Varda Konstam

Baseline Quality of Life as a Predictor of Mortality and Hospitalization in 5,025 Patients With Congestive Heart Failure

This study examined the independent relation of health-related quality of life (HRQL) to mortality and congestive heart failure (CHF)-related hospitalizations in patients with an ejection fraction of < 0.35 followed for a mean of 36.5 months. A brief HRQL questionnaire was administered at baseline to patients randomized to placebo or enalapril in the Studies of Left Ventricular Dysfunction (SOLVD) trial. Participants had an ejection fraction of < 0.35 and either symptomatic CHF (treatment trial, n = 2,465) or asymptomatic CHF (prevention trial, n = 2,560). Baseline assessment of HRQL predicted mortality and CHF-related hospitalizations in symptomatic and asymptomatic patients randomized to enalapril and placebo treatment. Domains that were the stronger univariate predictors of mortality and CHF-related hospitalizations were activities of daily living (relative risk [RR] for mortality: 1.163, p < 0.000; for hospitalization: 1.215, p < 0.000), general health (RR for mortality: 1.205, p < 0.000; for hospitalization: 1.188, p < 0.000), and social functioning (RR for mortality 1.098, p < 0.000; for hospitalization: RR 1.156, p < 0.000). In the multivariate model, activities of daily living (RR for mortality 1.41, p < 0.000; for hospitalization: RR 1.43, p < 0.002), general health (RR for mortality 1.21, p < 0.000; for hospitalization RR 1.16, p < 0.013) and heart failure symptoms (RR for mortality 1.02, p < 0.025; for hospitalization RR 1.03, p < 0.004) were found to be independent risk factors. HRQL independently predicted mortality and CHF-related hospitalizations after adjustment for ejection fraction, age, treatment, and New York Heart Association classification in patients with an ejection fraction of < 0.35, randomized to enalapril and placebo treatment. HRQL provides additional clinical information regarding disease course and outcome that is not captured by traditional indexes of clinical status.

Randomized, Controlled Evaluation of Short- and Long-Term Benefits of Heart Failure Disease Management Within a Diverse Provider Network The SPAN-CHF Trial

Background—Several trials support the usefulness of disease management (DM) for improving clinical outcomes in heart failure (HF). Most of these studies are limited by small sample size; absence of concurrent, randomized controls; limited follow-up; restriction to urban academic centers; and low baseline use of effective medications. Methods and Results—We performed a prospective, randomized assessment of the effectiveness of HF DM delivered for 90 days across a diverse provider network in a heterogeneous population of 200 patients with high baseline use of approved HF pharmacotherapy. During a 90-day follow-up, patients randomized to DM experienced fewer hospitalizations for HF [primary end point, 0.55±0.15 per patient-year alive versus 1.14±0.22 per patient-year alive in control subjects; relative risk (RR), 0.48, P=0.027]. Intervention patients experienced reductions in hospital days related to a primary diagnosis of HF (4.3±0.4 versus 7.8±0.6 days hospitalized per patient-year; RR, 0.54; P<0.001), cardiovascular hospitalizations (0.81±0.19 versus 1.43±0.24 per patient-year alive; RR, 0.57; P=0.043), and days in hospital per patient-year alive for cardiovascular cause (RR, 0.64; P<0.001). Intervention patients showed a trend toward reduced all-cause hospitalizations and total hospital days. On long-term (mean, 283 days) follow-up, there was substantial attrition of the 3-month gain in outcomes, with sustained significant reduction only in days in hospital for cardiac cause. Conclusions—In a population with high background use of standard HF therapy, a DM intervention, uniformly delivered across varied clinical sites, produced significant short-term improvement in HF-related clinical outcomes. Longer-term benefit likely requires more active chronic intervention, even among patients who appear clinically stable.

Health-Related Quality of Life in a Multicenter Randomized Controlled Comparison of Telephonic Disease Management and Automated Home Monitoring in Patients Recently Hospitalized With Heart Failure: SPAN-CHF II Trial

BACKGROUND Although disease management programs have been shown to provide a number of clinical benefits to patients with heart failure (HF), the incremental impact of an automated home monitoring (AHM) system on health-related quality of life (HRQL) is unknown. METHODS AND RESULTS We performed a prospective randomized investigation, examining the additive value of AHM to a previously described nurse-directed HF disease management program (SPAN-CHF), with attention to HRQL, in patients with a recent history of decompensated HF. A total of 188 patients were randomized to receive the SPAN-CHF intervention for 90 days, either with (AHM group) or without (NAHM, standard-care group) AHM, with a 1:1 randomization ratio after HF-related hospitalization. HRQL, measured by the Minnesota Living With Heart Failure Questionnaire (MLHFQ) (Physical, Emotional, and Total scores on MLHFQ) was assessed at 3 time points: baseline, 45 days, and 90 days. Although both treatments (AHM and NAHM) improved HRQL at 45 and 90 days compared with baseline with respect to Physical, Emotional, and Total domain scales, no significant difference emerged between AHM and NAHM groups. CONCLUSIONS AHM and NAHM treatments demonstrated improved HRQL scores at 45 and 90 days after baseline assessment. When comparing 2 state-of the-art disease management programs regarding HRQL outcomes, our results did not support the added value of AHM.

Heart failure disease management a sustainable energy source for the health care engine.

Despite the demonstrated value of heart failure (HF) disease management, many questions remain. Which program elements contribute most toward the observed benefits? What patient characteristics predict benefit? Importantly, do benefits persist beyond the intervention period? In this issue of the Journal, Ferrante et al. (1) bring us closer to answers, reporting clinical outcomes over 3 years after completion of a randomized, controlled disease management intervention in an Argentine population with stable HF. The observed persistent reduction of death or HF hospitalization helps us toward understanding the mechanism of benefit of disease management, developing an approach toward its cost-effective deployment, and establishing policy related to this growing and costly health care problem.

Meaning in the Lives of Caregivers of Individuals With Parkinson's Disease

This study explores the contribution of finding meaning in general and finding meaning specific to caregiving as potentially important explanatory variables in predicting well-being in caregivers of individuals with Parkinsons disease. Fifty-eight caregivers of individuals diagnosed with Parkinsons disease were provided self-report questionnaires to assess well-being and meaning (general and specific). Results showed a significant proportion of the variance of positive affect (PASS) and negative affect (DYS) related to well-being, as assessed by the Multiple Affect Adjective Checklist – Revised. Purpose and Existential Vacuum (two subtests of the Life Attitude Profile – Revised used to assess general meaning) predicted well-being. Purpose predicted 41.8% of the variance related to PASS; Existential Vacuum predicted 30.8% of the variance related to DYS. Meaning related specifically to caregiving (Finding Meaning Through Caregiving Scale) did not explain any additional variance. Our results suggest that finding meaning, beyond meaning specifically associated with caregiving, is the key to understanding well-being among caregivers of individuals with Parkinsons disease. The positive construct of finding meaning in general can empower researchers and professionals working with caregivers to better understand the variability in caregiver outcomes as well as assess and intervene more effectively.

Emerging Adults at Work and at Play: Leisure, Work Engagement, and Career Indecision

To expand the understanding of how leisure and recreational activities can inform career indecision, this research examined the relationship between career indecision, work engagement, and leisure in emerging adults, 25—30 years of age. Independent sample t tests reveal that career indecisive emerging adults scored significantly lower on all three leisure factors on the Leisure Diagnostic Battery, Short Form (LDB-B): Leisure Enjoyment t(62) = 6.997; Leisure Competence t(62) = 8.383; and Leisure Control t(62) = 6.792 (all at p < .001). Career indecisive emerging adults also scored significantly lower on work engagement t(62) = 5.488, p < .001. Work engagement and leisure activity provide an additional lens to understanding emerging adults in the throes of career decision making, some of whom are floundering and in need of professional assistance. Implications for career counselors are discussed.

Career Adaptability and Subjective Well-Being in Unemployed Emerging Adults A Promising and Cautionary Tale

Unemployment is associated with increased levels of anxiety, depression, and disconnection among emerging adults. Given the greater risk of unemployment for emerging adults (13.2% in the United States), career adaptability is relevant to understanding how emerging adults survive and thrive in today’s challenging work environment. This study examined the effect of career adaptability on subjective well-being in 184 unemployed diverse emerging adults of age 21–29. Results revealed that emerging adults with higher levels of control and confidence had higher life satisfaction. Control was positively related to positive affect while at the same time negatively related to negative affect. Control was the most consistent informant of subjective well-being (significant on all three subscale measures). The implications of the significant findings, and the caution warranted in relation to these findings, are discussed.

Volunteering and Reemployment Status in Unemployed Emerging Adults A Time-worthy Investment?

Given the alarming unemployment rates among emerging adults in the United States, this study investigates the relationships among volunteering, length of unemployment, likelihood/quality of reemployment, and job search strategies in a sample of emerging adults. Two hundred and sixty-five emerging adults aged between 21 and 29, all of whom were unemployed 6 months prior to taking the survey, completed an online survey. Results affirm positive associations between volunteering and likelihood of reemployment 6 months later. The number of hours spent volunteering was significantly related to reemployment status as was the length of unemployment. The use of an exploratory job search strategy, in contrast to the use of a focused or a haphazard job search strategy, was associated with reemployment. Implications of the findings and suggestions for further research are discussed along with the limitations of the present study.

Stigma and Divorce: A Relevant Lens for Emerging and Young Adult Women?

ABSTRACT Historically, divorced women have been vulnerable to devaluation. This study examined the experiences of divorce-related stigma in emerging and young adult women, who at the time of divorce were between the ages of 23 and 32. Using consensual qualitative research methodology, (Hill et al., 2005), the authors identified 5 categories pertaining to stigma and divorce: (a) self-stigma versus public stigma; (b) failure, embarrassment, and perceptions of blame; (c) religion and stigma; (d) nondisclosure and impression management; and (e) contextual considerations: “it would have been different if.” Analyses suggest that stigma informs the behavior of emerging and young adult women in nuanced and contradictory ways. Although a significant number of the participants acted in ways that were consistent with the belief that stigmatization is relevant to their lives, when they spoke of stigma, they assessed that stigma is no longer relevant. Implications for clinicians and related professionals are discussed.

Anger: A Neglected Group Treatment Issue with Cardiac Transplantation Recipients and Their Families.

Abstract This article describes the group process, specifically as it evolved with respect to anger in cardiac transplantation recipients and their families.