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Debra K Moser
Health Promotion Strategies to PreventHealth Promotion Strategies to Prevent Heart Failure Rehospitalization
FINANCIAL DISCLOSURE: none
UNLABELED/UNAPPROVED USES DISCLOSURE: none
Health Promotion Strategies toStrategies to
Prevent Heart FailureRehospitalizationRehospitalization
Debra K. Moser, DNSc, RN, FAANf G C fProfessor and Gill Chair of Nursing
University of Kentucky, College of NursingDirector, Center for Biobehavioral Research in Self-
Care of Cardiopulmonary [email protected]
Funding:NIH NINR R01 NR08567 RO1 NR007952 dNIH, NINR R01 NR08567, RO1 NR007952, and Center grant P20NR010679
American Association of Critical Care N rsesAmerican Association of Critical Care Nurses Philips Medical Systems Outcomes for Clinical Excellence Research GrantExcellence Research Grant
Heart failure incidence and prevalence i i i l d i d l d dincreasing (tripled) in developed and developing countries
Mainly among women in U SMainly among women in U.S.McCullough et al., 2002; Mendez & Cowie, 2001; Roger et al. JAMA 2004;292:344; AHA, 2009; Butler et al., 2008
R h it li ti t i hi hRehospitalization rate remains highIncreasing in women at a faster rate than men
Zannad et al., 1999; Stewart et al., 2001; Koelling et al., 2004, 999; , ; g , 4
Mortality still extremeRates increasing in women and elderlyg y
Stewart et al., 2001; Cleland et al., 1999; Koelling et al., 2004
27% readmitted within 90 days7% ead tted t 90 days29% of these are readmitted more than once6‐month readmission rates are 44%‐47%.In patients aged over 65 years who have three or more risk predictors, 6‐month all‐cause readmission is nearly 60%readmission is nearly 60%
~ 70% of costs associated with HF attributable to hospitalizationsatt butab e to osp ta at o s~ 50%‐66% of hospitalizations preventable
O’Connell, 2000; Starling, 1998; Krumholz et al, 1997; Massie & Shah, 1996
Hospitalizations rates increasingRates increase sharply with agep y gMore than 80% of hospitalizations among patients ≥ 65 years p 5 y
Hospitalizations resulting in transfers to long‐term care facilities increasing
Fang et al., 2008
700
s
400
500
600
Thou
sand
s
200
300
400
char
ges
in T
0
100
79 80 85 90 95 00 06
Dis
c
79 80 85 90 95 00 06
Years
Male Female
Hospital discharges for heart failure by sex.Hospital discharges for heart failure by sex.(United States: 1979(United States: 1979‐‐2006). 2006). Source: NHDS/NCHS and NHLBISource: NHDS/NCHS and NHLBI..
A i H t A i ti H t d St k St ti ti 2010American Heart Association Heart and Stroke Statistics, 2010
American Journal of Health Promotion, 1986f , 9“The science and art of helping people change their lifestyle to move toward a state of optimal y phealth" Health Promotion is "aimed at informing, ginfluencing and assisting both individuals and organizations so that they will accept more
ibili d b i i responsibility and be more active in matters affecting mental and physical health
Commonly viewed as simply education and promotion of self carepromotion of self‐careUltimately ineffective without multi‐
d hpronged approaches
Mutual Aid
Self‐Care Healthy EnvironmentsEnvironments
Health Promotion
Epp, 1986, Canadian Minister of National Health & Welfare
Fiscal Measures Organizational Change
Legislation Community Developmentp
Health Promotion
Self‐Care
Spontaneous Local Action
Against Health Promotion gHazards
Local ActionsCommunity DevelopmentOrganization ChangeOrganization ChangeFiscal MeasuresL i l tiLegislationSelf‐Care
Local ActionsLocal patient and family efforts (web pages)
No evidence of effectivenessCommunity Development & Organization Change
H f il di Heart failure disease managementClear benefit for reduction of rehospitalization
Professional organization initiatives, e.g. Get with the Guidelines± evidence± evidence
Fiscal MeasuresChange in Medicare reimbursement
No evidence of effectiveness (yet)No evidence of effectiveness (yet)Legislation
noneSelf‐CareSelf‐Care
S lf i h h b i di id l Self‐care is the process whereby individuals and/or their informal caregivers perform the daily activities that serve to maintain health daily activities that serve to maintain health and well‐being, prevent illness, manage chronic illness, or restore healthchronic illness, or restore healthprevention or early detection of health problemsbetter overall health and quality of lifebetter overall health and quality of lifeimproved clinical outcomes and reduced healthcare costs
Deakin, McShane, Cade, & Williams, 2005; Jovicic, Holroyd‐Leduc, & Straus, 2006.
A naturalistic decision‐A naturalistic decisionmaking process involving…
the choice of behaviors that maintain physiologic p y gstability (self‐care maintenance)th t the response to symptoms when they occur (self‐care fmanagement)
Riegel, Carlson, Moser, Sebern, Hicks, Roland, 2004, J Card Fail
Most heart failure care done by patients and their families at home;in fact, community dwelling individuals can’t avoid self‐care
Medication takingMedication takingTake, don’t stop, identify side effects and differentiate them from other effectsdifferentiate them from other effectsAverage of 9‐13 pills per dayComplex instructions for someComplex instructions for some
Following a low sodium dietF ll i di b ti di t l f t di t thFollowing a diabetic diet, low fat diet, othersKnow levels, know how to calculate, shop, cook follow when not at home adapt family cook, follow when not at home, adapt family customs
Monitoring symptoms of worsening heart failureD il i hi d h t t d t iti Daily weighing and what to do; symptom recognition and what to do; which symptoms are important, which are not; when to act with symptom escalation; y p
Physical activityHow much, how, what if never done, rest?How much, how, what if never done, rest?
Alcohol and smoking restriction
Manage co‐morbidities, emotional problems, cognitive impairment, functional impairment,
i l i l ti l k f fi i l social isolation, lack of financial resources Flu shots, other prevention activitiesNegotiate the health care systemKeep appointments, transitions, multiple care
idprovidersAverage Medicare HF patient sees 15 providers/year; 50% prescribe medsproviders/year; 50% prescribe meds
Page et al., 2007, Circulation; Bayliss et al., 2007, Chronic Illness
70% of costs Factors Contributing to HF Hospitalizations~ 70% of costs associated with HF attributable to
i d t d th
iatrogenesis
Factors Contributing to HF Hospitalizations
hospitalizations~ 50%‐66% of h it li ti h h
social issues
inadequate drug therapy
hospitalizations preventable
most of these HTN
arrhythmias
ost o t eseattributable to failed self‐care 0% 20% 40% 60% 80%
poor self‐care
Ghali JK et al. Arch Intern Med 1988;148:2013-6.
O’Connell, 2000; Starling, 1998; Krumholz et al, 1997; Massie & Shah, 1996; Vinson 1990; Bennett et al., 1998; Michelson et al., 1998; Morgan et al., 2006; Hope et al., 2004; Opasich et al., 2001; Tsuyuki et al., 2001; Jovicic, Holroyd‐Leduc, & Straus, 2006.
Ghali JK et al. Arch Intern Med 1988;148:2013 6.
Lee, Moser, Lennie, Riegel, 2010
Adherence to prescribed prescribed medications produces better outcomes in patients with heart failure
Wu, J.R., Moser, D.K., Chung, M.L., Lennie, T.A. Journal of Cardiac Failure 2008:14(3); 203‐10.
60
s
40
50
36.1
of p
atient
s
20
30
16.320.4
6rcen
tage o
109.5 11.6Pe
0
all of the time
most of time good bit some none
60
69.6
50
60
dos
es
30
40 30.4
entage of d
10
20
Perce
0
≥ 89% <89%
Objectively Measured Adherence
6049.7
adherent nonadherent
adherent Over‐confident non‐adherers: thought theywere more adherent thanthey were
Realistic adherers:accurately assessedtheir adherence
40
50
of patient
s Patient‐AssessedAdherence
nonadherent
Realistic non‐adherers: accurately assessed their non‐adherence
Under‐confident adherers: adherent, thought they were not
20
30
14.3 15 12 9rcen
tage o
10
4 3 12.9
Per
0
under‐confident adherer
realistic non‐adherer
over‐confident nonadherer
realistic adherer
Event‐Free Survival Compared by Groupsurviva
l
under‐confident adherers, 15.6%
li i dh %
ulative Su realistic adherers, 54.1%
Cumu
realistic non‐adherers, 16.3%
overconfident non‐adherers, 14%
Days Follow‐up
nicity
Aging StatusPsychosocial Status
r, ra
ce/eth
n
g g
Cognitive StatusSensory ImpairmentSymptom Status
Psychosocial Status
DepressionAnxiety
d l
age
, gen
de
Symptom StatusChanging Symptom Intensity
Functional StatusComorbidities
Perceived ControlSocial Support/IsolationSocioeconomic StatusEducational Level
nd Fac
tors: Educational Level
Health Literacy
d Bac
kgroun
Heart Failure Self‐Care
e Co
urse and
Heart Failure Self CareSelf‐Care Maintenance & Management
Life
Rehospitalization & Mortality
Quality of LifeMoser & Watkins, 2008
HFHF CABGCABG MIMI Healthy Healthy EldersEldersEldersElders
% anxious% anxious 4242 3434 4242 1111
% depressed% depressed 6161 5151 5555 2929
CABG = coronary artery bypass grafting; HF = heart failure; MI = myocardial infarctionea t a u e; yoca d a a ct o
Moser et al., 2006
100 Depressed Non depressed
90
100
84
9085
93Depressed Non-depressed
nts
**
*
8081
84
of P
atie
n * *
60
70 66 68
rcen
tage
*
50
52Per
% Prescribed % Prescribed % % Days% Prescribed # Doses Taken
% Prescribed Doses Taken on Schedule
Therapeutic Coverage
% Days Correct #
Doses TakenMoser et al., 2007
Do patients understandwhat we teach?p90 million in U.S. lack basic health literacyStudy of English speaking patientsStudy of English‐speaking patients (AMA, 1998)
27% could not read their appointment slipsld d d h d il h i42% could not understand the details on their
prescription bottles
H f ilHeart failure38% of patients unable to read and understand
di i l b l i i i imedication labels → increase in ED visits
Hope et al., 2004
Cognitive impairment far more prevalent than recognizedg23‐53% in community‐dwelling HF patients >65 years
f d dOften undetected28.6% (12/42) HF patients living independently identified as impaired by 1 of 4 screening testsidentified as impaired by 1 of 4 screening tests
Cacciatore et al, 1998; DeGeest, et al 2003; Riegel et al, 2002; Zuccala et al; 1997
Electronic database search from 1966‐2006 for investigations of cognitive function in for investigations of cognitive function in heart failure22 controlled studies22 controlled studies2937 HF patients, 14,848 controlsOdds for cognitive impairment in HF = 1 62 Odds for cognitive impairment in HF = 1.62 (1.48‐1.79, p < 0.001)Characterized by: forgetfulness attention and Characterized by: forgetfulness, attention and memory problems, decreased concentration
Vogels et al., 2006
202 patients recently discharged from hospitalization for decompensated heart hospitalization for decompensated heart failure
75% had substantial symptom burden in prior 75 y p pweek70% NYHA class III or IV live alone live with someone
60
80
100
f pat
ient
s
Moser et al 200520
40
perc
ent o
f
Moser et al., 20050
I II III IVNew York Heart Association Functional Class
Lack of supportInadequate
livealoneandpoor*q
financespoorlivealone,notpoor
34% of 281 HF %patients lived alone
*Poor defined as <$15,000 annually
Most heart failure patients have numerous comorbiditiescomorbidities
HTN 78%, diabetes 46%, lung disease or asthma 24%
P i h i li d f HF b iPatients hospitalized for HF exacerbation
every patient had one or more comorbidities
Medicare sample of HF patients
% h d biditi40% had 5 or more comorbidities
Braunstein et al., 2003; Klapholz, 2004; Lien et al 2002
Expert at selfExpert at self‐‐care, 10%care, 10% Poor at selfPoor at self‐‐carecarepp ,,Able to describe their symptoms, link them to HF pathophysiology, and manage
Low HF knowledge and misconceptions
“If I t thi lt I t pathophysiology, and manage them
“I came to realize that salt retains fluid. I don’t feel good
“If I eat something salty, I try to flush it out of myself by drinking lots of water…”
L k kill t bl lf f g
when I retain fluid so we don’t cook with salt or use salt.”
Verbalize understanding of
Lack skill to problem‐solveNo action plan for managing symptomsg
treatments and their impactComprehensive understanding of medication regimen
“I didn’t know what to do… I waited to call the squad until it was almost too late.”
Bentley et al., 2005, Eur J Cardiovasc Nurs; Riegel et al., 2007, Nurs Res
Expert at selfExpert at self carecare Poor at selfPoor at self carecareExpert at selfExpert at self‐‐carecare Poor at selfPoor at self‐‐carecareSubstantially less daytime sleepiness
Daytime sleepinessImpaired memory, attention
Vigilance with self‐care“It is a routine..I feel like everyday my main
t ti i it ”
p y,and cognitive processing
“..the little things that I can’t figure out right now..”concentration is on it…”
Experience either with another family member or in themselves
figure out right now..
Depression“Sometimes you just get fed up that day was a themselves
Actively sought information about heart failure
up…that day was a downward spiral and I just ate everything I wanted..I just didn’t care ”didn t care..
Bentley et al., 2005, Eur J Cardiovasc Nurs Riegel et al., 2007, Nurs Res
Expert at selfExpert at self carecare Poor at selfPoor at self carecareExpert at selfExpert at self‐‐carecare Poor at selfPoor at self‐‐carecareGood family functioningEngaged family members
Poor family functioning/lack of a support persong g y
who know when to helpPatient: “..sometimes I’m just a noodle and need help with
Reported difficulty managing day to day tasks and feeling isolateda noodle and need help with
everything..”Daughter: “..when she is feeling lousy you really need
“At family parties, there was never anything for me to eat.”feeling lousy you really need
someone else to help…”
Bentley et al., 2005, Eur J Cardiovasc Nurs ; Riegel et al., 2007, Nurs Res
Suspect problems with HF self‐careSuspect problems with HF self‐careVery few patients are experts
Suspect misconceptions about basic conceptsp p pLook for factors that interfere with learning
Cognitive impairmentHealth literacy; education levelHealth literacy; education levelAnxiety
Look for factors that interfere with the willingness gor ability to engage in self‐care
Depression □ Functional impairmentSleep problems □ Sensory impairment Sleep problems □ Sensory impairment No social support □ Lack of financial resources
l d i b ffi iKnowledge is necessary but not sufficientBuild skill in self‐care
H t d l b l d h hi h d l di f dHow to read labels and choose high and low sodium foodsHow to remember to take medicines on time How to recognize and respond to symptoms g p y pWhen to call the providerHow to manage comorbiditiesHow to problem solveHow to talk to clinicians and navigate the healthcare systemy
Knowledge is necessary but not sufficientKnowledge is necessary but not sufficientBuild confidence in self‐care
Encourage shared decision‐makingE HF di tEncourage HF disease management
Overcome barriers to self‐careAssess for and treat depression and anxietyAssess for and treat depression and anxietyAssess for cognitive impairment, treat “treatable” causes, and social networkAssess for and treat sleep disordersAssess for and address health literacy problems
Engage family and other informal caregivers
Fiscal Measures Organizational Change
Legislation Community Developmentp
Health Promotion
Self‐Care
Spontaneous Local Action
Against Health Promotion gHazards