Shared Decision-Making in Cardiovascular Risk Factor Management: A Systematic Review and Meta-Analysis.

Importance: The effect of shared decision-making (SDM) and the extent of its use in interventions to improve cardiovascular risk remain unclear. Objective: To assess the extent to which SDM is used in interventions aimed to enhance the management of cardiovascular risk factors and to explore the association of SDM with decisional outcomes, cardiovascular risk factors, and health behaviors. Data Sources: For this systematic review and meta-analysis, a literature search was conducted in the Medline, CINAHL, Embase, Cochrane, Web of Science, Scopus, and ClinicalTrials.gov databases for articles published from inception to June 24, 2022, without language restrictions. Study Selection: Randomized clinical trials (RCTs) comparing SDM-based interventions with standard of care for cardiovascular risk factor management were included. Data Extraction and Synthesis: The systematic search resulted in 9365 references. Duplicates were removed, and 2 independent reviewers screened the trials (title, abstract, and full text) and extracted data. Data were pooled using a random-effects model. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Main Outcomes and Measures: Decisional outcomes, cardiovascular risk factor outcomes, and health behavioral outcomes. Results: This review included 57 RCTs with 88 578 patients and 1341 clinicians. A total of 59 articles were included, as 2 RCTs were reported twice. Nearly half of the studies (29 [49.2%]) tested interventions that targeted both patients and clinicians, and an equal number (29 [49.2%]) exclusively focused on patients. More than half (32 [54.2%]) focused on diabetes management, and one-quarter focused on multiple cardiovascular risk factors (14 [23.7%]). Most studies (35 [59.3%]) assessed cardiovascular risk factors and health behaviors as well as decisional outcomes. The quality of studies reviewed was low to fair. The SDM intervention was associated with a decrease of 4.21 points (95% CI, -8.21 to -0.21) in Decisional Conflict Scale scores (9 trials; I2 = 85.6%) and a decrease of 0.20% (95% CI, -0.39% to -0.01%) in hemoglobin A1c (HbA1c) levels (18 trials; I2 = 84.2%). Conclusions and Relevance: In this systematic review and meta-analysis of the current state of research on SDM interventions for cardiovascular risk management, there was a slight reduction in decisional conflict and an improvement in HbA1c levels with substantial heterogeneity. High-quality studies are needed to inform the use of SDM to improve cardiovascular risk management.

The Edmonton Symptom Assessment Scale in Heart Failure: A Systematic Review.

BACKGROUND: Heart failure is a troublesome condition with high healthcare utilization and cost. Most individuals with heart failure experience multiple symptoms including breathlessness, pain, depression, and anxiety. PURPOSE: The aim of this study was to review the literature describing the use of the Edmonton Symptom Assessment Scale to assess the burden of symptoms and the impact of symptoms on heart failure outcomes including quality of life and functional outcomes. METHODS: The search engines PubMed, Scopus, CINAHL, and Web of Science were searched from January 2001 to March 2020. A review of literature was undertaken using key terms "heart failure," "CHF," "cardiac failure," "heart decompensation," "myocardial failure," "Edmonton Symptom Assessment Scale". Hand searching of articles was also undertaken. RESULTS: The search resulted in 33 relevant articles, which were imported into Rayyan, a Web-based systematic review software program. We present synthesis of results of studies (1) using the Edmonton Symptom Assessment Scale as an assessment of symptom burden and (2) evaluating the impact of symptom burden on quality of life and functional status. CONCLUSION: This review highlighted the Edmonton Symptom Assessment Scale as a predictive instrument to identify symptom burden, symptom clusters, and symptom changes for patients living with heart failure. The clinical use of the Edmonton Symptom Assessment Scale may identify treatment priorities, promote self-management, inform the treatment plan, and advance effective therapeutic adjustments. The symptom burden in heart failure is high, and improving the symptom experience is an important focus of future healthcare interventions. The Edmonton Symptom Assessment Scale has utility in heart failure management due to psychometric properties and ease of administration. CLINICAL IMPLICATIONS: The Edmonton Symptom Assessment Scale may be useful in measuring patient-reported symptom burden in patients with heart failure in the clinical setting because it correlates well with other heart failure measures on quality of life and functional outcomes and provides useful information on symptom burden.

The use of clinical decision support in reducing readmissions for patients with heart failure: a quasi-experimental study.

BACKGROUND: Heart failure is a chronic, progressive condition which affects over six million Americans and 26 million people worldwide. Evidence-based guidelines, protocols, and decision-support tools are available to enhance the quality of care delivery but are not implemented consistently. AIMS: To examine the effect of clinical decision-making support during patient discharge on 30-day hospital readmission among patients admitted with heart failure and evaluate provider utilization and satisfaction of clinical decision support tool. DESIGN: A quasi-experimental study. METHODS: An intervention group of hospitalized patients (N = 55) with heart failure were provided the intervention over a 3-month period and compared to the pre-intervention comparison group (N = 109) of patients who did not receive the intervention. An evidence-based discharge checklist and a pocket guide was implemented by an advanced practice nurse to assist health providers with clinical decision making. Descriptive statistics among samples, 30-day readmission rates, and provider utilization and satisfaction were examined. RESULTS: Readmission rates slightly decreased (N = 109, 9.2% vs. N = 55, 9.1%) in the post-intervention period, but no significant difference. Heterogeneity between the two groups were minimal related to use of specific medications, age, length-of-stay and comorbidities. Descriptively, there was a significant difference the use of diuretics among each group (p = .002).The discharge checklist was used regularly by 67% of (N = 15) providers, and 93% expressed satisfaction with use. CONCLUSION: There was no significant reduction in 30-day readmission rates between both groups. However, a slight reduction was noted which indicates the need for further examination into how the use of checklists for clinical decision support can reduce readmissions. A well-designed evidence-based discharge plan remains a critical component of the patient discharge process. Advance practice nurses are uniquely qualified to implement evidence-based interventions that promote practice change among health care providers and improve health outcomes.

Religious Involvement, Depressive Symptoms, and Burden in Caregivers of Terminally Ill Patients.

Caring for terminally ill patients can be emotionally burdensome. Previous research has demonstrated that caregiving is associated with anxiety and depression. Research on caregivers of terminally ill patients is limited by retrospective studies with small samples. This study aimed to (1) describe religiosity, religious coping, and depressive symptoms in caregivers of persons with amyotrophic lateral sclerosis or advanced cancer; (2) examine the relationship between religiosity and depressive symptoms in caregivers of persons with amyotrophic lateral sclerosis or advanced cancer; (3) examine the relationship between religious coping and depressive symptoms in caregivers of persons with amyotrophic lateral sclerosis or advanced cancer. A descriptive exploratory design was used to analyze data from a larger 5-year National Institutes of Health-funded multisite randomized controlled trial (the TAILORED study). Nearly half of the caregivers screened positive for depressive symptoms, and negative religious coping was associated with higher depressive symptoms (P < .001). Spouse caregivers reported higher depressive symptoms than nonspouse caregivers. Many caregivers experienced depression, which was mitigated by positive religious coping.

Patient perspectives of a heart failure action plan: A qualitative study.

Individuals with heart failure (HF) have difficulty evaluating their symptoms, understanding when to seek health care, and implementing self-care activities. The purpose of this qualitative study was to inform the development of a heart failure action plan (HFAP) for individuals living with HF. This study used a prospective, descriptive qualitative design with a content analysis approach. The HFAP included clinical indicators of self-reported symptoms, adherence to medication regimen, and physiologic changes. Patients with HF reviewed the HFAP and provided their perceptions to assist in developing the action plan. Participants had a mean age of 65 years, predominately male (78%) and African American (89%). Comorbidities included hypertension, atrial fibrillation, chronic kidney disease, ischemic heart disease, valvular heart disease, and diabetes mellitus. Five thematic categories emerged: (1) Understanding of symptoms and symptom severity, (2) management of symptoms, (3) educational opportunities, (4) changes, and (5) satisfaction. Participants suggested adding content about exercise, diet, additional symptom management, and a compact portable HFAP. Participants provided their perceptions of the HFAP. Their feedback was instrumental in modifying the action plan for use in a broader HF patient population to assist patients in self-management, including the understanding of when to seek health care.

Rationale for targeted self-management strategies for breathlessness in heart failure.

To provide a conceptual rationale for targeted self-management strategies for breathlessness in chronic heart failure. Breathlessness is a defining symptom of chronic heart failure and is the primary cause for hospital readmissions and emergency room visits, resulting in extensive health care utilization. Chronic breathlessness, punctuated by acute physiological decompensation, is a sentinel symptom of the heart failure syndrome and often intensifies towards the end of life. Drawing upon evidence-based guidelines, physiological mechanisms and existing conceptual models for the management of breathlessness is proposed. Key elements of this model include adherence to evidence-based approaches (pharmacological and non-pharmacological management to optimize heart failure treatment), self-monitoring of symptoms, identification of modifiable factors (such as fluid overload), and targeted strategies for breathlessness including distraction and gas flow. Self-management is an essential component in heart failure management which could positively influences health outcomes and quality of life. Refining programs to focus on breathlessness may have the potential to reduce symptom burden and improve quality of life.

Oxygen use in chronic heart failure to relieve breathlessness: A systematic review.

To appraise published studies on the use of supplemental oxygen in chronic heart failure. Chronic breathlessness is a characterizing symptom of symptomatic heart failure resulting in substantial disability and healthcare utilization and is the primary reason for emergency room visits and hospitalizations. In spite of the variable evidence, oxygen therapy is commonly administered both acutely and chronically. Moreover, the role of oxygen therapy to relieve chronic breathlessness in heart failure is not well described, particularly in normoxemic or mild or intermittent hypoxemic states. In fact, several studies have shown the detrimental effects of oxygen therapy with normal oxygen saturation levels. A systematic review using PRISMA guidelines. Four databases PubMed, Embase, CINAHL, and Web of Science were systematically searched from January 2001 to January 2019 investigating the use of oxygen in heart failure. Duplicate articles were removed from the review. Titles and abstracts were screened for inclusion and exclusion criteria. The remaining full-text articles were reviewed and hand-searched for additional references. The quality of the full-text articles was assessed using standardized critical appraisal instruments by the Joanna Briggs Institute. A total of 11 studies, including three intervention and eight non-interventions studies, were included in this review from 1072 non-duplicated records retrieved. Sample size ranged from 4 to 5862. In spite of common usage, this review suggests that there are scant data available to justify the use of oxygen in individuals with non-hypoxemic chronic heart failure and chronic breathlessness.

Heart failure and social determinants of health in Thailand: An integrative review.

BACKGROUND: Heart failure is a highly burdensome syndrome and is rapidly increasing in prevalence in low and middle-income countries and outcomes are influenced at the level of the patient, provider and health system. Understanding heart failure beyond a biomedical perspective and the relationship between health outcomes and social determinants of health is critical for informing policy development and improving health outcomes. AIM: To identify the social determinants of health for improving health outcomes for individuals with heart failure in Thailand. METHOD: This integrative review included studies published between January 1, 2008, and March 31, 2016 in both the Thai and English language identified through searching Scopus, PubMed, and CINAHL. RESULTS: Six experimental, eight descriptive and two qualitative studies were identified met the inclusion and exclusion criteria. The majority of study participants were elderly, female, had low-education and income levels, were participating in a universal coverage scheme and living in a rural setting. All interventions were delivered at the level of the individual, focusing on education to improve knowledge, self-care, and functional status. Findings showed an improvement in health outcomes which were moderated by social determinants of health such as gender and income. CONCLUSION: As the burden of heart failure increases in Thailand and other emerging economies, developing culturally appropriate, affordable and acceptable models of intervention considering social determinants of health is necessary.

Global service learning and health systems strengthening: An integrative literature review.

INTRODUCTION: The sustainability of many global interventions, in the absence of adequate local financial and human resources to sustain them in the long term, is questioned. In response, there has been a shift in focus among global health actors towards the strengthening of local health systems via global service learning to effectively, efficiently and sustainably deliver healthcare and build capacity. There has been considerable research examining the benefits of global service learning experiences for students, but limited research has been conducted to determine the impact that health sciences global service learning experiences are having on the host country health systems. MAIN TEXT: An integrative review of the literature was conducted to examine the linkages between global service-learning and health systems strengthening. A comprehensive search of international literature from 2005 to 2017 in PubMed, CINAHL, Embase, ERIC, Scopus and Web of Science databases was conducted. The search was limited to peer-reviewed articles published in English language. Thematic analysis revealed three key themes: a dominant service-LEARNING typology, a unidirectional pattern from high-income to low and middle-income countries, and the preeminence of the nursing discipline in global service learning. There was limited evidence on sustainability and health systems strengthening. CONCLUSIONS: The healthcare workforce of the future is willing to meet the challenges facing health systems across the globe. Global service-learning has yet to be examined in the context of health systems strengthening and particularly within a context of reciprocity. The onus is on higher education institutions in high-income countries to develop and deliver evidence-based global service-learning that is beneficial and engaging for students while most effectively meeting the need of the global community.