Heart failure prevalence is projected to rise in the United States over the ensuing decades. Typical health education should be focused on primary prevention strategies; however, for those stricken with the disease, health educators should determine appropriate secondary prevention strategies for individuals to live a healthy life. One such strategy, recently approved for coverage by the Centers for Medicare and Medicaid, is cardiac rehabilitation. The impetus for the policy change was the heart failure ACTION trial. The trial unfortunately did not include patients that lived too far from cardiac rehabilitation centers, thus putting rural heart failure patients at a disadvantage. The purpose of the current study was to delineate how rural heart failure patients were referred to cardiac rehabilitation from an inpatient setting, to determine what factors were associated with initiation of cardiac rehabilitation, and to gain insight into rural heart failure patients’ motivation to partake in exercise. A purposive sample of rural heart failure patients were used for the study. Patients were selected from a rural hospital based upon their ejection fraction, per Medicare requirements. Participants completed a demographic survey as well as surveys regarding motivation to partake in exercise; six weeks later, the researcher determined if the rural heart failure participants initiated outpatient cardiac rehabilitation. Cardiac rehabilitation diagnosis, increased distance to cardiac rehabilitation, transportation and assistance, higher income, Caucasian race, and higher levels of educational attainment were independently associated with cardiac rehabilitation initiation. Further, higher levels of perceived autonomous motivation, autonomy support, and competence were associated with cardiac rehabilitation initiation. Conversely, low levels of perceived amotivation scores were associated with cardiac rehabilitation initiation. Not all heart failure patients in the current study were managed by a cardiologist while hospitalized. Lastly, the impetus of attaining the cardiac rehabilitation order for a primary diagnosis of heart failure came from the inpatient exercise physiologists.

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Heart failure (HF) is the leading cause of cardiovascular morbidity and health care utilization inCanada. Much of the cost for HF is related to hospitalization, strategies to decrease cost need tofocus on avoiding unnecessary readmissions to the hospital. Interactive voice response (IVR) is anautomated telephony system that leverages existing telephone lines to monitor patients post-discharge from a hospital, for early intervention. Limited evidence exists on the pattern of use andsuccess of IVR technology among patients with heart failure and how IVR impacts theircompliance. This study explores the pattern of IVR use by HF patients in the IVR program at theUniversity of Ottawa Heart Institute (UOHI), describes their characteristics and IVR patterns ofuse in relation to occurrence of symptoms, compliance behavior (e.g., weighing themselves,medication compliance) and service utilization (i.e., hospital readmission). The system is based onan algorithm that triggers automated telephone calls to patients at a predetermined time for 3months after discharge. A total of 902 HF patients were considered with a mean age of 70 years(59.4% male). Over the 12 weeks, results showed an overall increase in medication adherence anda decrease in symptom occurrence, weight gain and readmission rates. The highest compliancerate in this study was found in medication adherence and the lowest was found in the variableassociated with exercise. The risk of readmission for patients who completed the IVR call,answered all the questions and listened to the educational prompts was lower than the patients whowere called back by nurses. These results suggest that IVR calls do have a positive impact on HFpatients. The increased use of IVR in remote patient monitoring will allow for a cheaper and moreaccessible form of at home monitoring. Leveraging IVR technology to support other conditions,especially during a pandemic, may be beneficial for patients to avoid unnecessary visits to thehospital and complications due to delay in seeking care.

The theophylline clearance was evaluated in patients with liver dysfunction and/or congestive heart failure. One hundred and twenty two patients were categorized into four groups; Group I: Liver dysfunction (n=20), Group II: Congestive heart failure (CHF, n=22), Group III: Both liver dysfunction and CHF (n=12), and Group IV: Control group (n=68). The severity of liver dysfunction and CHF were evaluated using Child-Turcotte- Pugh index (CTP) and a Cardiac Function index, respectively. Theophylline clearance was significantly decreased in Groups I, II, and III when compared to the control group; but, no significant difference was found among these three groups (mean values were 0.515, 0.479, 0.417, and 0.682 mllmin/kg, respectively). Moreover, patients with compensated cirrhosis or moderate to severe CHF had the lowest theophylline clearance values (mean values 0.344, and 0.335 ml/min/kg, respectively). There was a significant correlation between Cardiac Function index and theophylline clearance (r=-0.621) in Group II. Smokers had larger theophylline clearance values than those of nonsmokers in Groups I, II, and IV. Impairment of theophylline clearance did not correlate well with any of the indices of liver function or the CTP index. A model for prediction of the clearance in CHF was developed, which consisted of a Cardiac Function index and smoking habit. This model accounts for approximately 60% of the variation of theophylline clearance. However, models describing theophylline clearance in liver dysfunction and in congestive heart failure with liver dysfun ction did not appear to be useful. Thus, routine laboratory data and indices of liver function were not helpful in evaluating the impaired hepatic theophylline elimination. The Cardiac Function index appeared to be useful in estimation of theophylline clearance in CHF; however, the association between the theophylline clearance and severe CHF needs to be evaluated further.

Yes / Medicines are often suboptimally managed for heart failure patients across the transition from hospital to home, potentially leading to poor patient outcomes. The Improving the Safety and Continuity Of Medicines management at Transitions of care programme included: understanding the problems faced by patients and healthcare professionals; developing and co-designing the Medicines at Transitions of care Intervention (MaTI); a cluster randomized controlled trial testing the effectiveness of a complex behavioural MaTI aimed at improving medicines management at the interface between hospitals discharge and community care for patients with heart failure; and a process evaluation. The MaTI included a patient-held My Medicines Toolkit; enhanced communication between the hospital and the patient's community pharmacist and increased engagement of the community pharmacist postdischarge. This paper reports on the patients' experiences of the MaTI and its implementation from the process evaluation. Twenty one-to-one semi-structured patient interviews from six intervention sites were conducted between November 2018 and January 2020. Data were analysed using the Framework method, involving patients as co-analysts. Interview data were triangulated with routine trial data, the Consolidated Framework for Implementation Research and a logic model. Within the hospital setting patients engaged with the toolkit according to whether staff raised awareness of the My Medicines Toolkit's importance and the time and place of its introduction. Patients' engagement with community pharmacy depended on their awareness of the community pharmacist's role, support sources and perceptions of involvement in medicines management. The toolkit's impact on patients' medicines management at home included reassurance during gaps in care, increased knowledge of medicines, enhanced ability to monitor health and seek support and supporting sharing medicines management between formal and informal care networks. Many patients perceived that the MaTI offered them support in their medicines management when transitioning from hospital into the community. Importantly, it can be incorporated into and built upon patients' lived experiences of heart failure. Key to its successful implementation is the quality of engagement of healthcare professionals in introducing the intervention. Patients were involved in the study design, as qualitative data co-analysts and as co-authors. / Programme Grants for Applied Research. Grant Number: RP-PG-0514-20009.

<p> Background: There is strong evidence to suggest that emotional distress, particularly depression, is common in patients with heart failure (HF). Caregivers of patients with HF play a pivotal role in improving HF patient outcomes; however, these caregivers are at risk for caregiver burden and emotional distress. Objectives: The objectives of this study were to explore potential relationships among patient and caregiver emotional status, uncertainty and caregiver appraisal. For the purposes of this study, emotional distress is defined as the presence of symptoms of anxiety or depression. Methods: Using a longitudinal exploratory design, 48 HF patient-caregiver pairs were recruited. Patients and caregivers completed the Hospital Anxiety and Depression Scale, Mishel Uncertainty in Illness Scale (MUIS) and caregivers also completed the Caregiver Reaction Assessment at baseline, 2 months and 4 months. Results: Patients had advanced HF symptoms and were older than caregivers (mean age 72.6 years, 54% male versus mean age 58.4 years, 54% female). The majority of caregivers were spouses (58%) but many were adult children (42%). There were significant relationships between: a) HF patient and caregiver uncertainty, and b) caregiver emotional distress and caregiver burden. There were no significant relationships between: a) patient and caregiver symptoms of anxiety and depression, b) emotional distress and uncertainty, or c) patient emotional distress and caregiver burden. Over time, there was a trend for a decrease in: a) patient symptoms of depression, b) caregiver symptoms of anxiety, and c) patient and caregiver uncertainty. Conclusions: Contrary to findings in other studies, there was no significant relationship between symptoms of anxiety and depression in patients and their primary caregivers. There was no relationship between emotional distress and uncertainty; however, this is one of the first studies using the MUIS in HF patients and caregivers and further research with this tool is needed. Finally, this study supports findings from other studies suggesting a strong relationship between caregiver emotional distress and caregiver burden. </p> / Thesis / Doctor of Philosophy (PhD)

Thesis (M.D.)—Boston University

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