Trajectories and predictors of high-occurrence pain flares in ambulatory cancer patients on opioids.

BACKGROUND: Pain flares have a substantive impact on the quality of life and well-being of patients with cancer. We identified longitudinal trajectories (clusters) of cancer pain flares in ambulatory patients and sociodemographic and clinical predictors of these trajectories. METHODS: In a prospective cohort study using ecological momentary assessment (mEMA), we collected patient-reported daily pain flare ratings data over 5 months and identified predictors and correlates using validated measures. RESULTS: The mean age of the sample (N = 270) was 60.9 years (SD = 11.2), 64.8% were female, and 32.6% self-identified as African American. Four pain flare clusters were identified. The "high-occurrence" cluster (23% of patients) experienced 5.5 (SD = 5.47) daily flares, whereas low-moderate clusters (77%) reported 2.4 (SD = 2.74) daily flares (P < .000). Those in the high-occurrence cluster reported higher pain scores (P = .000), increased pain-related interference (P = .000), depressive symptoms (P = .023), lower quality of life (P = .001), and reduced pain self-efficacy (P = .006). Notably, 67.2% of those prescribed opioids as needed (PRN only) were in the high-occurrence pain flare cluster, compared with 27.9% with PRN and around-the-clock opioid prescriptions (P = .024). Individual predictors of high-occurrence pain flares were income below $30 000, unemployment, being African American, lower education level, Medicaid insurance, current opioid misuse (COMM), baseline inpatient hospital stay duration, and PRN-only opioid regimen. In the multiple predictor model, lower education level, unemployment, COMM score, extended inpatient duration, and PRN-only opioid regimen remained significant. CONCLUSION: In ambulatory patients with cancer, high occurrence of pain flares may be mitigated by attention to opioid prescription factors and addressing social determinants of health needs of underserved patients.

Family adaptation in families of individuals with Down syndrome from 12 countries.

Our current understanding of adaptation in families of individuals with Down syndrome (DS) is based primarily on findings from studies focused on participants from a single country. Guided by the Resiliency Model of Family Stress, Adjustment, and Adaptation, the purpose of this cross-country investigation, which is part of a larger, mixed methods study, was twofold: (1) to compare family adaptation in 12 countries, and (2) to examine the relationships between family variables and family adaptation. The focus of this study is data collected in the 12 countries where at least 30 parents completed the survey. Descriptive statistics were generated, and mean family adaptation was modeled in terms of each predictor independently, controlling for an effect on covariates. A parsimonious composite model for mean family adaptation was adaptively generated. While there were cross-country differences, standardized family adaptation mean scores fell within the average range for all 12 countries. Key components of the guiding framework (i.e., family demands, family appraisal, family resources, and family problem-solving communication) were important predictors of family adaptation. More cross-country studies, as well as longitudinal studies, are needed to fully understand how culture and social determinants of health influence family adaptation in families of individuals with DS.

A study of error reporting by nurses: the significant impact of nursing team dynamics.

Background: Error reporting is crucial for organisational learning and improving patient safety in hospitals, yet errors are significantly underreported. Aims: The aim of this study was to understand how the nursing team dynamics of leader inclusiveness, safety climate and psychological safety affected the willingness of hospital nurses to report errors. Methods: The study was a cross-sectional design. Self-administered surveys were used to collect data from nurses and nurse managers. Data were analysed using linear mixed models. Bootstrap confidence intervals with bias correction were used for mediation analysis. Results: Leader inclusiveness, safety climate and psychological safety significantly affected willingness to report errors. Psychological safety mediated the relationship between safety climate and error reporting as well as the relationship between leader inclusiveness and error reporting. Conclusion: The findings of the study emphasise the importance of nursing team dynamics to error reporting and suggest that psychological safety is especially important to error reporting.

An analysis of reproductive outcomes for conceptions of participants of the Air Force Health Study.

Analyses were conducted of reproductive outcomes for conceptions of participants of the Air Force Heath Study. Participants were male Air Force veterans of the Vietnam War. Conceptions were categorized into conceived before and after the start of the participant's Vietnam War service. Analyses accounted for correlation between outcomes for multiple conceptions for each participant. For each of three non-sparsely occurring outcomes, including not live born, miscarriage, and preterm, the probability of occurrence increased substantially when conceived after compared to before the start of Vietnam War service. These results support the conclusion of an adverse effect due to Vietnam War service on these reproductive outcomes. Data for conceptions after the start of Vietnam War service for participants with measured dioxin values were used to estimate dose-response curves for the effect of dioxin exposure on the occurrence of each of the three non-sparsely occurring outcomes. These curves were assumed to be constant up to a threshold and then monotonic after that threshold. For each of the three non-sparsely occurring outcomes, the estimated dose-response curves increased nonlinearly after associated thresholds. These results support the conclusion that the adverse effect due to conception after the start of Vietnam War service is attributable to high enough exposures to dioxin, a toxic contaminant of Agent Orange used for herbicide spraying in the Vietnam War. Sensitivity analyses supported the conclusion that dioxin results were not substantially affected by the assumption of monotonicity, decay due to elapsed time from exposure to measurement, and available covariates.

Where are the critical care nurses? A statewide analysis of actively practicing nurses' transitions out of the clinical area.

BACKGROUND: Critical care nurse shortages and burnout have spurred interest in the adequacy of nursing supply in the United States. Nurses can move between clinical areas without  additional education or licensure. PURPOSE: To identify transitions that critical care nurses make into non-critical care areas, and examine the prevalence and characteristics associated with those transitions. METHODS: Secondary analysis of state licensure data from 2001-2013. DISCUSSION: More than 75% of nurses (n = 8,408) left critical care in the state, with 44% making clinical area transitions within 5 years. Critical care nurses transitioned into emergency, peri-operative, and cardiology areas. Those observed in recession years were less likely to make transitions; female and nurses with masters/doctorate degrees were more likely. CONCLUSION: This study used state workforce data to examine transitions out of critical care nursing. Findings can inform policies to retain and recruit nurses back into critical care, especially during public health crises.

An analysis of birth defects and developmental disabilities for children of participants of the Air Force Health Study.

Analyses were conducted of the occurrence of eight general categories of birth defects and developmental disabilities for children fathered by participants of the Air Force Heath Study (AFHS). Participants were male Air Force veterans of the Vietnam War. Children were categorized into conceived before and after the start of the participant's Vietnam War service. Analyses accounted for correlation between outcomes for multiple children fathered by each of the participants. For each of the eight general categories of birth defects and developmental disabilities, the probability of its occurrence increased substantially for children conceived after compared to before the start of Vietnam War service. These results support the conclusion of an adverse effect on reproductive outcomes due to Vietnam War service. Data for children conceived after the start of Vietnam War service for participants with measured dioxin values were used to estimate dose-response curves for the effect of dioxin exposure on the occurrence of each of the eight general categories of birth defects and developmental disabilities. These curves were assumed to be constant up to a threshold and then monotonic after that threshold. For seven of the eight general categories of birth defects and developmental disabilities, the estimated dose-response curves increased nonlinearly after associated thresholds. These results support the conclusion that the adverse effect to conception after the start of Vietnam War service may be attributable to high enough exposures to dioxin, a toxic contaminant of Agent Orange used for herbicide spraying in the Vietnam War.

Regression Modeling of Individual-Patient Correlated Discrete Outcomes with Applications to Cancer Pain Ratings.

Purpose: To formulate and demonstrate methods for regression modeling of probabilities and dispersions for individual-patient longitudinal outcomes taking on discrete numeric values. Methods: Three alternatives for modeling of outcome probabilities are considered. Multinomial probabilities are based on different intercepts and slopes for probabilities of different outcome values. Ordinal probabilities are based on different intercepts and the same slope for probabilities of different outcome values. Censored Poisson probabilities are based on the same intercept and slope for probabilities of different outcome values. Parameters are estimated with extended linear mixed modeling maximizing a likelihood-like function based on the multivariate normal density that accounts for within-patient correlation. Formulas are provided for gradient vectors and Hessian matrices for estimating model parameters. The likelihood-like function is also used to compute cross-validation scores for alternative models and to control an adaptive modeling process for identifying possibly nonlinear functional relationships in predictors for probabilities and dispersions. Example analyses are provided of daily pain ratings for a cancer patient over a period of 97 days. Results: The censored Poisson approach is preferable for modeling these data, and presumably other data sets of this kind, because it generates a competitive model with fewer parameters in less time than the other two approaches. The generated probabilities for this model are distinctly nonlinear in time while the dispersions are distinctly non-constant over time, demonstrating the need for adaptive modeling of such data. The analyses also address the dependence of these daily pain ratings on time and the daily numbers of pain flares. Probabilities and dispersions change differently over time for different numbers of pain flares. Conclusions: Adaptive modeling of daily pain ratings for individual cancer patients is an effective way to identify nonlinear relationships in time as well as in other predictors such as the number of pain flares.

Development of Training in Problem Solving for Caregivers of Childhood Brain Tumor Survivors.

BACKGROUND: Family management (FM) challenges of maternal caregivers of young adult survivors of childhood brain tumors are well documented, but there are no evidence-based caregiver interventions to improve FM. OBJECTIVES: The aims of this study were to (1) generate the knowledge necessary for developing a caregiver intervention (stage 0) and (2) modify an existing, efficacious intervention by engaging stakeholders (stage 1). METHODS: Stages 0 and 1 of the National Institutes of Health Stage Model for Behavioral Intervention Development and the FM Styles Framework were used in this study. RESULTS: In stage 0, families with condition-focused FM patterns were identified as at risk for poor problem solving. The 12-item Condition Management Ability scale of the FM Measures was selected as the screener to identify condition-focused maternal caregivers. Problem solving was identified as a potential mechanism for promoting behavior change. In stage 1, Bright IDEAS for Everyday Living was modified by integrating the FM Styles Framework creating Training in Problem Solving for Caregivers of Young Adult Survivors of Childhood Brain Tumors. Qualitative and quantitative assessments of feasibility and acceptability by maternal caregivers were excellent and used to improve selected areas of concern. CONCLUSION: Feedback from stakeholders indicates that Training in Problem Solving is a promising approach to shifting FM patterns and improving the functioning of caregivers, young adult survivors, and families. IMPLICATIONS FOR NURSING PRACTICE: When developing interventions, the use of systemic methods can provide both clinically based and scientifically acceptable solutions. Those interventions based on both problem solving and FM are potentially promising but need further testing.

Methodological Considerations in Scale Refinement with Diverse Populations: A Case Example Using the CES-D with a Community Sample of American Indian Women.

Although many psychometric assessments are used extensively in population-based research to determine psychopathology, these tools have not been thoroughly validated or appropriately adapted for use in diverse populations. Indeed, depression measurement studies among American Indian and female populations are scarce, omitting key opportunities to tailor psychological measurement for this population. To build psychometric evidence of measures in this population, we used a procedural method to examine a standard psychological instrument-the Center for Epidemiological Studies Depression Scale (CES-D)-with a community sample of southeast American Indian women. Our results showed strong psychometric reliability of the 20-item CES-D. The "effort" item presented diminished validity, as demonstrated by a negative counter-intuitive item-to-total correlation (ITC) value. Dropping the "effort" item resulted in a 19-item scale with a better fit in the within-group examination of community-based American Indian women. Compared to the 20-item CES-D scale, the revised 19-item measure ("effort" item removed) resulted in minimal changes to women's depression categories. However, we did detect patterns in shifts such that the 19-item scale generally underestimated (i.e., placed women in a lower category) depressive symptoms compared to the 20-item scale. Depending on their study goals, researchers engaging in population-based research should carefully weigh the use of original scales that allow for consistency in reporting with refined scales that fit psychometrically. We present the outlined method as a tool that expands on current approaches in scale refinement, and aids researchers in making more informed decisions regarding refined scales with diverse populations.

Supporting the Dynamic Careers of Licensed Practical Nurses: A Strategy to Bolster the Long-Term Care Nurse Workforce.

As the U.S. population ages and the demand for long-term care increases, an insufficient number of licensed practical nurses (LPNs) is expected in the nursing workforce. Understanding the characteristics of LPN participation in the workforce is essential to address this challenge. Drawing on the theory of boundaryless careers, the authors examined longitudinal employment data from LPNs in North Carolina and described patterns in LPN licensure and career transitions. Two career patterns were identified: (a) the continuous career, in which LPNs were licensed in 75% or more of the years they were eligible to be licensed and (b) the intermittent career, in which lapses in licensure occurred. Findings indicated that LPNs who made job transitions were more likely to demonstrate continuous careers, as were Black LPNs. These findings suggest the importance of organizational support for LPN career transitions and support for diversity in the LPN workforce.

Modeling Individual Patient Count/Rate Data over Time with Applications to Cancer Pain Flares and Cancer Pain Medication Usage.

The purpose of this article is to investigate approaches for modeling individual patient count/rate data over time accounting for temporal correlation and non-constant dispersions while requiring reasonable amounts of time to search over alternative models for those data. This research addresses formulations for two approaches for extending generalized estimating equations (GEE) modeling. These approaches use a likelihood-like function based on the multivariate normal density. The first approach augments standard GEE equations to include equations for estimation of dispersion parameters. The second approach is based on estimating equations determined by partial derivatives of the likelihood-like function with respect to all model parameters and so extends linear mixed modeling. Three correlation structures are considered including independent, exchangeable, and spatial autoregressive of order 1 correlations. The likelihood-like function is used to formulate a likelihood-like cross-validation (LCV) score for use in evaluating models. Example analyses are presented using these two modeling approaches applied to three data sets of counts/rates over time for individual cancer patients including pain flares per day, as needed pain medications taken per day, and around the clock pain medications taken per day per dose. Means and dispersions are modeled as possibly nonlinear functions of time using adaptive regression modeling methods to search through alternative models compared using LCV scores. The results of these analyses demonstrate that extended linear mixed modeling is preferable for modeling individual patient count/rate data over time, because in example analyses, it either generates better LCV scores or more parsimonious models and requires substantially less time.

Gaps in the Use of Long-Acting Opioids Within Intervals of Consecutive Days Among Cancer Outpatients Using Electronic Pill Caps.

OBJECTIVE: This study describes individual cancer patients' nonuse of extended-release or long-acting (ER/LA) opioids, including periods of gap between opioid doses taken. DESIGN: Secondary analysis of a three-month observational study of prescribed ER/LA opioids monitored using electronic pill caps. SETTING: Two outpatient oncology clinics of a large health system in the Mid-Atlantic region. PARTICIPANTS: Inclusion was based on self-identified African Americans and whites, at least 18 years old, diagnosed with solid tumors or multiple myeloma. For the current analysis, the additional inclusion criterion was prescription of an oral ER/LA opioid for cancer pain to be taken around the clock. METHODS: The electronic monitoring period for each study participant was partitioned into intervals of days between days with one or more openings (using medication event monitoring systems) representing rates of ER/LA opioid nonuse over consecutive days and over time. RESULTS: Of the sample (N = 109), two-thirds of the cancer patients had some nonuse of prescribed ER/LA opioids, with one in four having nonuse during 31.5-87.5% of their electronic-monitoring periods. Nonuse over periods of five or more, six or more, and seven or more consecutive days occurred for 37.6%, 34.9%, and 30.3% of the participants, respectively. CONCLUSIONS: About one in three ambulatory cancer patients in this study had substantial gaps between days of ER/LA opioid use, potentially resulting in risk of overdose depending upon the prescribed ER/LA opioid type, dose, and length of the time the opioid was stopped and resumed at the previous dose. This phenomenon has received little to no attention in the opioid safety discourse.

Measurement of Family Management in Families of Individuals With Down Syndrome: A Cross-Cultural Investigation.

Down syndrome (DS) is the most common genetic cause of intellectual disability worldwide. The purpose of this analysis was to determine the internal consistency reliability of eight language versions of the Family Management Measure (FaMM) and compare family management of DS across cultures. A total of 2,740 parents of individuals with DS from 11 countries completed the FaMM. The analysis provided evidence of internal consistency reliability exceeding .70 for four of six FaMM scales for the entire sample. Across countries, there was a pattern of positive family management. Cross-cultural comparisons revealed parents from Brazil, Spain, and the United States had the most positive family management and respondents from Ireland, Italy, Japan, and Korea had the least positive. The rankings were mixed for the four remaining countries. These findings provide evidence of overall strong internal consistency reliability of the FaMM. More cross-cultural research is needed to understand how social determinants of health influence family management in families of individuals with DS.

Mothers' and fathers' views of family management and health-related quality of life for young adult survivors of childhood brain tumors.

PURPOSE: To examine associations between fathers' and mothers' appraisals of family management and physical and emotional health-related quality of life (QOL) for young adult survivors of childhood brain tumors. DESIGN: Cross-sectional. SAMPLE: 47 mothers and 39 fathers (39-67 years old); 47 survivors (18-33 years old). METHODS: Analyses evaluated relationships among family management (Survivor's Daily Life, Condition Management Ability, Condition Management Effort, Family Life Difficulty, View of Condition Impact, Parental Mutuality), quality of life, and parental role. FINDINGS: Except for Parental Mutuality, family management ratings were not significantly different for mothers and fathers, and parental views of survivors' physical and emotional QOL improved with better family management. Parental role moderated associations between physical and emotional QOL and Survivors' Daily Life and between emotional QOL and Condition Management Ability, Condition Management Effort, and View of Condition Impact. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: Assess and address survivor QOL through family management from multiple perspectives.

Communication Cues and Engagement Behavior: Identifying Advertisement Strategies to Attract Middle-Aged Adults to a Study of the Chronic Disease Self-Management Program.

INTRODUCTION: Low- and middle-income, middle-aged adults have high rates of disease and death from chronic disease, yet their participation in self-management programs is low. This may be because advertisements for such programs often target elderly, predominantly white, affluent adults. Our study used data from a parent randomized controlled trial to identify theoretically driven advertisement cues to engage low- and middle-income, middle-aged adults in the Chronic Disease Self-Management Program (CDSMP). METHODS: A framework that combined the Elaboration Likelihood Model and Protection Motivation Theory was used to guide χ2 and regression analyses to assess relationships between advertisement cue preferences and 5 stages of cognitive engagement (cue processing, cognitive appraisal of the advertised study, motivation to enroll) and behavioral engagement of study participants (enrollment and program participation). RESULTS: One advertisement cue (taking control of one's future) and 1 cue combination (financial security and taking control of one's future) were significantly associated with study enrollment, as were motivation to enroll and cue processing. CONCLUSION: These results can inform CDSMP recruitment efforts to better engage low- and middle-income, middle-aged adults in an effort to mitigate the disproportionate burden of chronic disease in this population.

Discontinuation of angiotensin-converting enzyme inhibitors or beta-blockers and the impact on heart failure hospitalization rates.

BACKGROUND: Adherence to evidence-based therapy is essential for optimal management of heart failure. Yet, medication adherence is poor in heart failure patients. The Ascertaining Barriers to Compliance Project decomposed the medication adherence process into initiation, implementation, and discontinuation stages, but electronic monitoring-based adherence analyses usually do not consider this process. AIMS: The aim of this study was to describe individual-patient patterns of medication adherence from electronic monitoring data among adults with chronic heart failure, adherence types, and risk factors for increased all-cause hospitalization including measures of poor adherence such as discontinuation. METHODS: Data from two prospective studies of adherence measured with electronic monitoring for heart failure patients were combined and restricted to monitoring of angiotensin-converting enzyme inhibitors and beta-blockers over an initial three-month period. Hospitalizations were recorded for this period as well as for a three-month follow-up period. Analyses were conducted using adaptive modeling methods to identify individual-patient adherence patterns, adherence types, and risk factors for an increased hospitalization rate. RESULTS: Using electronic monitoring data for 254 heart failure patients, four adherence types were identified: highly consistent, consistent but variable, moderately consistent, and poorly consistent. Sixteen individually significant risk factors for increased hospitalization rates were identified and used to generate a multiple risk factors model. Medication discontinuation was the most important individual risk factor and most important in the multiple risk factors model. CONCLUSION: Discontinuation of angiotensin-converting enzyme inhibitors or beta-blockers increases hospitalization rates for heart failure patients. Interventions that effectively address this problem are urgently needed.

A multi-component, family-focused and literacy-sensitive intervention to improve medication adherence in patients with heart failure-A randomized controlled trial.

BACKGROUND: Medication nonadherence is prevalent and links to serious outcomes (e.g., rehospitalization/death) in heart failure (HF) patients; therefore, an urgent need exists for an intervention to improve and sustain adherence after intervention completion. OBJECTIVES: To test the efficacy of a multi-component, family-focused, literacy-sensitive (FamLit) intervention on medication adherence in HF patients. METHODS: Forty-three HF patients and their care partners were enrolled and randomized to receive FamLit or attention-only intervention, including an in-person session at baseline and bi-weekly phone boosters for 3 months. We measured medication adherence from baseline to 3-month post-intervention using the Medication Event Monitoring System. RESULTS: After 3-month intervention, intervention patients had significantly better medication adherence than control patients. At 6 months (3-months post-intervention), intervention effect on adherence was sustained in the FamLit intervention group, while adherence decreased in the control group. CONCLUSION: Incorporating care partner support and providing an easy-to-understand intervention to patients-care partners may improve/sustain adherence.

Family-clinician communication in the ICU and its relationship to psychological distress of family members: A cross-sectional study.

BACKGROUND: Effective communication between family and clinicians has been identified as one of the most important factors in end-of-life care. Family members' perception of communication quality with clinicians may be associated with their psychological symptoms. OBJECTIVES: To examine the association between family-clinician (physicians or nurses) communication quality and symptoms of anxiety, depression, and stress among family members of chronically critically ill patients in intensive care units (ICUs). DESIGN: A cross-sectional study. SETTINGS AND PARTICIPANTS: The participants were 71 adult family members of 71 patients who required prolonged mechanical ventilation in ten ICUs at three medical centres in Korea. METHODS: Participants completed the Quality of Communication (QOC) questionnaire, Hospital Anxiety and Depression Scale (HADS), and Impact of Event Scale-Revised (IES-R). The data were analysed using correlation, bivariate regression, and multiple regression analysis. RESULTS: The mean (SD) QOC score for physicians and nurses was 50.3 (15.2) and 42.9 (14.2), respectively. Forty-six participants (64.8%) were identified as being at risk for having anxiety symptoms; 22 (31%) had a mild risk and 24 (33.8%) had a moderate or severe risk. More family members (76.1%) were at risk for having depressive symptoms; 15 (21.1%) had a mild risk and 39 (54.9%) had a moderate or severe risk. For post-traumatic stress symptoms, 48 (67.6%) were at risk. While the QOC scores for nurses were negatively associated with participants' HADS-depression scores (ß = -.01, p = .03), the QOC scores for physicians were not associated with the HADS or IES-R scores. This conclusion held after consideration of covariates. CONCLUSIONS: The findings suggest that communication between family members and ICU nurses may be more influential than that with ICU physicians on psychological distress of family members in Korea. However, further research is warranted to confirm this relationship. Future interventions to reduce psychological distress in family members of chronically critically ill patients may need to target ICU nurses for improving communication skills.

A community-engaged approach to investigate cardiovascular-associated inflammation among American Indian women: A research protocol.

American Indian women are more likely to die from cardiovascular disease (CVD) than White or African American women. Inflammatory processes may underlie CVD disparities by gender and race and may be critical to understanding population-specific drivers and potential buffers. Exposure to environmental air pollutants, especially particulate matter (PM), is known to be an important catalyst in CVD-associated inflammation. Positive psychological states, associated with low levels of inflammatory gene expression, could serve to moderate the inflammatory response to environmental air pollutants and ultimately lead to better cardiovascular health outcomes. The aim of the ongoing community-engaged and NIH-funded study described in this study protocol is to address the racial and gender gaps in CVD mortality by investigating the contextually relevant and culturally important determinants of health among American Indian women. In this paper we describe the procedures used to examine the relationship between environmental air pollutant exposures (PM10-2.5 and PM 2.5 ), psychological factors (e.g., depressive symptoms, posttraumatic stress symptoms, eudemonic well-being, and positive emotions), and cardiovascular-associated inflammation (hs-CRP, IL-6, Amyloid A, CBCs with differentials) in a sample of 150 women 18-50 years of age from the Lumbee Tribe in southeastern North Carolina. We describe lessons learned and strategies used in developing a community-engaged approach to enhance recruitment of American Indian women in biomedical research. The empirical data and community infrastructure resulting from this study will be foundational in designing and testing future interventions to reduce CVD-associated morbidity and mortality in American Indian women.

Patterns of adherence to diuretics, dietary sodium and fluid intake recommendations in adults with heart failure.

BACKGROUND: Three behaviors advocated to minimize fluid-related hospitalizations in patients with heart failure (HF) are restricted sodium and fluid intake and consistent oral diuretic use. Adherence to behaviors intended to decrease risk of hospitalization is believed to vary over time, but surprisingly little research has addressed patterns of adherence in HF patients. OBJECTIVE: To describe patterns over time of 3 recommended self-care behaviors (i.e., diet, fluid intake, and diuretic dosing) in adults with HF and to determine how time and behavior influenced adherence rates. METHODS: We enrolled 24 adults hospitalized for a HF exacerbation and discharged on a loop diuretic into a descriptive, longitudinal pilot study. Over 3-months, diuretic use was measured using electronic event monitoring, and participants were telephoned regularly to assess sodium and fluid intake. Data were summarized for each 2-week intervals. RESULTS: The overall adherence rates were 42.4% for low sodium diet, 96.4% for fluid restriction, and 84.7% for the diuretic regimen. Early after hospital discharge, medication adherence was the highest, and dietary adherence was the lowest, but adherence to diet and diuretic use decreased significantly over time. CONCLUSION: Although participants were just discharged from the hospital after an acute exacerbation of HF, all three behavioral patterns decreased markedly over the 3-month follow-up period.