Care-seeking decisions for worsening symptoms in heart failure: a qualitative metasynthesis

© 2015, Springer Science+Business Media New York. Over 50 % of heart failure (HF) patients delay seeking help for worsening symptoms until these reach acute levels and require emergency hospitalisation. This metasynthesis aimed to identify and explore factors influencing timely care-seeking in patients with HF. Electronic databases searched were MEDLINE, Embase, and CINAHL. Studies were included if they were peer-reviewed journal articles, written in English, and reported perspectives of HF patients following qualitative data collection and analysis. Forty articles underwent analysis following the approach of Thomas and Harden. Leventhal’s self-regulatory model (SRM) was used to organise the literature. Much of the literature fits within the SRM; however, this model did not account for all factors that influence patients’ care-seeking for worsening symptoms. Factors not accounted for included patients’ appraisals of previous care-seeking experiences, perceived system and provider barriers to accessing care, and the influence of external appraisals. When added to factors already represented in the model, such as misattribution of symptoms, not identifying with HF diagnosis, cognitive status, lack of understanding information provided, adaptation to symptoms, and emotional responses, a more comprehensive account of patients’ decision-making was revealed. This metasynthesis identified factors, as yet unaccounted for, in a prominent model, and has suggested a more comprehensive framework for addressing care-seeking in HF patients. This information can be used to tailor education, communication, and service initiatives to improve HF patients’ responses to worsening symptoms and target those most at risk of delay

Care-seeking decisions for worsening symptoms in heart failure: a qualitative metasynthesis

Purpose: Over 50% of heart failure (HF) patients delay seeking help for worsening symptoms until these reach acute levels and require emergency hospitalisation. This metasynthesis aimed to identify and explore factors influencing timely care-seeking in patients with HF. Methods: Electronic databases searched were Medline, EMBASE and CINAHL. Studies were included if they were peer reviewed journal articles written in English, and reported perspectives of HF patients following qualitative data collection and analysis. Forty articles underwent analysis following the approach of Thomas and Harden. Leventhal's self-regulatory model (SRM) was used to organise the literature. Results: Much of the literature fit within the SRM, however this model did not account for all factors that influence patients’ care-seeking for worsening symptoms. Factors not accounted for included patients’ appraisals of previous care-seeking experiences, perceived system and provider barriers to accessing care, and the influence of external appraisals. When added to factors already represented in the model, such as misattribution of symptoms, not identifying with HF diagnosis, cognitive status, lack of understanding information provided, adaptation to symptoms, and emotional responses, a more comprehensive account of patients’ decision-making was revealed. Implications: This metasynthesis identified factors, as yet unaccounted for, in a prominent model, and has suggested a more comprehensive framework for addressing care-seeking in HF patients. This information can be used to tailor education, communication, and service initiatives to improve HF patients’ responses to worsening symptoms

Evaluation of an online toolkit for carers of people with life-limiting illness at the end-of-life: health professionals’ perspectives

Carers of people with a life-limiting illness report unmet information, practical, and emotional support needs, and are often unaware of services available to help improve preparedness, wellbeing, and reduce strain. CarerHelp is the first e-health toolkit that focuses on the information and support needs of carers of people with a life-limiting illness at the end-of-life, using a pathway approach. This study investigated the usefulness of CarerHelp, from the perspective of health professionals who care for these people. Through a 10-min online survey, health professionals provided feedback about their user experience and perceived usefulness of the website. Their expert opinion was sought to ascertain whether CarerHelp could increase carers’ preparedness and confidence to support the person for whom they are caring and thereby improve carers’ own psychological wellbeing. Health professionals also evaluated whether CarerHelp adequately raised awareness of support services available. CarerHelp was perceived as a useful resource for increasing preparedness for the caring role, including physical tasks and emotional support. Health professionals reported that CarerHelp would increase carers’ knowledge of services, confidence to care and ability for self-care. Health professionals endorsed CarerHelp as a useful information source, guide for support, and would promote CarerHelp to clients and their families

Hospital service use in the last year of life by Indigenous Australians who died of heart failure or cardiomyopathy : a linked data study

Background: Aboriginal and Torres Strait Islander peoples experience disproportionate rates of heart failure. However, information regarding their use of hospital services in the last year of life is poorly delineated to inform culturally appropriate end-of-life health services. Objectives: To quantify hospital service use in the last year of life of Aboriginal and Torres Strait Islander peoples who died of heart failure or cardiomyopathy in Queensland, Australia. Methods: A subgroup analysis of a larger retrospective linkage study using administrative health data in Queensland, Australia. Individuals that identified as an Aboriginal and Torres Strait Islander person from their first hospital admission in the last year of life, who died of heart failure or cardiomyopathy from 2008 to 2018, were included. Results: There were 99 individuals, with emergency department presentation/s recorded for 85 individuals. Over 50% of individuals presenting to the Emergency Department were from regional areas (n = 43, 51%). The 99 individuals had a total of 472 hospital admissions, excluding same day admissions for haemodialysis, and 70% (n = 70) died in hospital. Most admissions were coded as acute care (n = 442, 94%), and fewer were coded as palliative care (n = 19, 4%). Median comorbidities or factors that led to hospital contact = 5 (interquartile range 3–9). Conclusion: Acute care hospital admissions in the last year of life by this population are common for those who died of heart failure or cardiomyopathy. Multimorbidity is prevalent in the last year of life, underscoring the importance of primary health care, provided by nurses and Indigenous health workers

Real Effective Corporate Tax Rates in Canada and the United States. After Tax Reform

Both Canada and the United States have recently undertaken comprehensive reforms of their tax systems. In the case of the corporate tax, the main thrust of the reforms has been to lower tax rates,broaden the tax base, and curtail or eliminate incentives such as investment tax credits. This article examines the significance for Canada of the corporate tax reforms in both countries. It uses the concept of the marginal real effectivetax rate on new investment to analyze the impact of the corporatetax changes on the size and distribution of the corporate tax burdenin each country, given various assumptions about the rate of inflation and the extent to which investment is debt financed. It is in the manufacturing sector that competition between Canada andthe United States is most intense and that real effective corporate tax rates probably have their greatest potential impact on the location of investment and employment. Before tax reform, the real effective tax rateon manufacturing investment in machinery and equipment in Canada was considerably lower than the rate in the United States. Under the post-reform regime, however, Canada's advantage is significantly smaller and decreases as the degree of debt financing increases.Indeed, in the absence of the investment incentives introduced by Ontario and Quebec in 1988, Canada's favourable tax position in the critical area of manufacturing investment in machinery andequipment would be lost altogether. In contrast, tax reform has significantly increased the real effective taxrate on equity-financed investment in non-residential construction in the United States, but not the rate in Canada. In this case, tax reform has transformed what was a tax advantage for the United States into an advantage for Canada. The overall effect of tax reform in the two countries, given the real effective tax rates, appropriately weighted, for both investment in machinery and equipment and investment in non-residential construction, has been to slightly reduce Canada's tax advantage in the manufacturing sector. This advantage is still a substantial one, however. Two important questions emerge from the analysis. First, what are the implications of the factthat federal efforts to reduce tax incentives for manufacturing investment in machinery and equipment have been offset by subsequent provincial efforts to restore the preferential position of their manufacturing sectors? Second, given that one of the main rationales for the Canadian tax reform package was that it would reduce tax-induced distortion of resource allocation by reducing or eliminating special tax incentives, why has reform actually increased the relative value of the tax credit for investment in the Atlantic region

Insights from Australians with respiratory disease living in the community with experience of self-managing through an emergency department 'near miss' for breathlessness: A strengths-based qualitative study

© 2017 Article author(s). Objectives: Breathlessness 'crises' in people with chronic respiratory conditions are a common precipitant for emergency department (ED) presentations, many of which might be avoided through improved self-management and support. This study sought insights from people with experience of ED 'near misses' where they considered going to the ED but successfully self-managed instead. Design and methods: A qualitative approach was used with a phenomenological orientation. Participants: were eligible if they reported breathlessness on most days from a diagnosed respiratory condition and experience of ≥1 ED near miss. Recruitment was through respiratory support groups and pulmonary rehabilitation clinics. Semistructured interviews were conducted with each participant via telephone or face-to-face. Questions focused on ED-related decision-making, information finding, breathlessness management and support. This analysis used an integrative approach and independent coding by two researchers. Lazarus and Cohen's Transactional Model of Stress and Coping informed interpretive themes. Results: Interviews were conducted with 20 participants, 15 of whom had chronic obstructive pulmonary disease. Nineteen interviews were conducted via telephone. Analysis identified important factors in avoiding ED presentation to include perceived control over breathlessness, self-efficacy in coping with a crisis and desire not to be hospitalised. Effective coping strategies included: taking a project management approach that involved goal setting, monitoring and risk management; managing the affective dimension of breathlessness separately from the sensory perceptual and building three-way partnerships with primary care and respiratory services. Conclusions: In addition to teaching non-pharmacological and pharmacological management of breathlessness, interventions should aim to develop patients' generic self-management skills. Interventions to improve self-efficacy should ensure this is substantiated by transfer of skills and support, including knowledge about when ED presentation is necessary. Complementary initiatives are needed to improve coordinated, person-centred care. Future research should seek ways to break the cyclical relationship between affective and sensory-perceptual dimensions of breathlessness

Care-seeking behaviours for worsening symptoms in heart failure

University of Technology Sydney. Faculty of Health.Purpose: Symptoms of breathlessness, fatigue, and peripheral oedema are a part of daily life for patients with heart failure (HF). These symptoms are the number one cause of HF-related hospitalisation, yet over 50% of patients with HF delay seeking professional care for worsening symptoms. Delayed care-seeking increases the risk of emergency hospitalisation, can lead to frequent re-admissions, longer lengths of stay, and death. Little is known about what lies behind patients’ decisions to seek or avoid professional care. The literature shows that misconceptions and lack of understanding of HF is common amongst patients with HF. The literature also tells us that patients with HF are likely to be cognitively impaired, have inadequate health literacy, and get most of their HF information from their providers. Whilst knowledge and understanding is assumed to be a major contributor to delayed care-seeking, educational interventions to reduce pre-hospital delay have, to-date, been unsuccessful. This thesis aimed to measure what is known to impact health related decisions, ascertain patients’ educational needs and perspectives of patient/provider communication, and explore their perspectives of factors that influence care-seeking behaviour, to inform a novel approach to promote timely care-seeking in HF. Methods: This mixed-methods study, guided by the self-regulation model of illness behaviour, involved 72 symptomatic patients with HF recruited from a larger longitudinal study at a tertiary hospital in Sydney, Australia. Quantitative data measuring illness perceptions, health literacy, HF knowledge, and self-efficacy were collected via validated questionnaires, and analysed using descriptive statistics in SPSS. Qualitative data eliciting patients’ experiences of and attitudes and beliefs about seeking professional care, educational needs, and perceptions of patient-provider communication were obtained through in-depth semi-structured interviews with 15 participants. Interviews were conducted face-to-face in hospital or over the phone, audio-recorded, transcribed verbatim, and were analysed using interpretative phenomenological analysis (IPA). Results: Interview findings revealed avoidance of care-seeking despite quantitative data reflecting high levels of self-efficacy, HF knowledge (12.3±1.9 out of 15), and above-average health literacy levels (75% adequate - 15% higher than average in HF). Participants described delayed care-seeking due to values and beliefs associated with healthcare use, and desire to avoid hospitalisation. The experience of being hospitalised represented a loss of freedom and control and served as a reminder of being ill. Perception of illness as a threat to identity led to rejection of treatment, whilst fear of being a burden to others also led to avoidance behaviours. Uncertainty about the cause and likely trajectory of symptoms often led to a ‘wait and see’ response, as symptoms were not perceived as serious. Professional care was often viewed as a last resort, when all alternative coping strategies were exhausted, and participants could no longer cope with the physical and emotional impact of symptoms. Patient-provider interpersonal relationships and preferences for continuity also impacted care-seeking. Participants relied heavily on providers for HF information and support, expressed numerous unmet educational needs, and had mixed feelings about quality of communication, which influenced subsequent care-seeking. Conclusion: Findings suggest that whilst patients may possess skills and HF knowledge, previous healthcare experience affects subsequent action. Improving patient-provider communication is key, not only to keep patients informed, but also to build supportive, trusting relationships to encourage timely care-seeking