a costly and highly disabling syndrome affecting nearly 5 million individuals yearly. Lifestyle changes are crucial to the successful management of HF, and daily weight monitoring is an essential component of self-care. Daily weights provide an objective indicator of fluid volume status in patients with HF. However, the practice of performing daily weights is underappreciated and infrequently implemented by patients. This may contribute to an inability to recognize worsening HF and, ultimately, delay in seeking medical care. Objective:The aim of this study was to evaluate weight monitoring diaries for adherence to daily weight monitoring, reasons for nonadherence, prevalence of weight gain of 3 lb or more in 1 day, and medical advice-seeking behavior after weight gain in a sample of patients with documented HF. Methods:A cohort study design was used to analyze data from 20 HF patients who participated in a tailored, one-on-one educational intervention. The analysis is part of a parent pilot study designed to improve symptom recognition and response to symptoms of fluid overload. Diary data were collected for 3 months after the intervention. The diaries provided information regarding symptoms that participants experienced, daily weights, and a record of unplanned hospital visits or contacts with their physician. Results:Of 20 participants in the study, 16 returned diaries for analysis. Two participants withdrew participation before the conclusion of the study and 2 participants who claimed to have completed their diary never returned the diary despite repeated reminders and telephone calls. Sixteen participant diaries were therefore available for analysis. The mean adherence score for these 16 participants was 79.4%. Seventy-five percent had weight gains of 3 lb or more in 1 day and only 1 person contacted his/her physician for weight gain. Vacation time was the most common reason for weighing nonadherence. Conclusion:This study revealed high adherence to daily weights in patients receiving an education session focused on fluid weight management. However, behavior related to daily weights did not lead to more appropriate use of physician or provider consultation. Diaries offer promise for symptom management and an opportunity for patients to engage in self-care; however, clinicians need to encourage patients to use the diary data to seek prompt medical care.

The evolving role of the acute care nurse practitioner in critical care.

Purpose of reviewThe newest nurse practitioner role is the acute care nurse practitioner. This paper presents the latest data on the role from both a US and international perspective. Recent findingsNow present in the USA for at least 15 years, the acute care nurse practitioner role has become well established in critical care settings and is moving into international healthcare. The few outcome studies conducted to date demonstrate the acute care nurse practitioner provides quality patient and family care, improves patient satisfaction, is cost effective, and is an answer to the hospitals shortage of medical residents with new restrictions on working hours. SummaryThe role of acute care nurse practitioners in critical care is increasing worldwide. Most countries are experimenting with this latest nurse practitioner as an extended-role healthcare provider with many potential benefits to patients and their families, as well as the healthcare system.

Yoga in heart failure patients: a pilot study.

BACKGROUND Complementary therapies such as yoga practice have become commonplace, yet the safety, physical, and psychological effects on patients with heart failure (HF) are unknown. The purpose of this study was to determine whether an 8-week yoga program was safe and would positively influence physical and psychological function in HF patients. METHODS AND RESULTS Stable HF patients were recruited (n = 15) and completed (n = 12) 8 weeks of yoga classes. Data collected were: safety (cardiac and orthopedic adverse events); physical function (strength, balance, endurance, flexibility); and psychological function (quality of life [QOL], depression scores, mindfulness) before and after 8 weeks of yoga classes. RESULTS Mean age was 52.4 + or - 11.6 with three-fourths (n = 9) being male and Caucasian. No participant had any adverse events. Endurance (P < .02) and strength (upper P = .04 and lower body P = .01) significantly improved. Balance improved by 13.6 seconds (26.9 + or - 19.7 to 40.0 + or - 18.5; P = .05). Symptom stability, a subscale of QOL, improved significantly (P = .02). Although no subject was depressed, overall mood was improved. Subjects subjectively reported improvements in overall well-being. CONCLUSIONS Yoga practice was safe, with participants experiencing improved physical function and symptom stability. Larger studies are warranted to provide more nonpharmacological options for improved outcomes in patients with HF.

Psychosocial factors and medication adherence among patients with coronary heart disease: A text messaging intervention:

Objective: Medication adherence is a complex behavior that is influenced by numerous factors. Applying self-efficacy theory, the primary aim of this randomized controlled trial was to compare medication self-efficacy among patients with coronary heart disease who received: (a) text messages (TMs) for medication reminders and education, (b) TMs for education, or (c) no TMs. The second aim was to identify the personal (sociodemographic and clinical characteristics) and psychosocial factors that were associated with and predicted medication adherence. Methods: Customized TMs were delivered over 30 days. Repeated measures analysis of variance was used to analyze medication self-efficacy. A multiple regression analysis was performed at baseline and follow-up to determine variables that were associated with and predicted self-reported medication adherence. Results: Among 90 subjects with mean age 59.2 years (standard deviation (SD) 9.4, range 35–83), total scores for medication self-efficacy improved over 30 days; however, there was no significant difference in this improvement as a function of the different treatment groups (p=0.64). Controlling for other variables in the model (age, education, depression, and social support), less depression (p=0.004) and higher social support (p=0.02) positively predicted higher medication adherence in the final model. Conclusions: TM medication reminders and/or health education did not improve medication self-efficacy. Further theory testing of current and future models and interventions are required to understand variables related to self-efficacy and medication adherence. Addressing psychosocial factors such as depression and social support should be a priority to improve medication adherence among patients with coronary heart disease.

Electronic Measurement of Medication Adherence

The measurement of medication adherence is important in both clinical practice and research settings to offer effective medical therapy, improve clinical outcomes, and determine the efficacy of therapy. The aims of this article are to (a) present an overview of current and developing electronic methods of medication measurement, (b) explore the advantages and disadvantages to each approach, and (c) discuss the implications of using electronic monitoring devices for clinical practice and research. A comprehensive review of electronic forms of medication measurement was performed. A description of each method is presented including oral medication monitors, personal electronic devices, electronic blisters, wirelessly observed therapy, inhaled medication monitors, mobile phones, video/photo-assisted observation, and electronic health records. Familiarity with using electronic devices and advances in technology will continue to develop and influence the measurement of medication adherence.