Prehospitalization Symptom Perceptions, Lay Consultations, and Treatment-Seeking for Acute Decompensating Heart Failure: Implications for Nursing Practice.

Heart failure is a common, serious condition associated with frequent exacerbations and hospitalizations. Preventable causes of more than 70% of heart failure hospitalizations are attributable to ineffective heart failure self-care, including symptom recognition and interpretation, and delayed symptom reporting and treatment seeking. The social context in which illness symptoms occur is an important aspect of symptom self-management. Self-initiated medical and nonmedical treatments for symptom relief and engaging in lay consultations with persons in social networks for symptom evaluation are common. This article highlights socially delineated aspects of symptom self-management leading to hospitalization, many of which are amenable to nursing intervention.

Lay Consultations in Heart Failure Symptom Evaluation.

PURPOSE: Lay consultations can facilitate or impede healthcare. However, little is known about how lay consultations for symptom evaluation affect treatment decision-making. The purpose of this study was to explore the role of lay consultations in symptom evaluation prior to hospitalization among patients with heart failure. METHODS: Semi-structured interviews were conducted with 60 patients hospitalized for acute decompensated heart failure. Chi-square and Fisher's exact tests, along with logistic regression were used to characterize lay consultations in this sample. RESULTS: A large proportion of patients engaged in lay consultations for symptom evaluation and decision-making before hospitalization. Lay consultants provided attributions and advice and helped make the decision to seek medical care. Men consulted more often with their spouse than women, while women more often consulted with adult children. CONCLUSIONS: Findings have implications for optimizing heart failure self-management interventions, improving outcomes, and reducing hospital readmissions.

Symptom perceptions and self-care behaviors in patients who self-manage heart failure.

BACKGROUND: Patients with heart failure (HF) are at heightened risk for acute exacerbation requiring hospitalization. Although timely reporting of symptoms can expedite outpatient treatment and avoid the need for hospitalization, few patients recognize and respond to symptoms until acutely ill. OBJECTIVE: The purpose of this study was to explore patients' perceptions of symptoms and self-care behaviors for symptom relief, leading up to a HF hospitalization. METHODS: To examine prehospitalization symptom scenarios, semistructured interviews were conducted with 60 patients hospitalized for acute decompensated HF. RESULTS: Thirty-seven patients (61.7%) said that they had a sense that "something just wasn't quite right" before their symptoms began but were unable to specify further. Signs and symptoms most often recognized by the patients were related to dyspnea (85%), fatigue (53.3%), and edema (41.7%). Few patients interpreted their symptoms as being related to worsening HF and most often attributed symptoms to changes in diet (18.3%) and medications (13.3%). Twenty-six patients (43.3%) used self-care strategies to relieve symptoms before hospital admission. More than 40% of the patients had symptoms at least 2 weeks before hospitalization. CONCLUSIONS: Despite the wide dissemination of HF evidence-based guidelines, important components of symptom self-management remain suboptimal. Because most of HF self-management occurs in the postdischarge environment, research is needed that identifies how patients interpret symptoms of HF in the specific contexts in which patients self-manage their HF. These findings suggest the need for interventions that will help patients expeditiously recognize, accurately interpret, and use appropriate and safe self-care strategies for symptoms.

Multidisciplinary group clinic appointments: the Self-Management and Care of Heart Failure (SMAC-HF) trial.

BACKGROUND: This trial tested the effects of multidisciplinary group clinic appointments on the primary outcome of time to first heart failure (HF) rehospitalization or death. METHODS AND RESULTS: HF patients (n=198) were randomly assigned to standard care or standard care plus multidisciplinary group clinics. The group intervention consisted of 4 weekly clinic appointments and 1 booster clinic at month 6, where multidisciplinary professionals engaged patients in HF self-management skills. Data were collected prospectively for 12 months beginning after completion of the first 4 group clinic appointments (2 months post randomization). The intervention was associated with greater adherence to recommended vasodilators (P=0.04). The primary outcome (first HF-related hospitalization or death) was experienced by 22 (24%) in the intervention group and 30 (28%) in standard care. The total HF-related hospitalizations, including repeat hospitalizations after the first time, were 28 in the intervention group and 45 among those receiving standard care. The effects of treatment on rehospitalization varied significantly over time. From 2 to 7 months post randomization, there was a significantly longer hospitalization-free time in the intervention group (Cox proportional hazard ratio=0.45 (95% confidence interval, 0.21-0.98; P=0.04). No significant difference between groups was found from month 8 to 12 (hazard ratio=1.7; 95% confidence interval, 0.7-4.1). CONCLUSIONS: Multidisciplinary group clinic appointments were associated with greater adherence to selected HF medications and longer hospitalization-free survival during the time that the intervention was underway. Larger studies will be needed to confirm the benefits seen in this trial and identify methods to sustain these benefits. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00439842.