Caregiver status: a simple marker to identify cardiac surgery patients at risk for longer postoperative length of stay, rehospitalization, or death.

BACKGROUND: Patients who have undergone cardiac surgery, especially those with greater comorbidities, may be cared for by family members or paid aides. OBJECTIVE: The purpose of this study was to evaluate the association between having a caregiver among patients who underwent cardiac surgery and clinical outcomes at 1 year. We hypothesized that patients with a caregiver would have longer lengths of stay and higher rehospitalization or death rates 1 year after surgery. METHODS: We studied 665 patients consecutively admitted for cardiac surgery as part of the Family Cardiac Caregiver Investigation To Evaluate Outcomes sponsored by the National Heart, Lung, and Blood Institute. The participants (mean age, 65 years; women, 35%; racial/ethnic minorities, 21%) completed an interviewer-assisted questionnaire to determine caregiver status. Outcomes were documented by a hospital-based information system; demographics/comorbidities, by electronic records. Associations between having a caregiver and outcomes were evaluated by logistic regression, adjusted for demographic and comorbid conditions. RESULTS: At baseline, 28% of the patients (n = 183) had a caregiver (8%, paid; 20%, informal only). Having a caregiver was associated with longer (>7 days) postoperative length of stay in univariate analysis among the patients with paid (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.57-5.74) or informal (OR, 1.55; 95% CI, 1.04-2.31) caregivers versus none; the association remained significant for the patients with paid (OR, 2.13; 95% CI, 1.00-4.55) but not with informal (OR, 1.12; 95% CI, 0.70-1.80) caregivers after adjustment. Having a paid caregiver was significantly associated with rehospitalization/death at 1 year in univariate analysis (OR, 2.09; 95% CI, 1.18-3.69); having an informal caregiver was not (OR, 1.39; 95% CI, 0.94-2.06). Increased odds of rehospitalization/death associated with having a paid caregiver attenuated after adjustment (OR, 1.39; 95% CI, 0.74-2.62). CONCLUSIONS: The patients who underwent cardiac surgery who had a paid caregiver had a significantly longer length of stay independent of comorbidity. The increased risk of rehospitalization/death associated with having a paid caregiver was explained by demographics and comorbidity. These data suggest that caregiver status assessment may be a simple method to identify cardiac surgery patients at increased risk for adverse clinical outcomes.

Effect of an intervention to improve the cardiovascular health of family members of patients with coronary artery disease: a randomized trial.

BACKGROUND: Family members of patients with coronary artery disease (CAD) have higher risk of vascular events. We conducted a trial to determine if a family heart-health intervention could reduce their risk of CAD. METHODS: We assessed coronary risk factors and randomized 426 family members of patients with CAD to a family heart-health intervention (n = 211) or control (n = 215). The intervention included feedback about risk factors, assistance with goal setting and counselling from health educators for 12 months. Reports were sent to the primary care physicians of patients whose lipid levels and blood pressure exceeded threshold values. All participants received printed materials about smoking cessation, healthy eating, weight management and physical activity; the control group received only these materials. The main outcomes (ratio of total cholesterol to high-density lipoprotein [HDL] cholesterol; physical activity; fruit and vegetable consumption) were assessed at 3 and 12 months. We examined group and time effects using mixed models analyses with the baseline values as covariates. The secondary outcomes were plasma lipid levels (total cholesterol, low-density lipoprotein cholesterol, HDL cholesterol and triglycerides); glucose level; blood pressure; smoking status; waist circumference; body mass index; and the use of blood pressure, lipid-lowering and smoking cessation medications. RESULTS: We found no effect of the intervention on the ratio of total cholesterol to HDL cholesterol. However, participants in the intervention group reported consuming more fruit and vegetables (1.2 servings per day more after 3 mo and 0.8 servings at 12 mo; p < 0.001). There was a significant group by time interaction for physical activity (p = 0.03). At 3 months, those in the intervention group reported 65.8 more minutes of physical activity per week (95% confidence interval [CI] 47.0-84.7 min). At 12 months, participants in the intervention group reported 23.9 more minutes each week (95% CI 3.9-44.0 min). INTERPRETATION: A health educator-led heart-health intervention did not improve the ratio of total cholesterol to HDL cholesterol but did increase reported physical activity and fruit and vegetable consumption among family members of patients with CAD. Hospitalization of a spouse, sibling or parent is an opportunity to improve cardiovascular health among other family members. TRIAL REGISTRATION: clinicaltrials.gov, no NCT00552591.

Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey.

BACKGROUND: The purpose of this study was to evaluate trends in awareness of cardiovascular disease (CVD) risk among women between 1997 and 2012 by racial/ethnic and age groups, as well as knowledge of CVD symptoms and preventive behaviors/barriers. METHODS AND RESULTS: A study of awareness of CVD was conducted by the American Heart Association in 2012 among US women >25 years of age identified through random-digit dialing (n=1205) and Harris Poll Online (n=1227), similar to prior American Heart Association national surveys. Standardized questions on awareness were given to all women; additional questions about preventive behaviors/barriers were given online. Data were weighted, and results were compared with triennial surveys since 1997. Between 1997 and 2012, the rate of awareness of CVD as the leading cause of death nearly doubled (56% versus 30%; P<0.001). The rate of awareness among black and Hispanic women in 2012 (36% and 34%, respectively) was similar to that of white women in 1997 (33%). In 1997, women were more likely to cite cancer than CVD as the leading killer (35% versus 30%), but in 2012, the trend reversed (24% versus 56%). Awareness of atypical symptoms of CVD has improved since 1997 but remains low. The most common reasons why women took preventive action were to improve health and to feel better, not to live longer. CONCLUSIONS: Awareness of CVD among women has improved in the past 15 years, but a significant racial/ethnic minority gap persists. Continued effort is needed to reach at-risk populations. These data should inform public health campaigns to focus on evidenced-based strategies to prevent CVD and to help target messages that resonate and motivate women to take action.

Caregiver burden and nonachievement of healthy lifestyle behaviors among family caregivers of cardiovascular disease patients.

PURPOSE: To determine whether caregiver burdens are associated with lifestyle behaviors 1 year following the hospitalization of a family member with cardiovascular disease (CVD). DESIGN: Prospective follow-up study of National Heart Lung and Blood Institute sponsored Family Intervention Trial for Heart Health participants. SETTING: Hospital-based recruitment/baseline visit with 1-year follow-up. SUBJECTS: Family members of hospitalized CVD patients (N  =  423; 67% female; 36% racial/ethnic minority; mean age 49 years). MEASURES: Systematic evaluation at 1 year to determine heart-healthy diet (defined as <10% kcal from saturated fat; Block 98 Food Frequency Questionnaire) and physical activity (defined as ≥4 d/wk; Behavioral Risk Factor Surveillance System Survey) behaviors and caregiver burdens (five domains: employment, financial, physical, social, and time; Caregiver Strain Questionnaire). ANALYSIS: Logistic regression adjusted for covariates. RESULTS: Heart-healthy diet was less frequent among caregivers citing feeling overwhelmed (odds ratio [OR]  =  .50; 95% confidence interval [CI]  =  .26-.97), sleep disturbance (OR  =  .51; 95% CI  =  .27-.96), financial strain (OR  =  .41; 95% CI  =  .20-.86), upsetting behavior (OR  =  .48; 95% CI  =  .25-.92), and/or time demands (OR  =  .47; 95% CI  =  .26-.85) as burdens. Physical activity was less frequent among caregivers reporting financial strain (OR  =  .32; 95% CI  =  .13-.81) or upsetting patient behavior (OR  =  .33; 95% CI  =  .15-.76) as burdens. The most commonly cited caregiver burdens included changes in personal plans (39%), time demands (38%), and sleep disturbance (30%). CONCLUSION: Caregiver burdens were associated with nonachievement of heart-healthy diet and physical activity behaviors among family caregivers 1 year after patient discharge. When developing heart-health promotion interventions, caregiver burden should be considered as a possible barrier to prevention among family members of CVD patients.

Patterns of caregiving among patients hospitalized with cardiovascular disease.

BACKGROUND AND OBJECTIVES: Cardiac caregivers may represent a novel low-cost strategy to improve patient adherence to medical follow-up and guidelines and, ultimately, patient outcomes. Prior work on caregiving has been conducted primarily in mental health and cancer research; few data have systematically evaluated caregivers of cardiac patients. The purpose of this study was to evaluate the patterns of caregiving and characteristics of caregivers among hospitalized patients with cardiovascular disease (CVD) to assess disparities in caregiver burden and to determine the potential for caregivers to impact clinical outcomes. SUBJECTS AND METHODS: Consecutive patients admitted to the cardiovascular service line at a university medical center during an 11-month period were included in the Family Cardiac Caregiver Investigation To Evaluate Outcomes (FIT-O) study. Patients (n=4500; 59% white, 62% male, 93% participation rate) completed a standardized interviewer-assisted questionnaire in English or Spanish regarding assistance with medical care, daily activities, and medications in the past year and plans for posthospitalization. In univariate and multiple variable analyses, caregivers were categorized as either paid/professional (eg, nurse/home aide) or nonpaid (eg, family member/friend). RESULTS AND CONCLUSIONS: Among CVD patients, 13% planned to have a paid caregiver and 51% a nonpaid caregiver at discharge. Planned paid caregiving was more prevalent among racial/ethnic minority versus white patients (odds ratio, 1.5; 95% confidence interval, 1.2-1.8); planned nonpaid caregiving prevalence did not differ by race/ethnicity. Most nonpaid caregivers were female (78%). Patients who had nonpaid caregivers in the year prior to hospitalization (28%) reported grocery shopping/meal preparation (32%), transport to/arranging doctor visits (30%), and medication adherence/medical needs (25%) as top tasks caregivers assisted with. Following hospitalization, a majority of patients expect nonpaid caregivers, primarily women, to assist with tasks that have the potential to improve CVD outcomes such as medical follow-up, medication adherence, and nutrition, suggesting that these are important targets for caregiver education.

Does stage of change modify the effectiveness of an educational intervention to improve diet among family members of hospitalized cardiovascular disease patients?

OBJECTIVE: The purpose of this study was to evaluate whether effectiveness of a special intervention to improve diet vs a control intervention differs by readiness to reduce dietary saturated fat based on the Transtheoretical Model Stages of Change among family members of hospitalized cardiovascular disease patients. DESIGN: Stages of change (ie, precontemplation, contemplation, preparation, action, maintenance) were assessed by standardized questionnaire. Diet was measured by Block 98 Food Frequency Questionnaire at baseline and 1 year in participants in the Family Intervention Trial for Heart Health (n=501; 36% racial/ethnic minorities; 66% female). Therapeutic Lifestyle Change diet education was provided to each special intervention subject tailored to baseline stage of change. STATISTICAL ANALYSES: Multivariable linear regression was used to examine whether the effect of the intervention was modified by stage of change. RESULTS: Baseline saturated fat and cholesterol intakes were lower among those in maintenance stage vs others (9.9% vs 11.2% kcal; P<0.0001 and 112.2 vs 129.7 mg/1,000 kcal; P=0.0003, respectively). Overall, change in the percentage of calories from saturated fat from baseline to 1 year was -0.7 in the special intervention vs -0.4 in the control intervention (P=0.18). Among participants in contemplation, greater reductions in saturated fat (-2.1% vs +0.3% kcal; P=0.04) and cholesterol (-34.0 vs +32.6 mg/1,000 kcal; P=0.01) were seen in the special intervention vs control intervention. The special intervention was more likely than control intervention to achieve new adherence to a diet of <10% saturated fat/<300 mg cholesterol at 1 year among those not in maintenance stage (30% vs 15%; P=0.03). Control intervention participants were more likely than special intervention to revert to lower levels on the stage of change continuum from baseline to 1 year (17% vs 7%; P=0.002). CONCLUSION: Effectiveness of an intervention to lower saturated fat varies by baseline stage of change among family members of hospitalized cardiovascular patients. This can be important to consider when designing research or clinical diet interventions.

A randomized clinical trial of secondary prevention among women hospitalized with coronary heart disease.

BACKGROUND: Secondary prevention improves survival, yet implementation is suboptimal. We tested the impact of a systematic hospital-based educational intervention vs. usual care to improve rates of adherence to secondary prevention guidelines among women hospitalized with coronary heart disease (CHD), according to their ethnic status. METHODS: Women (n = 304, 52% minorities) hospitalized with CHD were randomly assigned to a systematic secondary prevention educational intervention vs. usual care. Adherence to goals for smoking cessation, weight management, physical activity, blood pressure <140/90 mm Hg, low-density lipoprotein cholesterol (LDL-C) <100 mg/dL (2.59 mmol/L), and use of aspirin/anticoagulants, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors were assessed at 6 months. RESULTS: On admission, minority women were less likely than white women to meet the goals for blood pressure (OR = 0.46, 95% CI 0.26-0.80), LDL-C (OR = 0.57, CI 0.33-0.94), and weight management (OR = 0.40, 95% CI 0.20-0.82). There was no difference between the intervention and usual care groups in a summary score of goals met at study completion; however, minority women in the intervention group were 2.4 times more likely (95% CI 1.13-5.03) to reach the blood pressure goal at 6 months compared with minority women in usual care. White women in the intervention group were 2.86 times more likely (95% CI 1.06-7.68) to report use of beta-blockers at 6 months compared with white women in usual care. In a logistic regression model, the interaction term for ethnic status and group assignment was significant for achieving the blood pressure goal (p = 0.009). CONCLUSIONS: A healthcare systems approach to educate women about secondary prevention and blood pressure control may differentially benefit ethnic minority women compared with white women.