Background

The common reality of not following a recommended course of treatment is a major cause of poor health outcomes in patients with heart failure (HF). The purpose of this study was to identify predictors of adherence to HF self-care recommendations in rural HF patients who received an intervention to promote symptom management and self-care.

Methods

Data from 349 rural HF patients (42% female, 90% Caucasian) randomized to the intervention arms of the study were used. Adherence was measured using the European Heart Failure Self-Care Scale questionnaire, a brief measure that asks patients to report their adherence to a variety of recommended HF symptom management behaviors (ie, daily weight monitoring, when to call the physician, medications, diet, and exercise). The following predictors were tested: age, gender, marital status, education level, depression score (measured using PHQ-9), anxiety score (measured with the Brief Symptom Inventory), and level of perceived control (measured using Control Attitudes Scale-R). Multivariate linear regression was used to test the model.

Results

The model to predict adherence was significant (P < .0001). Of the covariates tested in the regression model, being a male (P = .009), having less anxiety (P = .018), not being depressed (P = .017), and having higher perceived control (P = .003) were predictors of improved self-care score at 3 months.

Conclusion

Adherence is a multifaceted and a challenging behavior based on the assumption that the patient agrees with self-care recommendations. These data suggest interventions designed to promote adherence behaviors should include an assessment of gender, anxiety, depression, and perceived control for optimal outcomes.

Background

The impact of depressive symptoms and anxiety on rural patients' decisions to seek care for worsening heart failure (HF) symptoms remains unknown. The purposes of this study were (1) to describe rural patients' reasons for delay in seeking care for HF, and (2) to determine whether depressive symptoms or anxiety was associated with patients' reasons for delay in seeking medical care for worsening symptoms.

Methods

A total of 611 rural HF patients were included. Data on reasons for patient delay in seeking medical care (The Reasons for Delay Questionnaire), depressive symptoms (PHQ-9), and anxiety (BSI-ANX) were collected. Statistical analyses included chi-square and multiple regression.

Results

A total of 85.4% of patients reported at least 1 reason for delay. Patients with higher levels of depressive symptoms were more likely to cite embarrassment, problems with transportation, and financial concerns as a reason for delay. Patients with anxiety not only cited nonsymptom-related reasons but also reported symptom-related reasons for delay in seeking care (ie, symptoms seemed vague, not sure of symptoms, symptoms didn't seem to be serious enough, and symptoms were different from the last episode). In multiple regression, patients with greater depressive symptoms and anxiety had a greater number of reasons for delay in seeking care (P = .003 and P = .023, respectively).

Conclusions

Our findings suggest that enhancement of patients' symptom appraisal abilities and improvement in psychological distress may result in a reduction in delay in seeking medical care for worsening symptoms in rural patients with HF.

Background

Patients hospitalized with heart failure are often readmitted. Health literacy may play a substantial role in the high rate of readmissions. The purpose of this study was to examine the association of health literacy with the composite end point of heart failure readmission rates and all-cause mortality in patients with heart failure living in rural areas.

Methods and results

Rural adults (n = 575), hospitalized for heart failure within the past 6 months, completed the Short Test of Functional Health Literacy in Adults (STOFHLA) to measure health literacy and were followed for ≥2 years. The percentage of patients with the end point of heart failure readmission or all-cause death was different (P = .001) among the 3 STOFHLA score levels. Unadjusted analysis revealed that patients with inadequate and marginal health literacy were 1.94 (95% confidence interval [CI] 1.43-2.63; P < .001) times, and 1.91 (95% CI 1.36-2.67; P < .001) times, respectively, more likely to experience the outcome. After adjustment for covariates, health literacy remained a predictor of outcomes. Of the other covariates, worse functional class, higher comorbidity burden, and higher depression score predicted worse outcomes.

Conclusions

Inadequate or marginal health literacy is a risk factor for heart failure rehospitalization or all-cause mortality among rural patients with heart failure.

Background

Attention to symptoms of weight gain and dyspnea are central tenets of patient education in heart failure (HF). However, it is not known whether diary use improves patient outcomes. The aims of this study were to compare mortality among rural patients with HF who completed versus did not complete a daily diary of weight and symptom self-assessment and to identify predictors of diary use.

Methods and results

This is a secondary analysis of a 3-arm randomized controlled trial on HF education of self-care with 2 intervention groups versus control who were given diaries for 24 months to track daily weight, HF symptoms, and response to symptom changes. Mean age was 66±13, 58% were men, and 67% completed diaries (n=393). We formed 5 groups (no use, low, medium, high, and very high) based on the first 3 months of diary use and then analyzed time to event (cardiac mortality, all-cause mortality, and HF-related readmission) starting at 3 months. Compared with patients with no diary use, high and very high diary users were less likely to experience all-cause mortality (P=0.02 and P=0.01, respectively). Self-reported sedentary lifestyle was associated with less diary use in an adjusted model (odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P=0.03). Depression and sex were not significant predictors of diary use in the adjusted model.

Conclusions

In this study of 393 rural patients with HF, we found that greater diary use was associated with longer survival. These findings suggest that greater engagement in self-care behaviors is associated with better HF outcomes.

Clinical trial registration

URL: https://www.clinicaltrials.gov. Unique Identifier: NCT00415545.

Aims

Heart failure (HF) patients are taught to identify a rapid 5 lb body-weight gain for early detection of cardiac decompensation. Few data support this common advice. The study aim was to determine whether a 5 lb weight gain in 1 week and signs and symptoms of HF increased risk for unplanned physician or emergency department (ED) visits or hospital admission in rural HF patients.

Methods and results

This was a secondary analysis of a randomized trial. Patients tracked body weight and HF symptoms using diaries. We included patients adherent to daily diaries >50% over 24 months (N = 119). Mean age was 69 ± 11 years; 77% (65) were male, and 67% completed diaries. A weight gain of 5 lb over 7 days was associated with a greater risk for ED visits but not hospital admission [hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.04, 1.08; P < 0.0001 vs. HR 1.01, 95% CI 0.88, 1.16; P = 0.79]. Increased dyspnoea over 7 days was associated with a greater risk of ED visits and hospital admissions (HR 9.64, 95% CI 3.68, 25.22; P < 0.0001 vs. HR 5.89, 95% CI 1.73, 20.04; P = 0.01). Higher diary adherence was associated with older age, non-sedentary behaviour, lower depression, and HF knowledge.

Conclusions

Heart failure patients are counselled to observe for body-weight gain. Our data do not support that a 5 lb weight gain was associated with hospital admission. Dyspnoea was a better predictor of ED visits and hospital admissions. Daily tracking of dyspnoea symptoms may be an important adjunct to daily weight to prevent hospitalization.