Lufei Young

Patient recovery and transitions after hospitalization for acute cardiac events: an integrative review.

Despite increased attention to providing seamless transitions after hospitalization, patients often feel unprepared, lack knowledge, and may be confused by what to expect during recovery at home after a cardiac event. Care transition after hospital discharge could be improved by informing and counseling patients more specifically about expected recovery after a cardiac event. Therefore, an integrative review of research was conducted to evaluate cardiac patients’ trajectory of recovery after hospitalization. A total of 61 studies were included in this review. Studies included were those of cardiac patients who had been hospitalized for significant cardiac events and those focused on acute coronary syndrome (n = 18), percutaneous coronary intervention (PCI) (n = 12), cardiac surgery (coronary artery bypass surgery and valve surgery; n = 25), and heart failure (n = 6). Studies included quantitative, mixed-methods, and qualitative designs, with sample sizes ranging from 4 to 2121 participants. Notwithstanding the limitations of this review, findings demonstrated that patients’ perceptions of their cardiac event evolved over time from uncertainty, fears, anxiety, and depression, which were often associated with a lack of knowledge of their cardiac condition, to a phase of self-management of their cardiac condition. Furthermore, patterns of commonly occurring symptoms and changes in functioning abilities during recovery after hospitalization were apparent among the different cardiac groups. These findings may be useful to both patients and clinicians to inform them about the recovery trajectory after a cardiac event to improve preparation for the transition from hospital to home.

Gender differences in recovery outcomes after an early recovery symptom management intervention.

BACKGROUND Despite known gender differences in recovery, few studies have examined symptom management (SM) interventions or responses by gender after coronary artery bypass surgery (CABS). OBJECTIVE The purpose of this subanalysis was to describe and evaluate differences in response by gender to an SM intervention on the presence and burden of symptoms, physical activity, and physical functioning in elderly CABS patients during the early discharge period (3 and 6 weeks after CABS, and 3 and 6 months after CABS). METHODS The parent study whose data were analyzed to examine gender differences involved a two-group, randomized clinical trial design. The 6-week early recovery SM telehealth intervention was delivered by the Health Buddy. Measures included the Cardiac Symptom Survey, a Modified 7-Day Activity Interview, an RT3 accelerometer, an Activity Diary, and the Medical Outcomes Study Short Form 36. This study was not powered for a gender × group analysis, and we used descriptive statistics, χ(2) tests, t tests, and analysis of variance for statistical analyses. RESULTS Subjects (n = 232) included 192 men and 40 women, with a mean age of 71.2 SD, 7 years. The intervention group consisted of 86 men and 23 women, and the usual care (UC) group consisted of 106 men and 17 women. Data trends suggest that the SM intervention exerted greater impact on women than on men for symptoms such as fatigue, depression, sleep problems, and pain. Again, men exhibited higher levels of physical activity than did women. However, women in the SM group generally had higher scores than did women in the UC group. CONCLUSION Although the parent study found no effect of an early recovery SM intervention, this exploratory secondary analysis indicated that women in the intervention group demonstrated more improvement in measures of physical activity than did those in the UC group. Further study, using a larger sample, is necessary to test these preliminary results.

Symptom profiles of coronary artery bypass surgery patients at risk for poor functioning outcomes.

The purpose of this secondary analysis was to profile or cluster 226 patients, who had participated in a randomized controlled trial, on symptoms after coronary artery bypass surgery and to examine how these profiles could potentially be used by clinicians to identify groups at risk for impaired functioning during the first 6 months after surgery. Variables measured were symptom presence and burden and functioning. The model-based clustering method was used for cluster analysis of the symptom burden measure, and analyses of covariance were used to determine if there were differences on functioning (physical functioning and physical activity) by symptom burden group at 6 weeks and at 3 and 6 months after dismissal. The majority of the 226 subjects were married (86%), male (83%), and had a mean age of 71 (SD, 4.96) years. Eight symptoms were used in the model-based clustering method-shortness of breath, fatigue, depression, sleep disturbances, pain, swelling, anxiety, and appetite problems-and demonstrated that there were 3 patient clusters of symptom burden. Cluster 1 had low symptom burden on all 8 symptoms, cluster 3 had moderate symptom burden on all 8 symptoms, and cluster 2 had a combination of low (shortness of breath, fatigue, depression, pain, and anxiety) and moderate symptom burden (sleep problems, swelling, and appetite problems). Analyses of covariance revealed no significant cluster × time interactions for any of the variables. However, there were significant main effects (P < .01) for symptom burden groups for physical functioning (physical and vitality functioning) and physical activity (estimated energy expenditure and mean daily total activity counts). Significant main effects for time indicated physical functioning and physical activity measures, except bodily pain, improved over time (P < .05). Study results indicate that the use of profiling coronary artery bypass surgery patients on their symptoms prior to hospital discharge may assist health care providers to identify patients who could be at risk for having more difficulty with physical functioning and physical activity during the first 6 months after surgery.

Relationships between activation level, knowledge, self-efficacy, and self-management behavior in heart failure patients discharged from rural hospitals.

Non-adherence to self-management guidelines accounted for 50% of hospital readmissions in heart failure patients. Evidence showed that patient activation affects self-management behaviors in populations living with chronic conditions. The purpose of this study was to describe patient activation level and its relationship with knowledge, self-efficacy and self-management behaviors in heart failure patients discharged from rural hospitals. Our study populations were recruited from two hospitals in rural areas of Nebraska. We found that two-thirds of the participants reported low activation levels (e.g., taking no action to manage their heart failure condition). In addition, low patient activation levels were associated with inadequate heart failure knowledge (p=.005), low self-efficacy (p<.001) and low engagement in heart failure self-management behaviors (p<.001) after discharge from hospital.

Promoting self-management through adherence among heart failure patients discharged from rural hospitals: a study protocol.

Background Heart failure is one of the most prevalent chronic conditions in adults, leading to prolonged morbidity, repeated hospitalizations, and placing tremendous economic burden on the healthcare system. Heart failure patients discharged from rural hospitals, or primarily critical access hospitals, have higher 30-day readmission and mortality rates compared to patients discharged from urban hospitals. Self-management improves heart failure patients’ health outcomes and reduces re-hospitalizations, but adherence to self-management guidelines is low. We propose a home based post-acute care service managed by advanced practice nurses to enhance patient activation and lead to the improvement of self-management adherence in heart failure patients discharged from rural hospitals. Objective This article describes the study design and research methods used to implement and evaluate the intervention. Method Our intervention is a 12-week patient activation (Patient AcTivated Care at Home [PATCH]) to improve self-management adherence. Patients were randomized into two parallel groups (12-week PATCH intervention + usual care vs. usual care only) to evaluate the effectiveness of this intervention. Outcomes were measured at baseline, 3 and 6 months. Discussion This study aimed to examine the effectiveness of a rural theory based, advance practice nurse led, activation enhancing intervention on the self-management adherence in heart failure patients residing in rural areas. Our expectation is to facilitate adherence to self-management behaviors in heart failure patients following discharge from rural hospitals and decrease complications and hospital readmissions, leading to the reduction of economic burden. Clinical Trial Registration Information: ClinicalTrials.gov; https://register.clinicaltrials.gov/ NCT01964053

A home-based comprehensive care model in patients with Multiple Sclerosis: A study pre-protocol.

Background Disability is prevalent in individuals with multiple sclerosis (MS), leading to difficulty in care access, significant caregiver burden, immense challenges in self-care and great societal burden. Without highly coordinated, competent and accessible care, individuals living with progressive MS experience psychological distress, poor quality of life, suffer from life-threatening complications, and have frequent but avoidable healthcare utilizations. Unfortunately, current healthcare delivery models present severe limitations in providing easily accessible, patient-centered, coordinated comprehensive care to those with progressive MS. We propose a home-based comprehensive care model (MAHA) to address the unmet needs, challenges, and avoidable complications in individuals with progressive MS with disabling disease. Objective The article aims to describe the study design and methods used to implement and evaluate the proposed intervention. Method The study will use a randomized controlled design to evaluate the feasibility of providing a 24-month, home-based, patient-centered comprehensive care program to improve quality of life, reduce complications and healthcare utilizations overtime (quarterly) for 24 months. A transdisciplinary team led by a MS-Comprehensivist will carry out this project. Fifty MS patients will be randomly assigned to the intervention and usual care program using block randomization procedures. We hypothesize that patients in the intervention group will have fewer complications, higher quality of life, greater satisfaction with care, and reduced healthcare utilization. The proposed project is also expected to be financially sustainable in fee-for-service models but best suited for and gain financial success in valued-based care systems. Discussion This is the first study to examine the feasibility and effectiveness of a home-based comprehensive care management program in MS patients living with progressive disability. If successful, it will have far-reaching implications in research, education and practice in terms of providing high quality but affordable care to population living with severe complex, disabling conditions.

A Conceptual Framework for Barriers to the Recruitment and Retention of Rural CVD Participants in Behavior Intervention Trials

BackgroundRural residents diagnosed with cardiovascular disease (CVD) or with CVD-related risks are underrepresented in behavioral intervention trials based on an extensive review of published studies. The low participation rate of rural residents weakens both the internal and external validity of published studies. Moreover, compared to urban residents, limited research exists to describe the unique barriers that limit the participation of rural residents in behavioral intervention trials.ObjectiveThe purpose of this review is to identify a conceptual framework (CF) underpinning common barriers faced by rural CVD patients to enroll in behavioral intervention trials.MethodsWe conducted a literature review using several electronic databases to obtain a representative sample of research articles, synthesized the evidence, and developed a CF to explain the barriers that may affect the research participation rate of rural residents with CVD or related risks.ResultsWe found our evidence-based CF well explained the barriers for rural CVD patients to take part in behavioral intervention trials. Besides contextual factors (i.e. patient, community and research levels), other common factors impacting rural patients’ intent to enroll are lack of awareness and understanding about behavioral trials, limited support from their healthcare providers and social circles, unfavorable attitudes, and the lack of opportunity to participating research.Conclusion and Implication of resultthe findings demonstrate the evidence-based model consisting of interlinked multi-level factors may help our understanding of the barriers encountered by rural CVD patients participating interventions to promote behavioral change. The implication for researchers is that identifying and developing strategies to overcome the barriers precedes conducting studies in rural communities.

Examining Factors Influencing Colorectal Cancer Screening of Rural Nebraskans Using Data from Clinics Participating in an Accountable Care Organization: A Study Protocol

Background: Although mortality rates of colorectal cancer (CRC) can be significantly reduced through increased screening, rural communities are still experiencing lower rates of screening compared to urban counterparts. Understanding and eliminating barriers to cancer screening will decrease cancer burden and lead to substantial gains in quality and quantity of life for rural populations. However, existing studies have shown inconsistent findings and fail to address how contextual and provider-level factors impact CRC screening in addition to individual-level factors. Purpose: The purpose of the study is to examine multi-level factors related to CRC screening, and providers’ perception of barriers and facilitators of CRC screening in rural patients cared for by accountable care organization (ACO) clinics. Methods/Design: This is a convergent mixed method design. For the quantitative component, multiple data sources, such as electronic health records (EHRs), Area Resource File (ARF), and provider survey data, will be used to examine patient-, provider-, clinic-, and county-level factors. About 21,729 rural patients aged between 50 and 75 years who visited the participating ACO clinics in the past 12 months are included in the quantitative analysis. The qualitative methods include semi-structured in-depth interviews with healthcare professionals in selected rural clinics. Both quantitative and qualitative data will be merged for result interpretation. Quantitative data identifies “what” factors influence CRC screening, while qualitative data explores “how” these factors interact with CRC screening. The study setting is 10 ACO clinics located in nine rural Nebraska counties. Discussion: This will be the first study examining multi-level factors related to CRC screening in the new healthcare delivery system (i.e., ACO clinics) in rural communities. The study findings will enhance our understanding of how the ACO model, particularly in rural areas, interacts with provider- and patient-level factors influencing the CRC screening rate of rural patients.

The Impact of Self-management Knowledge and Support on the Relationships Among Self-efficacy, Patient Activation, and Self-management in Rural Patients With Heart Failure.

Background: Self-management (SM) is an essential component of heart failure (HF) management. The mechanisms to improve SM behaviors are unclear. Objective: The objective of this study is to examine whether patient activation mediates the effect of self-efficacy on SM behaviors in rural HF patients. Methods: A secondary analysis was conducted using data collected from a randomized controlled trial aimed to improve SM behaviors. The main variables included were SM knowledge, self-efficacy, patient activation, and SM behaviors. Results: Mediation analysis showed patient activation mediated the effect of self-efficacy on SM. Both self-efficacy and patient activation were significantly related to SM behaviors, respectively (r = 0.46, P < .001; &bgr; = .48, P = .001). However, self-efficacy was no longer directly related to SM behaviors when patient activation was entered into the final model (&bgr; = .17, P = .248). Self-management knowledge and support were significant moderators. In patients with high levels of SM knowledge, patient activation did not mediate the effect of self-efficacy on SM behaviors (&bgr; = .15, P = .47). When SM support was entered in the path model, patient activation was not a significant mediator between self-efficacy and SM behavior at high (&bgr; = .27, P = .27) or low (&bgr; = .27, P = .25) levels of SM support. Conclusions: Study findings suggest that targeted SM support for high-risk HF patients with low SM knowledge and support may be useful. In addition, strategies to increase patient activation may improve HF patients’ SM confidence.

Review Strategies to Recruit and Retain Rural Patient Participating Self-management Behavioral Trials

Self-management plays a vital role in improving health outcomes and reducing costs in patients with cardiovascular disease (CVD) and associated risk factors. Based on existing studies, rural residents with CVD and/or risk factors show low engagement in self-management behaviors. Due to low participation in behavioral intervention trials, the most promising mechanism to promote self-management among rural populations is unknown. In turn, the purpose of this article is to review the evidence that supports strategies to recruit and retain rural patients to participate in behavioral intervention trials aimed to promote self-management of CVD and its risk factors. This review is expected to assist researchers in identifying effective solutions to overcome barriers in the recruitment and retention processes when conducting intervention research studies on the self-management of CVD in rural communities.