Psychometric Properties of Frailty Instruments in Adults With Rheumatoid Arthritis: A Systematic Review.

OBJECTIVE: Examine psychometric properties of frailty instruments used in adults with rheumatoid arthritis (RA) to inform selection of frailty instruments for clinical and research use. METHODS: A systematic review was registered in PROSPERO. Studies measuring frailty in adults with RA published before May 25, 2022, were searched in six electronic databases. Level of evidence of psychometric properties were synthesized and graded for each frailty instrument using Consensus-Based Standards for the Selection of Health Measurement Instruments methodology. RESULTS: There were 22 articles included in the review, and psychometric properties of 16 frailty instruments were examined. RA cohorts were predominantly female with moderate RA disease activity, mean age was 60.1 years, and frailty prevalence ranged widely from 10% to 85%. Construct validity was the only psychometric property routinely examined for frailty instruments in RA, and nearly all (14/16) performed favorably in this domain. Frailty correlated most frequently with older age, higher RA disease activity, and worse physical function. Internal consistency, measurement error, and content validity were examined infrequently. Reliability and responsiveness data were not reported. Six frailty instruments were rated highest in adults with RA: three adaptations of Fried's Criteria, 32-Item and 45-Item Frailty Indexes, and the Comprehensive Rheumatologic Assessment of Frailty. CONCLUSION: Six frailty instruments possessed the highest-rated psychometric properties in RA. These instruments demonstrated construct validity of frailty with important outcomes in RA. Frailty assessment shows promise to inform risk stratification in RA, but studies are needed to evaluate reliability, responsiveness, and validity to support accuracy of frailty measurement in adults with RA who may have disease-related features that differentially impact outcomes.

Cardiovascular Disease Risk in Rural Adults: A Pilot Intervention Study Using Registered Nurse/Community Health Worker Teams.

BACKGROUND: Cardiovascular disease (CVD) risk reduction programs led by a nurse/community health worker team are effective in urban settings. This strategy has not been adequately tested in rural settings. OBJECTIVE: A pilot study was conducted to examine the feasibility of implementing an evidence-based CVD risk reduction intervention adapted to a rural setting and evaluate the potential impact on CVD risk factors and health behaviors. METHODS: A 2-group, experimental, repeated-measures design was used; participants were randomized to a standard primary care group (n = 30) or an intervention group (n = 30) where a registered nurse/community health worker team delivered self-management strategies in person, by phone, or by videoconferencing. Outcomes were measured at baseline and at 3 and 6 months. A sample of 60 participants was recruited and retained in the study. RESULTS: In-person (46.3%) and telephone (42.3%) meetings were used more than the videoconferencing application (9%). Mean change at 3 months differed significantly between the intervention and control groups for CVD risk (-1.0 [95% confidence interval (CI), -3.1 to 1.1] vs +1.4 [95% CI, -0.4 to 3.3], respectively), total cholesterol (-13.2 [95% CI, -32.1 to 5.7.] vs +21.0 [95% CI, 4.1-38.1], respectively), and low-density lipoprotein (-11.5 [95% CI, -30.8 to 7.7] vs +19.6 [95% CI, 1.9-37.2], respectively). No between-group differences were seen in high-density lipoprotein, blood pressure, or triglycerides. CONCLUSIONS: Participants receiving the nurse/community health worker-delivered intervention improved their risk CVD profiles, total cholesterol, and low-density lipoprotein levels at 3 months. A larger study to explore the intervention impact on CVD risk factor disparities experienced by rural populations is warranted.

Feasibility, Acceptability, and Intervention Description of a Mobile Health Intervention in Patients With Heart Failure.

Mobile health (mHealth) is used to encourage and support self-management skills in patients with heart failure. The purpose of the study was to describe the feasibility, fidelity, usability, and acceptability of mHealth interventions. This pilot study used a randomized 3-group (enhanced usual care, mHealth, and mHealth plus, which included a nurse practitioner and community health worker) repeated-measure design to determine the feasibility of using a self-management behavior app and a Bluetooth-enabled scale for daily self-monitoring of weights and medications. In the 2 mHealth groups, of the 48 patients, 38 (79%) engaged partially in recording daily weights and medications, and of the 74 patients in the sample, we obtained partial to complete data on 63 (85%) of the patients during follow-up outcome phone calls. Most patients found the intervention to be feasible, usable, and acceptable, and (93%) patients in the mHealth group and 100% of patients in the mHealth plus group agreed or strongly agreed that they learned how to self-manage their heart failure using the app. The intervention was reasonable to implement and provided insight for future intervention improvements.

Mobile Health Self-management Interventions for Patients With Heart Failure: A Pilot Study.

BACKGROUND: Heart failure (HF) is a multifaceted syndrome that requires self-management for adherence to treatment to control symptoms. Symptoms need to be monitored to prevent impending HF exacerbations. Few HF study authors have assessed efficacy of mobile health (mHealth) interventions particularly with virtual visits to evaluate outcomes such as symptoms and healthcare utilization. OBJECTIVE: The aim of this pilot study was to evaluate the potential effect of mHealth self-management interventions on symptom status and health-related quality of life and describe health care utilization in patients with HF. METHODS: This 3-month pilot study included 74 patients with HF and used a randomized 3-group repeated-measures design (enhanced usual care, mHealth, and mHealth plus [+] virtual visits). Surveys included the Heart Failure Symptom Survey, EuroQol, and a specialized phone application for patients to report weights and medications. RESULTS: The mHealth groups had an overall decrease in most symptom severity and frequency, particularly shortness of breath. Compared to enhanced usual care, both the mHealth+ and mHealth groups showed promise with medium effect sizes (range .55-.60) in relation to shortness of breath and a medium effect (.51) for lower extremity edema for the mHealth+ group. There was a trend toward improvement in health-related quality of life in both intervention groups at month 3. The mHealth+ group had fewer rehospitalizations. CONCLUSIONS: In general, both mHealth groups fared better on symptoms and health care utilization. Small to medium effect sizes on selected symptom outcomes warrant this study to be conducted in a fully powered study. Virtual visits may assist in symptom recognition and self-management.

Health Status and Burden in Caregivers of Patients With Multimorbidity.

Caregivers of patients with multimorbidity are important for improving patient outcomes. This descriptive study examines health status and burden of 22 caregivers of patients with multimorbidity discharged from the hospital who were enrolled in a self-management intervention study. Caregivers did not receive an intervention. Factors that increased caregiver burden were financial issues, caring for others (e.g., family members), and home obligations. Caregivers averaged between 2 and 3 chronic conditions themselves. Perceived caregiver burden remained unchanged over time for the caregiver whether the patient was in the intervention or the usual care group. We recommend rigorous research with larger samples to better understand the caregiver role, needed resources and potential interventions to mitigate caregiver burden in the multimorbid population during and after care transitions. Longitudinal studies that include assessment and interventions for the caregivers of patients with multimorbidity are needed.

Participatory needs assessment and action planning for a clinical and translational research network.

The goal of this study was to assess the utility of participatory needs assessment processes for continuous improvement of developing clinical and translational research (CTR) networks. Our approach expanded on evaluation strategies for CTR networks, centers, and institutes, which often survey stakeholders to identify infrastructure or resource needs, using the case example of the Great Plains IDeA-CTR Network. Our 4-stage approach (i.e., pre-assessment, data collection, implementation of needs assessment derived actions, monitoring of action plan) included a member survey (n = 357) and five subsequent small group sessions (n = 75 participants) to better characterize needs identified in the survey and to provide actionable recommendations. This participatory, mixed-methods needs assessment and strategic action planning process yielded 11 inter-related recommendations. These recommendations were presented to the CTR steering committee as inputs to develop detailed, prioritized action plans. Preliminary evaluation shows progress towards improved program capacity and effectiveness of the network to respond to member needs. The participatory, mixed-methods needs assessment and strategic planning process allowed a wide range of stakeholders to contribute to the development of actionable recommendations for network improvement, in line with the principles of team science.

Changes in Patient Activation in a Self-Management Intervention.

The purpose of this study was to compare results using individual change in level of patient activation measure (PAM) scores, individual point change scores, and group means in an outcome analysis. We evaluated changes in PAM scores (increase in level or increase of ≥5 points) to mean group PAM scores on patients who completed a self-management intervention compared with usual care on health care utilization and health-related quality of life. The sample was a subset of 91 multimorbid patients with complete data at completion of a self-management intervention. Results indicated that using a change in points allowed for more refined analysis of change compared with level changes; however, both individual measures were more reflective of actual change than group means. When tailoring interventions, we should consider using individual change scores. Further research is needed to evaluate how best to use PAM scores to measure the impact on clinical and health care outcomes.

Adapting an Evidence-Based Cardiovascular Disease Risk Reduction Intervention to Urban American Indians.

PURPOSE: Using the RE-AIM framework, the primary purpose of this qualitative study was to conduct focus groups to identify areas for future adaptation of an evidence-based cardiovascular disease (CVD) risk intervention (COACH) developed for an urban primary care setting to urban American Indian (AI)-serving settings. METHODS: This qualitative study involved conducting three focus groups with 31 urban AI patients with two or more CVD risk factors to maximize reach and efficacy of COACH. The patients had not yet participated in an adapted COACH program. RESULTS: Findings from the focus groups indicate that a culturally adapted CVD risk reduction program modeled after COACH would be acceptable among urban AI populations. Recommendations for cultural adaptation include a need for images of AI people, traditional AI exercise activities and AI foods, information on the portion sizes of traditional foods, and expanded information on tobacco use and resources. CONCLUSION: With cultural adaptations, the COACH program can be pilot-tested in urban AI-serving primary care settings to address health concerns and behaviors that affect cardiovascular health outcomes.

Acute Coronary Syndrome Symptom Clusters: Illustration of Results Using Multiple Statistical Methods.

Researchers have employed various methods to identify symptom clusters in cardiovascular conditions, without identifying rationale. Here, we test clustering techniques and outcomes using a data set from patients with acute coronary syndrome. A total of 474 patients who presented to emergency departments in five United States regions were enrolled. Symptoms were assessed within 15 min of presentation using the validated 13-item ACS Symptom Checklist. Three variable-centered approaches resulted in four-factor solutions. Two of three person-centered approaches resulted in three-cluster solutions. K-means cluster analysis revealed a six-cluster solution but was reduced to three clusters following cluster plot analysis. The number of symptoms and patient characteristics varied within clusters. Based on our findings, we recommend using (a) a variable-centered approach if the research is exploratory, (b) a confirmatory factor analysis if there is a hypothesis about symptom clusters, and (c) a person-centered approach if the aim is to cluster symptoms by individual groups.

Weight management telehealth intervention for overweight and obese rural cardiac rehabilitation participants: A randomised trial.

AIMS AND OBJECTIVES: To determine whether a weight management intervention (WMI) plus cardiac rehabilitation (CR) compared to CR alone improves outcomes for overweight and obese cardiac revascularisation patients. BACKGROUND: Despite participating in cardiac rehabilitation (CR), few cardiac patients lose enough weight to achieve clinically significant cardiovascular disease risk reduction. DESIGN: A randomised controlled design was used with measurements at baseline, 4 and 6 months, guided by the CONSORT checklist, see Supporting Information File S1. Adults who had undergone either coronary artery bypass surgery (CABS) or percutaneous coronary intervention (PCI) and participated in a rural CR programmes were recruited. Subjects were randomised to a 12-week telehealth WMI or control group. The primary outcome was weight loss. Secondary outcomes included physical activity, patient activation, perceived self-efficacy and use of weight management behaviours. RESULTS: A total of 43 subjects participated, with a mean age of 63 (±9.3) years. The WMI group had significantly more weight loss averaged across the 4 and 6 months of 13.8 (±2.8) pounds compared to the control group [mean = 7.8 (±2.2) pounds]. There were no significant differences in physical activity (activity counts or daily minutes in moderate or more intense activity). The WMI group had significantly higher levels of patient activation. They also had significantly higher total scores on the Diet and Exercise Self-Management survey, and subscales that included self-efficacy for specific eating habits and managing diet behaviour. CONCLUSIONS: Findings demonstrated the usefulness and feasibility of using telehealth delivery of the WMI for cardiac rehabilitation participants in rural communities to improve weight management outcomes. RELEVANCE TO PRACTICE: Study findings underscore the opportunity to further improve weight loss of overweight and obese cardiac participants using a weight management intervention to augment CR participation.

Adapting an Evidence-based Cardiovascular Disease Risk Reduction Intervention to Rural Communities.

PURPOSE: Using the RE-AIM framework, the primary purpose of this qualitative study was to assess focus group data to generate information on the applicability of an evidence-based cardiovascular disease (CVD) risk intervention developed for an urban setting for rural areas in Nebraska. We also sought to determine potential adaptations that may be necessary to implement the study in a rural setting. The CVD risk reduction intervention is based on the Community Outreach and Cardiovascular Health (COACH) program, which included nurse practitioner/community health worker teams. METHODS: This qualitative study involved conducting 3 focus groups with patients with CVD risk factors to assess community readiness for participating in the intervention, the mode of the delivery of the intervention, the setting of the intervention, program content, and raising awareness of the intervention. FINDINGS: Findings from the focus groups indicate acceptability toward a CVD risk reduction program modeled after the COACH. Participants favored initial in-person face-to-face interactions with a nurse practitioner that could transition to phone-based meetings and Skype. In addition, participants underscored that confidentiality can be a concern in small communities and therefore community health workers need to be trusted individuals. Calls for additions to COACH materials were very specific and participants underscored the need for social support. CONCLUSIONS: With minor adaptations, the COACH program can be pilot tested in rural settings to address key health concerns and behaviors that affect risk for cardiovascular health.

Using Cluster Analysis to Identify Subgroups of College Students at Increased Risk for Cardiovascular Disease.

BACKGROUND AND PURPOSE:  To examine the co-occurrence of cardiovascular risk factors and cluster subgroups of college students for cardiovascular risks. METHODS: A cross sectional descriptive study was conducted using co-occurrence patterns and hierarchical clustering analysis in 158 college students. RESULTS: The top co-occurring cardiovascular risk factors were overweight/obese and hypertension (10.8%, n = 17). Of the total 34 risk factors that co-occurred, 30 of them involved being overweight/obese. A six-cluster-solution was obtained, two clusters displayed elevated levels of lifetime and 30-year cardiovascular disease risks. CONCLUSIONS: The hierarchical cluster analysis identified that single White males with a family history of heart disease, overweight/obese, hypertensive or diabetes, and occasionally (weekly) consumed red meat, take antihypertensive medication, and hyperlipidemia were considered the higher risk group compared to other subgroups.

Comparisons of measures used to screen for obstructive sleep apnea in patients referred to a sleep clinic.

STUDY OBJECTIVES: Obstructive Sleep Apnea (OSA) contributes to all-cause mortality. An American Academy of Sleep Medicine task force is focusing on improving detection and categorization of OSA symptoms and severity to promote screening, assessment, and diagnosis. The purpose of this study was to psychometrically compare measures used in OSA screening (Berlin, Epworth Sleepiness Scale (ESS), STOP Bang) and a portable sleep monitor (PSM) to apnea-hypopnea index (AHI) and levels from polysomnogram (PSG). METHODS: An observational, cross-sectional design was used. Patients referred to a sleep specialist were enrolled at initial sleep evaluation. Participants completed measures used in OSA screening, then sent home for one night using PSM. PSGs were ordered by the physician and AHI results were obtained from the medical record. RESULTS: Participants (N = 170) were enrolled in the study. Almost all participants completed the OSA measures, approximately half-completed PSM measurement, and the majority completed laboratory PSG. The STOP Bang had the highest levels of sensitivity; the ESS had the lowest. The ESS had the highest specificity and reliability levels; the STOP Bang had the lowest. The PSM measure had the highest positive predictive value (PPV) and the strongest psychometric properties of the screening measures. CONCLUSIONS: The STOP Bang was the preferred self-report OSA screening measure because of high levels of sensitivity. The ESS was the least desirable measure. PSM measurement consistently predicted the presence of OSA but at the expense of low sensitivity at AHI levels ≥30. This expands the knowledge of validity testing of screening measures used for OSA.

Seasonal Work and Cardiovascular Risk Factors in Farmers.

BACKGROUND: Cardiovascular disease is the leading cause of death and hospitalization in the rural United States. Midwestern farmers are integral to rural communities, but little is known about the effect of occupational variability of seasonal work and technology use on their cardiovascular disease risk. AIMS: This study describes the relationships of health behaviors and cardiovascular disease risk in 40 Midwestern farmers during peak and off-peak farming seasons. METHODS: Objectively measured physical activity and self-report of demographics, diet, and health-related quality of life were collected during each farming season. RESULTS AND CONCLUSIONS: Farmers in this study were physically active, ate consistent diets, and reported high health status ratings throughout the year. Cardiovascular disease risk was positively correlated with age and body mass index (P < .01), and half of young and middle-age farmers reported anxiety and depression problems. Cardiovascular disease risk reduction interventions for farmers should address both physical and emotional aspects of farming.

Cost-Effectiveness of a Care Transition Intervention Among Multimorbid Patients.

The purpose of this pilot study was to assess the cost-effectiveness of four different doses (based on patients' level of cognition and activation) of a home-based care transitions intervention compared with usual care at 2 and 6 months after hospital discharge to home for 126 adult patients with three or more chronic diseases. Health care utilization was measured, and a cost-effectiveness analysis was used to estimate incremental costs and quality-adjusted life-years associated with each intervention arm. At 6 months, results from this pilot study are very promising and support cost-effectiveness for Group 2-low cognition/high activation, Group 3-normal cognition/low activation, and Group 4-normal cognition/high activation patients. However, Group 1-low cognition/low activation needs a more intensive treatment than what was provided in the intervention, because of their low cognition and activation levels. Our intervention strategies provided to the groups would be scalable to a larger patient population and across different facilities.

Advancing Symptom Science Through Symptom Cluster Research: Expert Panel Proceedings and Recommendations.

An overview of proceedings, findings, and recommendations from the workshop on "Advancing Symptom Science Through Symptom Cluster Research" sponsored by the National Institute of Nursing Research (NINR) and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, is presented. This workshop engaged an expert panel in an evidenced-based discussion regarding the state of the science of symptom clusters in chronic conditions including cancer and other rare diseases. An interdisciplinary working group from the extramural research community representing nursing, medicine, oncology, psychology, and bioinformatics was convened at the National Institutes of Health. Based on expertise, members were divided into teams to address key areas: defining characteristics of symptom clusters, priority symptom clusters and underlying mechanisms, measurement issues, targeted interventions, and new analytic strategies. For each area, the evidence was synthesized, limitations and gaps identified, and recommendations for future research delineated. The majority of findings in each area were from studies of oncology patients. However, increasing evidence suggests that symptom clusters occur in patients with other chronic conditions (eg, pulmonary, cardiac, and end-stage renal disease). Nonetheless, symptom cluster research is extremely limited and scientists are just beginning to understand how to investigate symptom clusters by developing frameworks and new methods and approaches. With a focus on personalized care, an understanding of individual susceptibility to symptoms and whether a "driving" symptom exists that triggers other symptoms in the cluster is needed. Also, research aimed at identifying the mechanisms that underlie symptom clusters is essential to developing targeted interventions.

Cardiovascular risk factors among college students: Knowledge, perception, and risk assessment.

OBJECTIVE: To assess college students' knowledge and perception of cardiovascular risk factors and to screen for their cardiovascular risks. PARTICIPANTS: The final sample that responded to recruitment consisted of 158 college students from a midwestern university. METHODS: A cross-sectional, descriptive study was performed using convenience sampling. RESULTS: College students were knowledgeable about cardiovascular risk factors but did not perceive themselves at risk for cardiovascular disease (CVD). Knowledge of cardiovascular risk factors was correlated with the lifetime risk estimates (ρ = .17, p = .048), and perception of cardiovascular risk was positively associated with 30-year CVD risk estimates (ρ = .16, p = .048). More than 50% of the participants had 1 or more cardiovascular risk factors. CONCLUSIONS: High knowledge level of cardiovascular risk factors was not sufficient to lower cardiovascular risks within this study population, but changing perception of cardiovascular risk factors may play a bigger role in reducing long-term cardiovascular risks.

Systematic review of symptom clusters in cardiovascular disease.

BACKGROUND: Although individual symptoms and symptom trajectories for various cardiovascular conditions have been reported, there is limited research identifying the symptom clusters that may provide a better understanding of patients' experiences with heart disease. AIMS: To summarize the state of the science in symptom cluster research for patients with acute coronary syndrome, myocardial infarction, coronary artery bypass surgery, and heart failure through systematic review and to provide direction for the translation of symptom cluster research into the clinical setting. METHODS: Databases were searched for articles from January 2000 through to May 2015 using MESH terms "symptoms, symptom clusters, acute coronary syndrome (ACS), myocardial infarction (MI), coronary heart disease (CHD), ischemic heart disease (IHD), heart failure (HF), coronary artery bypass surgery (CABS), cluster analyses, and latent classes." The search was limited to human studies, English language articles, and original articles investigating symptom clusters in individuals with heart disease. Fifteen studies meeting the criteria were included. RESULTS: For patients with ACS and MI, younger persons were more likely to experience clusters with the most symptoms. Older adults were more likely to experience clusters with the lowest number of symptoms and more diffuse and milder symptom clusters that are less reflective of classic ACS presentations. For HF patients, symptom clusters frequently included physical and emotional/cognitive components; edema clustered in only three studies. Symptom expression was congruent across geographical regions and cultures. CONCLUSIONS: The findings demonstrated similarities in symptom clusters during ACS, MI, and HF, despite multiple methods and analyses. These results may help clinicians to prepare at-risk patients for proper treatment-seeking and symptom self-management behaviors.

Selecting symptom instruments for cardiovascular populations.

The purpose of this review is to provide a guide for researchers and clinicians in selecting an instrument to measure four commonly occurring symptoms (dyspnea, chest pain, palpitations, and fatigue) in cardiac populations (acute coronary syndrome, heart failure, arrhythmia/atrial fibrillation, and angina, or patients undergoing cardiac interventions). An integrative review of the literature was conducted. A total of 102 studies summarizing information on 36 different instruments are reported in this integrative review. The majority of the instruments measured multiple symptoms and were used for one population. A majority of the symptom measures were disease-specific and were multi-dimensional. This review summarizes the psychometrics and defining characteristics of instruments to measure the four commonly occurring symptoms in cardiac populations. Simple, psychometrically strong instruments do exist and should be considered for use; however, there is less evidence of responsiveness to change over time for the majority of instruments.