Ruth Masterson Creber

Motivational interviewing to improve self-care for patients with chronic heart failure: MITI-HF randomized controlled trial

OBJECTIVE The purpose of this study was to test the efficacy of a tailored motivational interviewing (MI) intervention versus usual care for improving HF self-care behaviors, physical HF symptoms and quality of life. METHODS This is a single-center, randomized controlled trial. Participants were enrolled in the hospital. Immediately after discharge, those in the intervention group received a single home visit and 3-4 follow-up phone calls by a nurse over 90 days. RESULTS A total of 67 participants completed the study (mean age 62±12.8 years), of which 54% were African American, 30% were female, 84% had class III/IV symptoms, and 63% were educated at a high school level or less. There were no differences between the groups in self-care maintenance, self-care confidence, physical HF symptoms, or quality of life at 90 days. CONCLUSION Patients who received the MI intervention had significant and clinically meaningful improvements in HF self-care maintenance over 90 days that exceeded that of usual care. PRACTICE IMPLICATIONS These data support the use of a nurse-led MI intervention for improving HF self-care. Identifying methods to improve HF self-care may lead to improved clinical outcomes.

Psychometric properties of the Kansas City Cardiomyopathy Questionnaire (KCCQ)

Background: The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a well-established instrument used to evaluate the health status of heart failure (HF) patients. There has been a lack of clarity about the best way to conceptualize the KCCQ. The purpose of this investigation of the KCCQ was to: (1) explore the factor structure with an exploratory factor analyses; (2) perform reliability and validity testing to determine the best factor solution for item groupings; and (3) determine the most meaningful components of health status captured by the KCCQ. Methods and Results: A secondary analysis of data from 280 adults with stage-C HF enrolled from three US northeastern sites was conducted to test the KCCQ subscale structure. Criterion-related validity for the Self-efficacy subscale was tested with the Dutch Heart Failure Knowledge Scale and the Self-care of Heart Failure Index Self-care Confidence Scale. Overall, internal consistency reliability (Cronbach’s alpha) for the KCCQ and subscales was 0.92, social interference (seven items, 0.90), physical limitation (four items, 0.84), symptoms (eight items, 0.86), independent care (two items, 0.80), and self-efficacy (two items, 0.63). Two items failed to correspond to a previously identified factor so the independent care subscale was added. Items intending to measure quality of life were loaded in the social interference subscale. Conclusions: We recommend eliminating the quality of life subscale and including those items in the social interference subscale, and eliminating the self-efficacy items and re-evaluating the items related to independent care.

Reliability and validity of the patient activation measure in hospitalized patients

OBJECTIVE The purposes of this paper are to describe the internal consistency reliability and construct validity of the PAM-13 for hospitalized cardiology and oncology patients and to examine the predictors of low patient activation in the same population. METHODS We evaluated the internal consistency reliability of the PAM-13 in the inpatient setting. Construct validity of the PAM-13 was then assessed using two approaches: expected known-groups differences between patients with planned and unplanned admissions PAM-13 levels and convergence of PAM-13 levels with other measures. RESULTS The PAM demonstrated adequate internal consistency overall (Cronbach α=0.81). Patients with unplanned admissions were more likely to have low activation than patients with planned admissions (adjusted OR=5.7, p=0.008). The PAM-13 was modestly correlated (p<0.001) with each of the PROMIS Global Health components used in this study (global, physical and mental health). CONCLUSION This study demonstrates the PAM-13 is a reliable and valid measure for use in the inpatient hospital setting and that type of admission (planned versus unplanned) is an important predictor of patient activation. PRACTICE IMPLICATIONS By measuring patient activation with the PAM-13, clinicians and researchers can provide tailored communication and care strategies to meet patients needs.

Mechanisms of change in self-care in adults with heart failure receiving a tailored, motivational interviewing intervention.

Self-care is challenging but we previously demonstrated that motivational interviewing (MI) was effective in improving heart failure (HF) self-care. OBJECTIVE To identify the mechanisms of intervention effectiveness by elucidating the MI techniques used and the relationship between the techniques and changes in self-care. METHODS Audiotaped sessions (first and subsequent sessions) from 8 participants were transcribed verbatim and coded to evaluate changes in self-care. Using a sequential mixed method design, quantitative and qualitative self-care data were triangulated; congruence was 97%. The MI techniques used and mechanisms of intervention effectiveness were identified from the qualitative data. RESULTS Three MI techniques used were related to improved self-care: 1) reflection and reframing, 2) genuine empathy, affirmation, and humor, and 2) individualized problem solving. These techniques stimulated openness to goal setting, positive self-talk, perceived ability to overcome barriers, and change talk. The mechanisms by which the techniques achieved the desired outcomes were the development of discrepancy and self-efficacy, which are consistent with the principles of MI. CONCLUSION This study contributes to clarifying the mechanism by which MI facilitates behavioral change. PRACTICE IMPLICATIONS Using MI to discuss self-care can help to overcome barriers and engage HF patients in goal setting for behavior change.

Effectiveness of Motivational Interviewing in Decreasing Hospital Readmission in Adults With Heart Failure and Multimorbidity.

Hospitalizations are common in heart failure (HF). Multimorbidity, defined as ≥2 comorbid conditions, drives many readmissions. The purpose of this pilot study was to test the effectiveness of motivational interviewing (MI) in decreasing these hospital readmissions. We enrolled 100 hospitalized HF patients into a randomized controlled trial, randomizing in a 2:1 ratio: intervention (n = 70) and control (n = 30). The intervention group received MI tailored to reports of self-care during one home visit and three to four follow-up phone calls. After 3 months, 34 participants had at least one hospital readmission. The proportion of patients readmitted for a condition unrelated to HF was lower in the intervention (7.1%) compared with the control group (30%, p = .003). Significant predictors of a non-HF readmission were intervention group, age, diabetes, and hemoglobin. Together, these variables explained 35% of the variance in multimorbidity readmissions. These preliminary results are promising in suggesting that MI may be an effective method of decreasing multimorbidity hospital readmissions in HF patients.

Motivational Interviewing Tailored Interventions for Heart Failure (MITI-HF): Study design and methods

OBJECTIVE Lack of engagement in self-care is common among patients needing to follow a complex treatment regimen, especially patients with heart failure who are affected by comorbidity, disability and side effects of poly-pharmacy. The purpose of Motivational Interviewing Tailored Interventions for Heart Failure (MITI-HF) is to test the feasibility and comparative efficacy of an MI intervention on self-care, acute heart failure physical symptoms and quality of life. METHODS We are conducting a brief, nurse-led motivational interviewing randomized controlled trial to address behavioral and motivational issues related to heart failure self-care. Participants in the intervention group receive home and phone-based motivational interviewing sessions over 90-days and those in the control group receive care as usual. Participants in both groups receive patient education materials. The primary study outcome is change in self-care maintenance from baseline to 90-days. CONCLUSION This article presents the study design, methods, plans for statistical analysis and descriptive characteristics of the study sample for MITI-HF. Study findings will contribute to the literature on the efficacy of motivational interviewing to promote heart failure self-care. PRACTICAL IMPLICATIONS We anticipate that using an MI approach can help patients with heart failure focus on their internal motivation to change in a non-confrontational, patient-centered and collaborative way. It also affirms their ability to practice competent self-care relevant to their personal health goals.

Using brief motivational interviewing to address the complex needs of a challenging patient with heart failure

Background:Hospitals and healthcare providers are looking for methods to reduce hospitalization rates and improve patient outcomes for patients with heart failure (HF). Using behavioral approaches to increase patients’ confidence in their abilities to perform self-care is 1 such approach. Motivational interviewing is an empirically validated modality that has shown promise in improving motivation to change and confidence in the ability to do so. Objective:This case represents a number of themes common in the management of care for a HF patient and explores a 4-session brief motivational interviewing approach to address these themes. The manner in which patient frustration is linked to hospitalization is discussed along with possible ways to address problems in self-care behaviors. Conclusions:With the use of this brief motivational interviewing approach, the patient reported an increase in her motivation and ability to change and developed a postdischarge plan for incorporating self-care behaviors in her daily routine. Clinical Implications:Motivational interviewing may be an effective method of increasing the self-care behaviors of patients with HF.

Overall perceived health predicts risk of hospitalizations and death in adults with heart failure: A prospective longitudinal study

BACKGROUND Patient overall perception of health may provide an effective early warning for risk of hospitalization and death among heart failure patients. OBJECTIVE Determine whether overall perceived health predicts all-cause hospitalization or death in heart failure patients after adjusting for confounding factors in a sample of adults with heart failure. DESIGN Prospective, longitudinal, observational study. SETTINGS Three outpatient urban settings in the northeast United States between 2007 and 2010. PARTICIPANTS Adults with chronic Stage C heart failure confirmed by echocardiographic and clinical evidence. METHODS A secondary analysis was conducted using data collected on 273 Stage C patients with heart failure. Participants in the parent study were followed for 6 months. Overall perceived health was measured by self-report. Hospitalization and death were assessed from electronic hospital records and confirmed with county death records as needed. Cox proportional hazards models were used to examine the association between perceptions of health and rates of hospitalization and death. RESULTS Patients with poor or fair perceived health had over 5.5 times the rate of death or hospitalization over the 6-month period (hazard ratio; 95% confidence interval: 2.0-15.6; p=0.001) after controlling for model covariates. The predictive ability of perceived health attenuated over time such that at 30-days patients who reported poor or fair perceived health had only 1.2 times the rate of an event and virtually no difference in event rate by 60-days. CONCLUSIONS Overall perceived health is a powerful indicator of impending events and can be a quick tool for prioritizing heart failure patients who are at highest risk of imminent death and hospitalization. Questions about perceived health need to be asked of patients regularly in order to have clinical utility.

Using Growth Mixture Modeling to Identify Classes of Sodium Adherence in Adults With Heart Failure

Background:The prevention of fluid retention is important to reduce hospitalizations in patients with heart failure (HF). Following a low-sodium diet helps to reduce fluid retention. Objective:The primary objective of this study was to use growth mixture modeling to identify distinct classes of sodium adherence—characterized by shared growth trajectories of objectively measured dietary sodium. The secondary objective was to identify patient-level determinants of the nonadherent trajectory. Methods:This was a secondary analysis of data collected from a prospective longitudinal study of 279 community-dwelling adults with previously or currently symptomatic HF. Growth mixture modeling was used to identify distinct trajectories of change in 24-hour urinary sodium excretion measured at 3 time points over 6 months. Logistic modeling was used to predict membership in observed trajectories. Results:The sample was predominantly male (64%), had a mean age of 62 years, was functionally compromised (59% New York Heart Association class III), and had nonischemic HF etiology. Two distinct trajectories of sodium intake were identified and labeled adherent (66%) and nonadherent (34%) to low-sodium diet recommendations. Three predictors of the nonadherent trajectory were identified, confirming our previous mixed-effect analysis. Compared with being normal weight (body mass index <25 kg/m2), being overweight and obese was associated with a 4-fold incremental increase in the likelihood of being in the nonadherent trajectory (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.66–12.91; P < .002). Being younger than 65 years (OR, 4.66; 95% CI, 1.04–20.81; P = .044) or having diabetes (OR, 4.15; 95% CI, 1.29–13.40; P = .016) were both associated with more than 4 times the odds of being in the nonadherent urine sodium trajectory compared with being older than 65 years or not having diabetes, respectively. Conclusions:Two distinct trajectories of sodium intake were identified in patients with HF. The nonadherent trajectory was characterized by an elevated pattern of dietary sodium intake shown by others to be associated with adverse outcomes in HF. Predictors of the nonadherent trajectory included higher body mass index, younger age, and diabetes.

Identifying predictors of high sodium excretion in patients with heart failure: A mixed effect analysis of longitudinal data

Background: A low-sodium diet is a core component of heart failure self-care but patients have difficulty following the diet. Aim: The aim of this study was to identify predictors of higher than recommended sodium excretion among patients with heart failure. Methods: The World Health Organization Five Dimensions of Adherence model was used to guide analysis of existing data collected from a prospective, longitudinal study of 280 community-dwelling adults with previously or currently symptomatic heart failure. Sodium excretion was measured objectively using 24-hour urine sodium measured at three time points over six months. A mixed effect logistic model identified predictors of higher than recommended sodium excretion. Results: The adjusted odds of higher sodium excretion were 2.90, (95% confidence interval (CI): 1.15–4.25, p<0.001) for patients who were obese; 2.80 (95% CI: 1.33–5.89, p=0.007) for patients with diabetes; and 2.22 (95% CI: 1.09–4.53, p=0.028) for patients who were cognitively intact. Conclusion: Three factors were associated with excess sodium excretion and two factors, obesity and diabetes, are modifiable by changing dietary food patterns.