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The Association of Perceived Control to Adherence in Heart Failure
The 12th Annual Scientific Meeting
HFSA
S101
Clinical Care/Management Strategies 327 Influence of Advance Practice Nurse and Dedicated Heart Failure Clinics on Delivery of Recommended Therapies in Outpatient Cardiology Practices: IMPROVE HF Findings N.M. Albert1, G.C. Fonarow2, C.W. Yancy3, A. Curtis4, W. Gattis Stough5, M. Gheorghiade6, J.T. Heywood7, M.L. McBride8, M. Mehra9, C. O’Connor10, D. Reynolds11, M.N. Walsh12; 1CCF; 2UCLA; 3Baylor; 4USF; 5Campbell U; 6 Northwestern; 7Scripps; 8Outcome; 9U MD; 10DCRI; 11U OK Health Sci; 12The Care Group Introduction: National guidelines recommend HF disease management programs and a team model of care to facilitate adherence to evidence-based practices. The effect of HF-devoted advance practice nurses or physician assistants (APN/PA) and dedicated HF clinics on delivery of recommended HF therapies in cardiology outpatient settings is not well understood. Methods: IMPROVE HF is a prospective cohort study that characterizes current management of outpatients with chronic systolic HF (EF # 35%) and evaluates the effect of practice-specific process improvement interventions on adherence to evidence-based HF therapies. Documented use of HF-specific APN/PA and dedicated HF clinics were assessed by survey; quality metrics were recorded by trained chart abstractors at each practice. Results: IMPROVE HF enrolled 167 cardiology practices with data abstracted for 15,381 patients. Of practices, 70.6% had $0.5 dedicated APN/PA and 41.3% had dedicated HF clinics. Presence of dedicated HF clinics (3/7 measures), but not APN/PA (0/7 measures), was associated with increased quality of care. After controlling for other site characteristics, use of APN/PA and HF clinic were not independent predictors of teh composite score, P 5 0.22 and 0.09 or all-or-none care score; P 5 0.10 and 0.16, respectively. Conclusions: Cardiology practices vary in use of multidisciplinary providers and dedicated HF clinics. These findings suggest a benefit on certain quality measures but do not convincingly support an independent benefit of APN/PA or HF clinics on composite quality measures at baseline. Further investigation of practice components needed to improve quality is warranted.
*Inclusion requires documentation of NYHA class. Eligible patients for these measures may be substantially larger and conformity rates lower due to incomplete documentation of NYHA class.
328 The Association of Perceived Control to Adherence in Heart Failure Martha J. Biddle1, Debra K. Moser1, Terry A. Lennie1, Misook L. Chung1; 1College of Nursing, University of Kentucky, Lexington, KY Introduction: Heart failure (HF) self-care behaviors require adherence to multiple aspects of the medical regimen, including the need to monitor and manage symptoms, restrict dietary intake of sodium, perform regular physical activity and take medication as prescribed. Adherence is problematic in patients with HF. Although limited, prior studies suggest that perceived control may influence adherence. Perceived control is important because it is a potential target for interventions to improve adherence and HF outcomes. The purpose of this study was to examine the relationship between levels of perceived control and self-reported adherence behaviors in HF patients. Methods: Using a comparative design, we studied 514 HF patients (mean age 5 63 6 12; 46% female) who were recruited from outpatient clinic settings at two community hospitals and an academic medical center in central Kentucky. Patients with a confirmed HF diagnosis on a stable medication regimen were included in this study. Patients’ levels of perceived control and adherence behaviors were assessed by self-reported questionnaires (Control Attitude Index [CAI] and the Medical Outcomes Study Specific Adherence Scale [MOS ADS] respectively). Patients were divided into two groups based on the 75th percentile of the CAI score. Associations between variables were analyzed using t tests and multiple regression analyses. Results: Patients with higher compared to lower perceived control reported better overall adherence (p!.001). With regard to individual behaviors, patients with higher perceived control reported better adherence to exercise (p5.001), following a low salt diet (p5.03), following a low fat diet (p5.05), taking prescribed medications (p5.004), and daily weight monitoring (p5.02), than patients with lower perceived control. Using regression analysis, we found higher levels of perceived control were associated with greater self reported adherence (p!.001.) even after controlling
for demographic (age, gender), clinical (NYHA, ejection fraction, functional status), and psychological (depressive symptoms, anxiety) characteristics, In addition to higher perceived control (p5 .03), older age (p5.001), and lower depression score (p5.05) predicted better adherence. Conclusions: These findings suggest that interventions should focus on increasing levels of perceived control in heart failure patients to improve adherence behaviors.
329 An Algorithm Based Approach to Determining Target Volume Removal in Acute Heart Failure Tracy Stephens1, Cheryl Bartone2, Santosh G. Menon2, Eugene S. Chung2; 1 Medicine, The Christ Hospital, Cincinnati, OH; 2The Ohio Heart and Vascular Center, Cincinnati, OH Background: Acute decompensated heart failure (ADHF) is a common reason for hospitalization, associated with poor outcomes, with little evidence based support of optimal treatment strategies. Assessing the optimal fluid removal target in the course of routine clinical care remains difficult and a standardized method of estimating a target volume/weight loss would be helpful. Methods: We hypothesized that major determinants of optimal target weight loss are baseline weight, renal function, and degree of volume overload. These factors were incorporated into an algorithm for determining the target weight to be removed. Combining these characteristics yielded 45 categories of patients each of whom were assigned a target weight loss.
This algorithm was then tested in 47 patients admitted with ADHF. Upon admission, the HF specialist determined target weight loss (MD), was compared with the algorithm determined target weight loss (algo). The patients were followed to discharge and clinical parameters collected. Results: All 47 patients were discharged from the hospital. Mean length of stay was 5.9 days. Mean BNP decreased from 1124 to 747 (p 5 0.0000021), while BUN and creatinine remained unchanged (40.3 to 42.5 mg/dl, p 5 0.22, and 1.66 to 1.68 mg/dl, p 5 0.75, respectively). Mean values for target weight loss were: MD: 13.6 lbs, algo: 12.9 lbs, and actual weight loss 13.9 lbs. There was good correlation between the MD and algo values (r 5 0.9, p ! 0.001).
Conclusion: In an attempt to assist physicians caring for those with ADHF, we have developed an algorithm to estimate an optimal target for weight loss during the hospitalization. Although validation in a larger population of patients is required, an accurate method for estimating target volume removal would be clinically valuable.
HFSA
S101
Clinical Care/Management Strategies 327 Influence of Advance Practice Nurse and Dedicated Heart Failure Clinics on Delivery of Recommended Therapies in Outpatient Cardiology Practices: IMPROVE HF Findings N.M. Albert1, G.C. Fonarow2, C.W. Yancy3, A. Curtis4, W. Gattis Stough5, M. Gheorghiade6, J.T. Heywood7, M.L. McBride8, M. Mehra9, C. O’Connor10, D. Reynolds11, M.N. Walsh12; 1CCF; 2UCLA; 3Baylor; 4USF; 5Campbell U; 6 Northwestern; 7Scripps; 8Outcome; 9U MD; 10DCRI; 11U OK Health Sci; 12The Care Group Introduction: National guidelines recommend HF disease management programs and a team model of care to facilitate adherence to evidence-based practices. The effect of HF-devoted advance practice nurses or physician assistants (APN/PA) and dedicated HF clinics on delivery of recommended HF therapies in cardiology outpatient settings is not well understood. Methods: IMPROVE HF is a prospective cohort study that characterizes current management of outpatients with chronic systolic HF (EF # 35%) and evaluates the effect of practice-specific process improvement interventions on adherence to evidence-based HF therapies. Documented use of HF-specific APN/PA and dedicated HF clinics were assessed by survey; quality metrics were recorded by trained chart abstractors at each practice. Results: IMPROVE HF enrolled 167 cardiology practices with data abstracted for 15,381 patients. Of practices, 70.6% had $0.5 dedicated APN/PA and 41.3% had dedicated HF clinics. Presence of dedicated HF clinics (3/7 measures), but not APN/PA (0/7 measures), was associated with increased quality of care. After controlling for other site characteristics, use of APN/PA and HF clinic were not independent predictors of teh composite score, P 5 0.22 and 0.09 or all-or-none care score; P 5 0.10 and 0.16, respectively. Conclusions: Cardiology practices vary in use of multidisciplinary providers and dedicated HF clinics. These findings suggest a benefit on certain quality measures but do not convincingly support an independent benefit of APN/PA or HF clinics on composite quality measures at baseline. Further investigation of practice components needed to improve quality is warranted.
*Inclusion requires documentation of NYHA class. Eligible patients for these measures may be substantially larger and conformity rates lower due to incomplete documentation of NYHA class.
328 The Association of Perceived Control to Adherence in Heart Failure Martha J. Biddle1, Debra K. Moser1, Terry A. Lennie1, Misook L. Chung1; 1College of Nursing, University of Kentucky, Lexington, KY Introduction: Heart failure (HF) self-care behaviors require adherence to multiple aspects of the medical regimen, including the need to monitor and manage symptoms, restrict dietary intake of sodium, perform regular physical activity and take medication as prescribed. Adherence is problematic in patients with HF. Although limited, prior studies suggest that perceived control may influence adherence. Perceived control is important because it is a potential target for interventions to improve adherence and HF outcomes. The purpose of this study was to examine the relationship between levels of perceived control and self-reported adherence behaviors in HF patients. Methods: Using a comparative design, we studied 514 HF patients (mean age 5 63 6 12; 46% female) who were recruited from outpatient clinic settings at two community hospitals and an academic medical center in central Kentucky. Patients with a confirmed HF diagnosis on a stable medication regimen were included in this study. Patients’ levels of perceived control and adherence behaviors were assessed by self-reported questionnaires (Control Attitude Index [CAI] and the Medical Outcomes Study Specific Adherence Scale [MOS ADS] respectively). Patients were divided into two groups based on the 75th percentile of the CAI score. Associations between variables were analyzed using t tests and multiple regression analyses. Results: Patients with higher compared to lower perceived control reported better overall adherence (p!.001). With regard to individual behaviors, patients with higher perceived control reported better adherence to exercise (p5.001), following a low salt diet (p5.03), following a low fat diet (p5.05), taking prescribed medications (p5.004), and daily weight monitoring (p5.02), than patients with lower perceived control. Using regression analysis, we found higher levels of perceived control were associated with greater self reported adherence (p!.001.) even after controlling
for demographic (age, gender), clinical (NYHA, ejection fraction, functional status), and psychological (depressive symptoms, anxiety) characteristics, In addition to higher perceived control (p5 .03), older age (p5.001), and lower depression score (p5.05) predicted better adherence. Conclusions: These findings suggest that interventions should focus on increasing levels of perceived control in heart failure patients to improve adherence behaviors.
329 An Algorithm Based Approach to Determining Target Volume Removal in Acute Heart Failure Tracy Stephens1, Cheryl Bartone2, Santosh G. Menon2, Eugene S. Chung2; 1 Medicine, The Christ Hospital, Cincinnati, OH; 2The Ohio Heart and Vascular Center, Cincinnati, OH Background: Acute decompensated heart failure (ADHF) is a common reason for hospitalization, associated with poor outcomes, with little evidence based support of optimal treatment strategies. Assessing the optimal fluid removal target in the course of routine clinical care remains difficult and a standardized method of estimating a target volume/weight loss would be helpful. Methods: We hypothesized that major determinants of optimal target weight loss are baseline weight, renal function, and degree of volume overload. These factors were incorporated into an algorithm for determining the target weight to be removed. Combining these characteristics yielded 45 categories of patients each of whom were assigned a target weight loss.
This algorithm was then tested in 47 patients admitted with ADHF. Upon admission, the HF specialist determined target weight loss (MD), was compared with the algorithm determined target weight loss (algo). The patients were followed to discharge and clinical parameters collected. Results: All 47 patients were discharged from the hospital. Mean length of stay was 5.9 days. Mean BNP decreased from 1124 to 747 (p 5 0.0000021), while BUN and creatinine remained unchanged (40.3 to 42.5 mg/dl, p 5 0.22, and 1.66 to 1.68 mg/dl, p 5 0.75, respectively). Mean values for target weight loss were: MD: 13.6 lbs, algo: 12.9 lbs, and actual weight loss 13.9 lbs. There was good correlation between the MD and algo values (r 5 0.9, p ! 0.001).
Conclusion: In an attempt to assist physicians caring for those with ADHF, we have developed an algorithm to estimate an optimal target for weight loss during the hospitalization. Although validation in a larger population of patients is required, an accurate method for estimating target volume removal would be clinically valuable.