Marco Paturzo

Patterns of Self-care in Adults With Heart Failure and Their Associations With Sociodemographic and Clinical Characteristics, Quality of Life, and Hospitalizations: A Cluster Analysis

Background: Self-care is important in heart failure (HF) treatment, but patients may have difficulties and be inconsistent in its performance. Inconsistencies in self-care behaviors may mirror patterns of self-care in HF patients that are worth identifying to provide interventions tailored to patients. Objectives: The aims of this study are to identify clusters of HF patients in relation to self-care behaviors and to examine and compare the profile of each HF patient cluster considering the patient’s sociodemographics, clinical variables, quality of life, and hospitalizations. Methods: This was a secondary analysis of data from a cross-sectional study in which we enrolled 1192 HF patients across Italy. A cluster analysis was used to identify clusters of patients based on the European Heart Failure Self-care Behaviour Scale factor scores. Analysis of variance and &khgr;2 test were used to examine the characteristics of each cluster. Results: Patients were 72.4 years old on average, and 58% were men. Four clusters of patients were identified: (1) high consistent adherence with high consulting behaviors, characterized by younger patients, with higher formal education and higher income, less clinically compromised, with the best physical and mental quality of life (QOL) and lowest hospitalization rates; (2) low consistent adherence with low consulting behaviors, characterized mainly by male patients, with lower formal education and lowest income, more clinically compromised, and worse mental QOL; (3) inconsistent adherence with low consulting behaviors, characterized by patients who were less likely to have a caregiver, with the longest illness duration, the highest number of prescribed medications, and the best mental QOL; (4) and inconsistent adherence with high consulting behaviors, characterized by patients who were mostly female, with lower formal education, worst cognitive impairment, worst physical and mental QOL, and higher hospitalization rates. Conclusion: The 4 clusters identified in this study and their associated characteristics could be used to tailor interventions aimed at improving self-care behaviors in HF patients.

MOTIVATional intErviewing to improve self-care in Heart Failure patients (MOTIVATE-HF): Study protocol of a three-arm multicenter randomized controlled trial

AIMS Heart Failure (HF) self-care improves patient outcomes but trials designed to improve HF self-care have shown inconsistent results. Interventions may be more effective in improving self-care if they mobilize support from providers, promote self-efficacy, increase understanding of HF, increase the family involvement, and are individualized. All of these elements are emphasized in motivational interviewing (MI); few trials have been conducted using MI in HF patients and rarely have caregivers been involved in MI interventions. The aim of this study will be to evaluate if MI improves self-care maintenance in HF patients, and to determine if MI improves the following secondary outcomes: a) in HF patients: self-care management, self-care confidence, symptom perception, quality of life, anxiety/depression, cognition, sleep quality, mutuality with caregiver, hospitalizations, use of emergency services, and mortality; b) in caregivers: caregiver contribution to self-care, quality of life, anxiety/depression, sleep, mutuality with patient, preparedness, and social support. METHODS A three-arm randomized controlled trial will be conducted in a sample of 240 HF patients and caregivers. Patients and caregivers will be randomized to the following arms: 1) MI intervention to patients only; 2) MI intervention to patients and caregivers; 3) standard of care to patients and caregivers. The primary outcome will be measured in patients 3months after enrollment. Primary and secondary outcomes also will be evaluated 6, 9 and 12months after enrollment. CONCLUSION This study will contribute to understand if MI provided to patients and caregivers can improve self-care. Because HF is rising in prevalence, findings can be useful to reduce the burden of the disease.

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.

Caregiver determinants of patient clinical event risk in heart failure

Background: Preventing hospitalization and improving event-free survival are primary goals of heart failure (HF) treatment according to current European Society of Cardiology guidelines; however, substantial uncertainty remains in our ability to predict risk and improve outcomes. Although caregivers often assist patients to manage their HF, little is known about their influence on clinical outcomes. Aims: To quantify the influence of patient and caregiver characteristics on patient clinical event risk in HF. Methods: This was a secondary analysis of data using a sample of Italian adults with HF and their informal caregivers (n = 183 patient–caregiver dyads). HF patients were followed over 12 months for the following clinical events: hospitalization for HF, emergency room visit for HF or all-cause mortality. Influence of baseline caregiver- and patient-level factors (patient and caregiver age; dyad relationship type; patient New York Heart Association (NYHA) Class, cognition, and comorbidities; and caregiver strain, mental health status, and contributions to HF self-care) on patient risk of death or hospitalization/emergency room use was quantified using Cox proportional hazards regression. Results: Over the course of follow up, 32.8% of patients died, 19.7% were hospitalized for HF and 10.4% visited the emergency room. Higher caregiver strain, better caregiver mental health status and greater caregiver contributions to HF self-care maintenance were associated with significantly better event-free survival. Worse patient functional class and greater caregiver contributions to patient self-care management were associated with significantly worse patient event-free survival. Conclusion: Considering caregiving factors together with patient factors significantly increases our understanding of patient clinical event risk in HF.

The lived experience of caregivers of persons with heart failure: A phenomenological study:

Background: Heart failure (HF) patients need to follow a strict pharmacological and nonpharmacological regimen in order to counteract the burden of the disease, and informal caregivers are an important resource for HF patients in managing and coping with their disease. Few studies have examined the lived experience of these caregivers with a rigorous phenomenological approach, and none have been conducted in Italy. Aim: To describe the lived experience of the caregivers of HF patients. Methods: A hermeneutic phenomenological method was used. Caregivers were enrolled in a HF clinic in central Italy. Interviews were analysed using a phenomenological approach. Credibility, dependability, confirmability and transferability were adopted in order to strengthen trustworthiness. Findings: Thirty HF caregivers (mean age: 53 years) were enrolled. Of these, 63% of the caregivers were female and 80% were patients’ spouses or children. Six themes emerged: (1) fear and worry related to the illness; (2) life changes and restrictions; (3) burden due to caregiving; (4) uncertainty about illness management; (5) helping patients to cope with the illness; and (6) love and affection towards the patient. Conclusion: The findings of our study may help providers to guide interventions for HF caregivers. Providers should be supportive of caregivers and provide them with education in order to reduce their fears and worries about the illness and to handle the course of HF and its symptoms. An empathetic and practical approach with caregivers that considers the patient–caregiver relationship may help caregivers to cope with the changes and restrictions that caregiving brings to their lives and to reduce their burden.

Psychometric characteristics of the caregiver burden inventory in caregivers of adults with heart failure

Background: A better understanding of caregiver burden and its determinants is essential to support caregivers. Many instruments have been developed to measure caregiver burden in various illness contexts, but few have been psychometrically tested for caregivers of heart failure patients. Aims: The aim of this study was to test the validity (factorial and concurrent validity) and reliability (internal consistency) of the caregiver burden inventory (CBI) in a cohort of caregivers of heart failure patients. Methods: This was a secondary analysis from a cross-sectional study on heart failure patients and their caregivers enrolled from various Italian outpatient centres. The factorial validity of the CBI was tested with confirmatory factor analysis, and concurrent validity was tested correlating CBI scores with the short form-12 health survey scores. The internal consistency reliability was assessed with Cronbach’s alpha. Results: In total, 505 caregivers of heart failure patients (52.2% women, mean age 56.59±14.9 years) were enrolled. Confirmatory factor analyses confirmed the original five-factor model: time-dependence, developmental, physical, social and emotional burden. This model fits the data better than the single-factor model, and the dimensions showed high internal consistency reliability (Cronbach’s alpha 0.91 for time-dependence burden, 0.92 for developmental burden, 0.88 for physical burden, 0.89 for social burden and 0.93 for emotional burden; 0.96 for the total score of burden). Conclusion: The CBI proved to be a good multidimensional instrument for evaluating the burden in caregivers of heart failure patients and can be used in clinical practice and research. This tool can be considered to tailor interventions aimed at improving caregiver outcomes.

Psychometric characteristics of the mutuality scale in heart failure patients and caregivers

BACKGROUND Higher patient-caregiver mutuality is associated with improved patient and caregiver outcomes, but no studies have tested the psychometric characteristics of the mutuality scale (MS) in heart failure (HF) patient and caregiver population. OBJECTIVES To test the validity and reliability of the MS. METHODS A cross-sectional design. The MS validity and reliability were tested with confirmatory factor analysis (CFA) and hypothesis testing, and with Cronbachs alpha and model-based internal consistency index, respectively. RESULTS CFA supported the validity of the MS in the HF patient and caregiver versions. Hypothesis testing showed significant correlations between both versions of the MS and anxiety, depression, quality of life, and self-care. Also, MS caregiver version scores correlated significantly with caregiver preparedness. Cronbachs alphas and the model-based internal consistency index ranged between 0.72 and 0.94 in both versions. CONCLUSIONS The Mutuality Scale showed supportive validity and reliability for HF patients and caregivers.

Self-care in heart failure patients: major results of a 7-year research program in Italy

Self-care improves patients’ outcomes in heart failure (HF). In this article we report the main results of a 7-year research program conducted in Italy. First, we established validity and reliability of the Self-Care of HF Index v.6.2 and the Caregiver Contribution to Self-Care of HF Index in the Italian population. Second, we tested the situation-specific theory of HF self-care that showed adequate fit to the data. Third, we showed in a sample of 1.192 HF patients that only about the 20% of them performs adequate self-care. Forth, we described caregiver contribution to self-care in a sample of 515 HF caregivers and we showed a low level of caregiver contribution to HF self-care. Fifth, we showed that patients and caregivers influence each other self-care. Six, we found that self-care confidence mediates between cognition and self-care, and comorbidity moderates between self-care confidence and self-care. Intervention studies are needed to improve self-care in Italian HF patients.

I disegni di ricerca con metodo misto: un approccio metodologico innovativo per la ricerca infermieristica

Mixed methods designs: an innovative methodological approach for nursing research. The mixed method research designs (MM) combine qualitative and quantitative approaches in the research process, in a single study or series of studies. Their use can provide a wider understanding of multifaceted phenomena. This article presents a general overview of the structure and design of MM to spread this approach in the Italian nursing research community. The MM designs most commonly used in the nursing field are the convergent parallel design, the sequential explanatory design, the exploratory sequential design and the embedded design. For each method a research example is presented. The use of MM can be an added value to improve clinical practices as, through the integration of qualitative and quantitative methods, researchers can better assess complex phenomena typical of nursing.