Religiosity and Patient Activation and Health Outcomes among Hospital Survivors of an Acute Coronary Syndrome

Background: Religious involvement is widespread and may influence patient engagement with their healthcare (patient activation) and health outcomes. This dissertation examined the association between religiosity and patient activation, changes in health-related quality of life (HRQOL), readmissions, and survival after hospitalization for acute coronary syndrome (ACS). Methods: We recruited 2,174 patients hospitalized for ACS in Georgia and Central Massachusetts (2011-2013) in a prospective cohort study. Participants self-reported three items assessing religiosity – strength/comfort from religion, petition prayers for health, and awareness of intercessory prayers by others. Patient activation was measured using the 6-item Patient Activation Measure. Generic HRQOL was assessed with the SF-36®v2 physical and mental component summary scores. Disease-specific HRQOL was evaluated with the Seattle Angina Questionnaire Quality of Life subscale. Unscheduled readmissions were validated from medical records. Mortality status was obtained from national and state vital statistics. Results: After adjustment for several sociodemographic, psychosocial, and clinical variables, reports of strength/comfort from religion and receipt of intercessions were associated with high activation. Praying for one’s health was associated with low activation. Prayers for health were associated with clinically meaningful increases in disease-specific and physical HRQOL. Neither strength/comfort from religion, petition, nor intercessory prayers were significantly associated with unscheduled 30-day readmissions and two-year all-cause mortality. Conclusions: Most ACS survivors acknowledge religious practices for their health. Religiosity was associated with patient activation and changes in HRQOL. These findings suggest that religiosity may influence patient engagement in their healthcare and recovery after a life-threatening illness, buttressing the need for holistic approach in patient management

Hypertension knowledge, heart healthy lifestyle practices and medication adherence among adults with hypertension

Objective: To assess patients’ knowledge about hypertension and its association with heart healthy lifestyle practices and medication adherence. Methods: We conducted a cross sectional survey of 385 adults with hypertension treated at 2 primary care clinics in Baltimore, Maryland, USA. We used an 11-item measure to assess hypertension knowledge and obtained self-reports on dietary changes, engagement in aerobic exercise and medication adherence. Results: Approximately 85% of patients properly identified high blood pressure, but more than two-thirds were unaware that hypertension lasts a lifetime once diagnosed; one-third were unaware that hypertension could lead to renal disease. Patients with low hypertension knowledge were less likely to reduce their salt intake (OR=0.44 [95% CI: 0.24-0.72]) and eat less to lose weight (OR=0.48 [95% CI: 0.26-0.87]) than patients with high hypertension knowledge. Conclusion: In general, patients were knowledgeable about hypertension, but most were unaware that hypertension is a lifelong condition and could lead to kidney disease. High knowledge of hypertension was associated with healthy lifestyle practices including eating less to lose weight and dietary salt reduction. Practice Implications: Intensifying education strategies to improve patients’ knowledge of hypertension may enhance their engagement in heart healthy lifestyle practices for optimal blood pressure control

Religiosity and Patient Engagement in their Healthcare Among Hospital Survivors of an Acute Coronary Syndrome

Background: Optimum management after an Acute Coronary Syndrome (ACS) requires considerable patient engagement/activation. Religious practices permeate people\u27s lives and may influence engagement in their healthcare. Little is known about the relationship between religiosity and patient activation in hospital survivors of an ACS. Methods: We recruited patients hospitalized for an ACS at six medical centers in Central Massachusetts and Georgia (2011-2013). Participants self-reported three measures of religiosity - strength and comfort from religion, making petition prayers, and awareness of intercessory prayers for health. Patient activation was assessed using the 6-item Patient Activation Measure (PAM-6). We categorized participants as either having low (levels 1 and 2) or high (levels 3 and 4) activation in examining the association between religiosity and patient activation while adjusting for sociodemographic, psychosocial, and clinical variables. Results: Patients (n=2,067) were on average, 61 years old, 34% were women, and 81% were non-Hispanic White. Approximately 85% reported deriving strength and comfort from religion, two-thirds prayed for their health, and 89% received intercessions for their health. Overall, 57.5% had low activation. Reports of a great deal (aOR: 2.02; 95% CI: 1.44-2.84), and little/some (aOR: 1.45; 95% CI: 1.07-1.98) strength and comfort from religion were associated with high activation respectively, as was the receipt of intercessions (aOR: 1.48; 95% CI: 1.07-2.05). Praying for one\u27s health was associated with low activation (aOR: 0.78; 95% CI: 0.61-0.99). Conclusion and Clinical Practice Implications: Patient activation was associated with religiosity, suggesting that healthcare providers may use this knowledge to enhance patient engagement in their care

Religious practices and changes in health-related quality of life after hospital discharge for an acute coronary syndrome

BACKGROUND: Religious beliefs and practices influence coping mechanisms and quality of life in patients with various chronic illnesses. However, little is known about the influence of religious practices on changes in health-related quality of life (HRQOL) among hospital survivors of an acute coronary syndrome (ACS). The present study examined the association between several items assessing religiosity and clinically meaningful changes in HRQOL between 1 and 6 months after hospital discharge for an ACS. METHODS: We recruited patients hospitalized for an ACS at six medical centers in Central Massachusetts and Georgia (2011-2013). Participants reported making petition prayers for their health, awareness of intercessory prayers by others, and deriving strength/comfort from religion. Generic HRQOL was assessed with the SF-36(R)v2 physical and mental component summary scores. Disease-specific HRQOL was evaluated using the Seattle Angina Questionnaire Quality of Life subscale (SAQ-QOL). We separately examined the association between each measure of religiosity and the likelihood of experiencing clinically meaningful increase in disease-specific HRQOL (defined as increases by \u3e /=10.0 points) and Generic HRQOL (defined as increases by \u3e /=3.0 points) between 1- and 6-months post-hospital discharge. RESULTS: Participants (n = 1039) were, on average, 62 years old, 33% were women, and 86% were non-Hispanic White. Two-thirds reported praying for their health, 88% were aware of intercessions by others, and 85% derived strength/comfort from religion. Approximately 42, 40, and 26% of participants experienced clinically meaningful increases in their mental, physical, and disease-specific HRQOL respectively. After adjustment for sociodemographic, psychosocial, and clinical characteristics, petition (aOR:1.49; 95% CI: 1.09-2.04) and intercessory (aOR:1.72; 95% CI: 1.12-2.63) prayers for health were associated with clinically meaningful increases in disease-specific and physical HRQOL respectively. CONCLUSIONS: Most ACS survivors in a contemporary, multiracial cohort acknowledged praying for their health, were aware of intercessory prayers made for their health and derived strength and comfort from religion. Patients who prayed for their health and those aware of intercessions made for their health experienced improvement in their generic physical and disease-specific HRQOL over time. Healthcare providers should recognize that patients may use prayer as a coping strategy for improving their well-being and recovery after a life-threatening illness

Clinically Meaningful Change in Quality of Life and Associated Factors Among Older Patients With Atrial Fibrillation

Background: Among older patients with atrial fibrillation, there are limited data examining clinically meaningful changes in quality of life (QoL). We examined the extent of, and factors associated with, clinically meaningful change in QoL over 1-year among older adults with atrial fibrillation. Methods and Results: Patients from cardiology, electrophysiology, and primary care clinics in Massachusetts and Georgia were enrolled in a cohort study (2015-2018). The Atrial Fibrillation Effect on Quality-of-Life questionnaire was used to assess overall QoL and across 3 subscales: symptoms, daily activities, and treatment concern. Clinically meaningful change in QoL (ie, difference between 1-year and baseline QoL score) was categorized as either a decline ( \u3c /=-5.0 points), no clinically meaningful change (-5.0 to +5.0 points), or an increase ( \u3e /=+5.0 points). Ordinal logistic models were used to examine factors associated with QoL changes. Participants (n=1097) were on average 75 years old, 48% were women, and 87% White. Approximately 40% experienced a clinically meaningful increase in QoL and 1 in every 5 patients experienced a decline in QoL. After multivariable adjustment, women, non-Whites, those who reported depressive and anxiety symptoms, fair/poor self-rated health, low social support, heart failure, or diabetes mellitus experienced clinically meaningful declines in QoL. Conclusions: These findings provide insights to the magnitude of, and factors associated with, clinically meaningful change in QoL among older patients with atrial fibrillation. Assessment of comorbidities and psychosocial factors may help identify patients at high risk for declining QoL and those who require additional surveillance to maximize important clinical and patient-centered outcomes

Hearing loss and cognitive decline among older adults with atrial fibrillation: the SAGE-AF study

Objective: To examine the association between hearing loss and cognitive function cross-sectionally and prospectively among older adults with atrial fibrillation (AF). Methods: Patients with AF \u3e /= 65-year-old (n = 1244) in the SAGE (Systematic Assessment of Geriatric Elements)-AF study were recruited from five internal medicine or cardiology clinics in Massachusetts and Georgia. Hearing was assessed by a structured questionnaire at baseline. Cognitive function was assessed by Montreal Cognitive Assessment (MoCA) at baseline and one year. Cognitive impairment was defined as score \u3c /= 23 on the MoCA. The associations between hearing loss and cognitive function were examined by multivariable adjusted logistic regression. Results: Participants with hearing loss (n = 451, 36%) were older, more likely to be male, and have depressive symptoms than patients without hearing loss. At baseline, 528 (42%) participants were cognitively impaired. Individuals with hearing loss were significantly more likely to have cognitive impairment at baseline [adjusted odds ratio (OR) = 1.37, 95% confidence interval (CI): 1.05-1.81]. Among the 662 participants who did not have cognitive impairment at baseline and attended the one-year follow-up visit, 106 (16%) developed incident cognitive impairment. Individuals with, versus those without, hearing loss were significantly more likely to develop incident cognitive impairment at one year (adjusted OR = 1.68, 95% CI: 1.07-2.64). Conclusions: Hearing loss is a prevalent but under-recognized factor associated with cognitive impairment in patients with AF. Assessment for hearing loss may be indicated among these patients to identify individuals at high-risk for adverse outcomes

Trends in the magnitude of chronic conditions in patients hospitalized with a first acute myocardial infarction

Background: Among adults with heart disease, there is a high prevalence of concomitant chronic medical conditions. We studied patients with a first acute myocardial infarction to describe: sample population characteristics; trends of the most prevalent pairs of chronic conditions; and differences in hospital management according to burden of these morbidities. Methods and Results: Patients (n = 1,564) hospitalized with an incident AMI at the 3 major medical centers in central Massachusetts during 2005, 2011, and 2015 comprised the study population. Hospital medical records were reviewed to identify 11 more prevalent chronic conditions. The median age of this population was 68 years and 56% were men. The median number of previously diagnosed chronic conditions was 2. Patients hospitalized during 2015 were more likely to be younger than those hospitalized in the earliest study cohorts. The most common pairs of chronic conditions for those hospitalized in 2005 were: anemia-chronic kidney disease (31%), chronic kidney disease-heart failure (30%), and stroke-atrial fibrillation (27%). Among patients hospitalized during 2011, chronic kidney disease-heart failure (29%), hypertension-hyperlipidemia (27%), and hypertension-diabetes (27%) were the most common pairs whereas hypertension-hyperlipidemia (43%), diabetes-heart failure (30%), and chronic kidney disease-diabetes (23%) were the most frequent pairs recorded in 2015. There was a significant decrease in the odds of undergoing cardiac catheterization and a percutaneous coronary intervention in those with higher chronic disease burden in the most recent as compared to earliest study years. Conclusions: Our findings highlight the magnitude of chronic conditions in patients with AMI and the challenges of caring for this vulnerable population

Religious practices and long-term survival after hospital discharge for an acute coronary syndrome

BACKGROUND: Prior studies of healthy populations have found religious practices to be associated with survival. However, no contemporary studies have examined whether religiosity influences survival among patients discharged from the hospital after an acute coronary syndrome (ACS). The present study examined the relationship between religious practices and 2-year all-cause mortality among hospital survivors of an ACS. METHODS: Patients hospitalized for an ACS were recruited from 6 medical centers in Massachusetts and Georgia between 2011 and 2013. Study participants self-reported three items assessing religiosity: strength/comfort from religion, petition prayers for health, and awareness of intercessory prayers by others. All cause-mortality within 2-years of hospital discharge was ascertained by review of medical records at participating study hospitals and from death certificates. Cox proportional hazards models were used to estimate the multivariable adjusted risk of 2-year all-cause mortality. RESULTS: Participants (n = 2,068) were on average 61 years old, 34% were women, and 81% were non-Hispanic White. Approximately 85% derived strength/comfort from religion, 61% prayed for their health, and 89% were aware of intercessions. Overall, 6% died within 2 years post-discharge. After adjusting for sociodemographic variables (age, sex, and race/ethnicity), petition prayers were associated with an increased risk of 2-year all-cause mortality (HR: 1.64; 95% CI: 1.01-2.66). With further adjustment for several clinical and psychosocial measures, this association was no longer statistically significant. Strength and comfort from religion and intercessory prayers were not significantly associated with mortality. CONCLUSIONS: Most ACS survivors acknowledge deriving strength and comfort from religion, praying for their health, and intercessions made by others for their health. Although the reported religious practices were not associated with post-discharge survival after multivariable adjustment, acknowledging that patients utilize their religious beliefs and practices as strategies to improve their health would ensure a more holistic approach to patient management and promote cultural competence in healthcare

Factors Associated With Patient Engagement in Shared Decision-Making for Stroke Prevention Among Older Adults with Atrial Fibrillation

Objective: To examine the extent of, and factors associated with, patient engagement in shared decision-making (SDM) for stroke prevention among patients with atrial fibrillation (AF). Methods: We used data from the Systematic Assessment of Geriatric Elements-Atrial Fibrillation study which includes older ( \u3e /=65 years) patients with AF and a CHA2DS2-VASc \u3e /=2. Participants reported engagement in SDM by answering whether they actively participated in choosing to take an oral anticoagulant (OAC) for their condition. Multiple logistic regression was used to assess associations between sociodemographic, clinical, geriatric, and psychosocial factors and patient engagement in SDM. Results: A total of 807 participants (mean age 75 years; 48% female) on an OAC were studied. Of these, 61% engaged in SDM. Older participants ( \u3e /=80 years) and those cognitively impaired were less likely to engage in SDM, while those very knowledgeable of their AF associated stroke risk were more likely to do so than respective comparison groups. Conclusions: A considerable proportion of older adults with AF did not engage in SDM for stroke prevention with older patients and those cognitively impaired less likely to do so. Clinicians should identify patients who are less likely to engage in SDM, promote patient engagement, and foster better patient-provider communication which may enhance long-term patient outcomes

Multimorbidity, physical frailty, and self-rated health in older patients with atrial fibrillation

BACKGROUND: Holistic care models emphasize management of comorbid conditions to improve patient-reported outcomes in treatment of atrial fibrillation (AF). We investigated relations between multimorbidity, physical frailty, and self-rated health (SRH) among older adults with AF. METHODS: Patients (n = 1235) with AF aged 65 years and older were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. Ten previously diagnosed cardiometabolic and 8 non-cardiometabolic conditions were assessed from medical records. Physical Frailty was assessed with the Cardiovascular Health Study frailty scale. SRH was categorized as either excellent/very good , good , and fair/poor . Separate multivariable ordinal logistic models were used to examine the associations between multimorbidity and SRH, physical frailty and SRH, and multimorbidity and physical frailty. RESULTS: Overall, 16% of participants rated their health as fair/poor and 14% were frail. Hypertension (90%), dyslipidemia (80%), and heart failure (37%) were the most prevalent cardiometabolic conditions. Arthritis (51%), anemia (31%), and cancer (30%), the most common non-cardiometabolic diseases. After multivariable adjustment, patients with higher multimorbidity were more likely to report poorer health status (Odds Ratio (OR): 2.15 [95% CI: 1.53-3.03], \u3e /= 8 vs 1-4; OR: 1.37 [95% CI: 1.02-1.83], 5-7 vs 1-4), as did those with more prevalent cardiometabolic and non-cardiometabolic conditions. Patients who were pre-frail (OR: 1.73 [95% CI: 1.30-2.30]) or frail (OR: 6.81 [95% CI: 4.34-10.68]) reported poorer health status. Higher multimorbidity was associated with worse frailty status. CONCLUSIONS: Multimorbidity and physical frailty were common and related to SRH. Our findings suggest that holistic management approaches may influence SRH among older patients with AF