Profiling Patients With Heart Failure and Testing a Motivational Interviewing Intervention to Improve Heart Failure Self-Care

Background: Heart failure (HF) is the fastest growing cardiovascular syndrome in the United States and the most common reason for hospitalization of Medicare recipients. HF is prevalent, costly to society and complex to manage. The purpose of this body of work was to strengthen the evidence base for self-care by studying understudied aspects of HF self-care maintenance. Methods/Results: This body of work entails four discrete studies. The first study identified modifiable predictors of patients who are at risk of consuming a diet higher in sodium than recommended by the 2010 Heart Failure Society of America guidelines. The second study identified two unique patterns of sodium intake, very high (mean 4.5 g/day) and generally adherent (mean 2.4 g/day). Predictors of the very high sodium intake group were being obese, having diabetes mellitus and less than 65 years old. The third study identified unique patterns of inflammation and myocardial stress in a sample of patients with HF from the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise TraiNing (HF-ACTION) clinical trial. Predictors of the worst biomarker pattern were identified and exercise was protective for being in the worst biomarker pattern. In response to these studies, the Motivational Interviewing Tailored Interventions for Heart Failure patients (MITI-HF) randomized controlled trial was designed and conducted to test the efficacy of a tailored motivational interviewing approach to improve self-care, physical HF symptoms and quality of life in patients with HF. Motivational interviewing was a successful approach for improving self-care maintenance, but there were no differences between groups for self-care management, self-care confidence, physical HF symptoms or quality of life. Conclusions: In the context of the rising prevalence of HF within an environment of increasing cost-conscious appropriation of healthcare resources, this body of work provides evidence for targeting self-care interventions to patients who are at highest risk of poor outcomes. It also provides evidence that motivational interviewing is a successful approach for improving self-care maintenance behaviors, specifically eating a lower sodium diet and exercising

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

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\u27s 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

Developing public disaster communication for volunteer recruitment: understanding volunteer motivations

Understanding spontaneous volunteers Spontaneous volunteers who converge on disaster areas play a critical response role, often being first on the scene and typically trusted by victims (Fulmer, Portelli, Foltin, Zimmerman, Chachkes, and Goldfrank, 2007). The term 'spontaneous volunteers' refers to individuals who provide assistance immediately following a disaster (Lowe and Forthergill, 2003). The sometimes overwhelming number of spontaneous volunteers, from both within and outside the disaster-affected community, poses significant challenges for disaster relief and recovery services (Barraket, Keast, Newton, Walters, and James, 2013). Characteristically, as spontaneous volunteers are seen to hinder relief efforts, government and emergency management agencies resist harnessing this workforce (Drabek and McEntire, 2003). Yet these untrained volunteers are integral to accomplishing many disaster recovery tasks (Barsky, Trainor, Torres, and Aguirre, 2007). Indeed, most response work is carried out by community members who are present or nearby during a disaster (Lowe and Fothergill, 2003). Designing communication that stimulates people to volunteer to assist community recovery efforts in large-scale emergencies is therefore crucial (Palttala and Vos (2011). To most effectively assist recovery efforts, this workforce needs to be instructed on how best to assist and be deployed to areas most needing assistance. In order to effectively recruit and manage this workforce, understanding spontaneous volunteers and their motivations is critical to establishing effective disaster communication plans (Lowe and Fothergill, 2003; Palttala and Vos, 2011). Since disasters often generate powerful emotions and different responses (Beyerlein and Sikkink, 2008), understanding emotions’ role in motivating behavior is important. Although emotion is intensely researched in other domains (e.g., organizational psychology, management, marketing), its influence has received little attention in volunteering and disaster research. In parallel with volunteer convergence onto physical disaster sites, convergence behavior is now evident on-line (Hughes, Palen, Sutton, Liu, and Vieweg, 2008). In the 2011 Brisbane floods, many individuals used social media such as Facebook and Twitter not only to exchange information, but for coordinating relief efforts (Knaus, 2011). The actual and potential use of social media in disasters has generated intense interest evidenced by a small, but burgeoning body of literature (Alexander, 2013). The use of social media as a method of communication and information exchange has been studied in 2011 Brisbane flood research (e.g., Barraket et al., 2013; Cheong and Cheong, 2011), but investigation of social media used by individuals for volunteer recruitment has only recently attracted research attention (e.g., Macias, Hilyard, and Fremuth, 2009; Jones, 2013). The widespread adoption and use of social media by members of the public during disasters (Alexander, 2013) suggest that social media is increasingly critical to future disaster management and relief efforts. Further, with the increasing use of online social networks in disaster volunteering, it is important to understand how – or whether – social media affects the interpersonal bonds known to influence volunteer recruitment. Consequently, this research investigates the factors motivating the spontaneous volunteering behavior of the 'Mud Army' following the 2011 Brisbane floods. As anecdotal evidence suggests that many volunteers used social media to co-ordinate volunteering efforts via the extended friendship network that is Facebook, the research also examines the role of social media in volunteer recruitment. This chapter concludes with implications for disaster communication

Growth rings in secondary xylem, their formation and interpretation through geological time

The secondary wood formed by cambial activity in the growth of trees records with varying degrees of precision the amount of seasonality and other aspects of the climate under which it grew. A survey is presented of the extent to which this climatic 'data-store' can be directly 'read back', based on the extensive literature on the environmental control of wood formation in modern plants. This led to the investigation of growth ring characters in selected fossil and recent wood in the course of which a cyclic phenomenon, apparently under endogenous control, was demonstrated. The potential of this information to deduce aspects of the palaeoclimate from fossil wood (of age extending back some 370 million years) is then considered. Attention was directed particularly to three intervals of geological time, namely the Upper Devonian, the Permo-Carboniferous and the later Mesozoic in which growth ring characteristics present features of particular interest. A classification of growth ring features is developed and five categories are defined. Some of these data are derived from direct observation of fossil wood material by the author and some from the literature. Growth ring characteristics are plotted on palaeo-reconstruction maps and the climatic significance is considered in relation to other indicators of palaeo-climate. Consideration is given to the phenomenon of tree growth (and very substantial increments) in high latitudes during two phases of geological time---the Permian and the later Mesozoic. At these times major forest growth evidently extended far beyond the present latitudinal range. Consideration of the radiation energy input at high latitudes, and the effect of a generally more isothermal global climate suggests that these growth ring phenomena can be explained in uniformitarian terms without the need to invoke shift in axial inclination or similar processes as some, have advocated.<p

Identifying Biomarker Patterns and Predictors of Inflammation and Myocardial Stress

BACKGROUND: Regular exercise is recommended to improve outcomes in patients with heart failure. Exercise is known to decrease inflammation and thought to decrease myocardial stress; however, studies of exercise in heart failure have had mixed results on levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hsCRP). A multimarker analysis may help to identify distinct subgroups of patients who respond to exercise. Our primary study objective was to identify common and distinct patterns of change in hsCRP and NT-proBNP and to quantify the influence of exercise therapy on the observed patterns of change. METHODS AND RESULTS: NT-proBNP and hsCRP were assessed in a random sample of 320 participants from the biomarker substudy of HF-ACTION, a randomized clinical trial of exercise training versus usual care in patients with stable and chronic heart failure. Growth mixture modeling was used to identify unique biomarker patterns over 12 months. Three statistically independent and clinically meaningful biomarker patterns of NT-proBNP and hsCRP were identified. Two patterns were combined and compared with the low/stable\u22 pattern, which was characterized by the lowest levels of NT-proBNP and hsCRP over time. Participants who were taking a loop diuretic and had hypertension or ischemic etiology were ∼2 times as likely to be in the elevated/worsening biomarker pattern. Participants randomized to the exercise intervention were less likely to be in the elevated/worsening pattern of NT-proBNP and hsCRP (relative risk ratio 0.56, 95% confidence interval 0.32-0.98; P = .04). CONCLUSIONS: Exercise therapy was protective for reducing the frequency of membership in the elevated/worsening biomarker pattern, indicating that exercise may be helpful in delaying the progression of heart failure

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