Julie Johnson Zerwic

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: A scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Cardiovascular Health: The Importance of Measuring Patient-Reported Health Status A Scientific Statement From the American Heart Association

The principal goals of health care are to help people “live longer and live better,” that is, to optimize both survival and health. In the American Heart Association’s (AHA) special report, “Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond,” the AHA set the following goal: > “By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%.” 1 The emphasis on improving cardiovascular health is laudable, yet it raises the question of how cardiovascular health is best measured. Indeed, the metrics of cardiovascular health have not been well delineated compared with other cardiovascular mortality and morbidity outcomes. The AHA’s strategic goals primarily focus on ideal health behaviors (eg, not smoking) and ideal health factors (eg, blood pressure control) as metrics of cardiovascular health.1 Although these are of clear import, they do not directly address the World Health Organization’s definition of health as “… a state of complete physical, mental and social well-being.”2 Moreover, the Institute of Medicine identified patient-centered care as 1 of the 6 domains of high-quality health care, wherein patient-centered care supports clinicians in “attending to their patients’ physical and emotional needs, and maintaining or improving their quality of life.”3 The Patient-Centered Outcomes Research Institute emphasizes the goal of “focusing on outcomes that people notice and care about such as survival, function, symptoms, and health related quality of life.”4 Recent concepts of value in health care and the “triple aim” center on improving patients’ health and experience with health care while reducing costs; each reinforces the importance of assessing the impact of disease and medical treatment on patients’ functional status and quality of life.5,6 The definition …

Treatment seeking for acute myocardial infarction symptoms: differences in delay across sex and race.

BackgroundPatients experiencing an acute myocardial infarction are known to delay seeking treatment between 2 and 4 hours. This delay is problematic because individuals who receive treatment 2 or more hours after the onset of symptoms are less likely to benefit from emergent reperfusion techniques. Persons most likely to delay seeking treatment for an acute myocardial infarction and their reasons have not been clearly identified. ObjectiveThe purpose of this study was to identify the effect of selected demographic, clinical, cognitive, and environmental variables on the length of the time of delay. In addition, the study was designed to identify whether women delayed longer than men, and whether African Americans delayed longer than non-Hispanic Whites during an acute myocardial infarction. MethodA structured interview was conducted in a convenience sample (N eq> 212) of African American and non-Hispanic White patients hospitalized after acute myocardial infarction. Patients were asked detailed information about the sequence of events prior to the acute myocardial infarction, and the symptoms experienced. Medical records were examined for clinical information. ResultsWomen did not delay significantly longer than men (2.0 vs. 2.5 median hours). African Americans delayed significantly longer than non-Hispanic Whites (3.25 hours vs. 2.0 median hours). Race did not contribute unique variance to delay time in a simultaneous multiple regression analysis; however, race was a significant predictor variable in whether or not participants sought treatment within the first hour after the onset of symptoms. The variance in delay time for African American and Non-Hispanic White men and women that could be explained by the predictor variables ranged from 23–47%. ConclusionsThe reasons for delay differed in part by sex and race.

Clinical simulation laboratory. An adjunct to clinical teaching.

Videotaped and telephone simulations role-played by students were used in a clinical laboratory setting to enhance student learning. The authors discuss the structure, implementation, evaluation, and potential uses of these simulated activities.

The symptoms of unstable angina: do women and men differ?

BackgroundResearch has shown that there are differences between women and men in the epidemiology, presentation, and outcomes of coronary heart disease. ObjectivesThe purpose of this study was to determine if there were sex differences in the symptoms of unstable angina (UA) and if so, to determine if these differences remained after controlling for age, diabetes, anxiety, depression, and functional status. MethodThis descriptive study used a nonexperimental, quantitative design. A convenience sample of 50 women and 50 men, hospitalized with UA, were recruited from an urban and a suburban medical center. Instruments included the Unstable Angina Symptoms Questionnaire (UASQ), the Hospital Anxiety and Depression Scale (HADS), and the Canadian Cardiovascular Society (CCS) classification of angina. ResultsMultivariate analysis indicated that women experienced significantly (p < .05) more shortness of breath (74% vs. 60%), weakness (74% vs. 48%), difficulty breathing (66% vs. 38%), nausea (42% vs. 22%), and loss of appetite (40% vs. 10%) than men. After controlling for age, diabetes, anxiety, depression, and functional status, women were still more likely than men to report weakness (p = .03), difficulty breathing (p = .02), nausea (p = .03), and loss of appetite (p = .02). Chi-square analysis of symptom descriptors revealed that women disclosed more (p < .05) upper back pain (42% vs. 18%), stabbing pain (32% vs. 12%), and knifelike pain (28% vs. 12%). Women also had a significantly higher incidence of depression (22% vs. 2%, p < .01). ConclusionsFindings suggest that women and men have similar symptoms during an episode of UA, however, a higher proportion of women have less typical symptoms.

Symptom Clusters in Acute Myocardial Infarction: A Secondary Data Analysis

Background: Early recognition of acute myocardial infarction (AMI) symptoms and reduced time to treatment may reduce morbidity and mortality. People having AMI experience a constellation of symptoms, but the common constellations or clusters of symptoms have yet to be identified. Objectives: To identify clusters of symptoms that represent AMI. Methods: This was a secondary data analysis of nine descriptive, cross-sectional studies that included data from 1,073 people having AMI in the United States and England. Data were analyzed using latent class cluster analysis, an atheoretical method that uses only information contained in the data. Results: Five distinct clusters of symptoms were identified. Age, race, and sex were statistically significant in predicting cluster membership. None of the symptom clusters described in this analysis included all of the symptoms that are considered typical. In one cluster, subjects had only a moderate to low probability of experiencing any of the symptoms analyzed. Discussion: Symptoms of AMI occur in clusters, and these clusters vary among persons. None of the clusters identified in this study included all of the symptoms that are included typically as symptoms of AMI (chest discomfort, diaphoresis, shortness of breath, nausea, and lightheadedness). These AMI symptom clusters must be communicated clearly to the public in a way that will assist them in assessing their symptoms more efficiently and will guide their treatment-seeking behavior. Symptom clusters for AMI must also be communicated to the professional community in a way that will facilitate assessment and rapid intervention for AMI.

Publishing Pilot Intervention Work

Pilot intervention studies can be viewed as rehearsals for subsequent full-scale trials. They can help investigators fine-tune later larger studies as well as explore issues related to project management and budget. Pilot studies permit testing of sampling strategies, participant recruitment, intervention content, delivery methods, data collection, and analysis. They also allow researchers to experience the more practical aspects of implementing a study, such as determining the number of study staff members needed to handle recruitment and data collection or identifying special equipment needs. Because pilot study findings may be generalizable, publication is encouraged as long as the preliminary nature of the work is clearly indicated in both the abstract and the article. The present article provides an overview of the types of information that can be gleaned from pilot intervention studies that are suitable for publication.

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke: A Scientific Statement From the American Heart Association Council on Cardiovascular Nursing and Stroke Council*

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Patient delay in seeking treatment for acute myocardial infarction symptoms.

Patient delay before seeking treatment for the symptoms of acute myocardial infarction has a significantly negative effect on morbidity and mortality. Most patients delay 2 or more hours before accessing the emergency medical system, which limits the ability to use reperfusion strategies. This article reviews variables that have been implicated in delay and explores possible explanations for why certain characteristics may be associated with longer delays. The outcomes of educational campaigns that have targeted delay behavior will be examined and directions for future research are identified.

Is the Medical Record an Accurate Reflection of Patients’ Symptoms During Acute Myocardial Infarction?

Documentation of symptoms in the medical record provides clinicians and researchers with valuable information about the patient’s experience during acute myocardial infarction (AMI). To examine the consistency between the patient’s reported symptoms and the medical record, 215 patients were interviewed and their medical records examined for information about their admission symptoms. Chest pain was the most frequently reported and recorded symptom, and there was good agreement between the patient’s report and the medical record. Although fatigue was the second most frequently reported symptom by patients, it was rarely documented in the medical record. Time of symptom onset was identified by 87.9% of patients but only documented in 60.5% of medical records. Clinicians may be recording those symptoms that support the AMI diagnosis and not those perceived to be less relevant. Findings suggest that the medical record is an inaccurate and inadequate source of information about patients’ actual experience of AMI symptoms.