American Heart Journal
Volume 150, Issue 5 , Pages 984.e7-984.e13, November 2005

Vulnerabilities of patients recovering from an exacerbation of chronic heart failure

  • Debra K. Moser, DNSc, RN, FAAN

      Affiliations

    • College of Nursing, University of Kentucky, Lexington, Ken
    • Corresponding Author InformationReprint requests: Debra K. Moser, DNSc, RN, FAAN, College of Nursing, University of Kentucky, 527 CON, Lexington, KY 40536-0232.
    • ,
  • Lynn V. Doering, DNSc, RN

      Affiliations

    • University of California, Los Angeles, Calif
    • ,
  • Misook L. Chung, PhD, RN

      Affiliations

    • College of Nursing, University of Kentucky, Lexington, Ken

Received 3 January 2005; accepted 30 July 2005.

Article Outline

Background

Many rehospitalizations for heart failure (HF) are preventable as they are precipitated by modifiable factors. High early readmission rates suggest that patients commonly are discharged from HF hospitalizations with such problems unaddressed. The purpose of this study was to describe the prevalence of multiple risk factors for rehospitalization in patients recently discharged from a hospitalization for decompensated HF.

Methods and Results

The following potentially modifiable risk factors for rehospitalization were evaluated in 202 patients: functional status; whether the patient lived alone; presence of anxiety, depression, or poor quality of life; and symptom status and adherence to prescribed medications, low-sodium diet, and symptom monitoring recommendations. Most patients were severely functionally impaired (70% New York Heart Association [NYHA] functional class III/IV). Of the 28% of patients who lived alone, 50% were rated as NYHA functional class III or IV. Fifty percent of patients were anxious, whereas 69% of patients were depressed. Health-related quality of life was substantially impaired. Patients reported substantial symptom burden. Adherence with recommended self-care strategies was poor: 14% weighed themselves daily, 9% of patients reported monitoring for symptoms of worsening HF, 31% could not name any symptom, and only 34% of patients taking all medications as prescribed. A total of 23% of patients had all of the following risk factors: NYHA functional class III or IV, lived alone, ≥1 comorbidities, and were depressed or anxious.

Conclusions

Patients newly discharged from a hospitalization for HF exhibit many psychosocial and behavioral risk factors for rehospitalization, although they have been judged clinically stable.

 

Most of the enormous costs associated with heart failure (HF) care are attributable to rehospitalizations.1 After discharge from an exacerbation of HF, the 30-day, 60-day, and yearly readmission rates may be as high as 30%, 35%, and 60%, respectively.2, 3, 4, 5 Reducing the private and public burden of HF depends on preventing as many rehospitalizations as possible. As many as one half to two thirds of HF rehospitalizations may be preventable,6, 7, 8 as they are precipitated by modifiable factors such as nonadherence to medication and low-sodium diet recommendations, failure of patients to seek treatment of escalating symptoms,6, 7, 9, 10, 11, 12 and depression and lack of support due to living alone.6, 10, 11, 12, 13, 14

Patients hospitalized for an exacerbation of HF undergo assessment and treatment so that precipitating causes of the exacerbation can be uncovered and clinical status stabilized. Patients are not discharged until they are judged stable and able to assume responsibility (with help if necessary) for their care. However, the high rate of early rehospitalization for preventable causes suggests that these judgments may not be accurate for many patients. The purpose of this study was to describe the prevalence of multiple risk factors for rehospitalization (ie, functional status; whether the patient lived alone or not; presence of comorbidities; presence of anxiety, depression or poor quality of life; symptom status; and adherence to prescribed medications, low-sodium diet, and symptom-monitoring recommendations) in patients recently discharged from a hospitalization for an exacerbation of HF.

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Methods 

In this descriptive study, we examined potentially modifiable risk factors among patients with HF enrolled in a randomized controlled trial of a home-based HF disease management intervention. The data reported in this paper were collected at baseline before intervention.

Sample and setting 

Patients were recruited from 3 community hospitals. The areas served included rural, urban, and suburban communities among which socioeconomic status varied. Patients meeting inclusion criteria during a 1-year period who agreed to participate were enrolled. Inclusion criteria were the following: (1) discharged with a primary diagnosis of HF from either preserved or nonpreserved systolic function;(2) confirmed HF exacerbation15; and (3) discharged home. Patients were excluded if they were (1) discharged to an extended care facility; (2) referred for cardiac rehabilitation, hospice services, home care, or other home health service; or (3) suffering dementia.

Protocol 

This study was approved by the appropriate institutional review board committees, and all patients gave written informed consent. Data were collected by an advanced practice nurse who was a cardiopulmonary clinical nurse specialist with expertise in the care of patients with HF during a home visit that occurred within 3 to 7 days of hospital discharge.

Usual discharge education at each of the hospitals consisted of teaching, by staff nurses, about prescribed medications, following a low-salt diet, and monitoring for symptoms of worsening HF. Each patient was given a written discharge instruction sheet that included each medication to be taken, diet, and activity recommendations.

Measures 

Marital status and whether the patient lived alone were assessed from patient interview. In addition, for purposes of sample characterization, other sociodemographic data were collected.

Comorbidity data were collected using patient interview and medical record review, as were additional clinical data.

Depression and anxiety were measured using the Multiple Adjective Affect Checklist, a valid and reliable instrument.16 The Multiple Adjective Affect Checklist consists of 132 alphabetically arranged adjectives. Respondents are asked to check all that describe how they feel. Higher scores reflect higher levels of anxiety and depression. A score <7 on the anxiety subscale indicates lack of anxiety, whereas a score <11 on the depression subscale indicates the respondent has no depressive symptoms.

Health-related quality of life was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ).17, 18 The MLHFQ consists of 21 questions rated on a scale from 0 (no effect on quality of life) to 5 (great effect). Higher scores indicated worse quality of life. Questions concern a variety of physical and psychological aspects of living with HF. The MLHFQ has been used extensively in HF research, and reliability and validity of the instrument have been established.

Symptom status was measured using the Dyspnea/Fatigue Index.19 Using the instrument, 3 scales indicating the pace, intensity, and magnitude of effort needed to produce dyspnea or fatigue are graded on a scale from 0 (symptomatic at rest) to 4 (extraordinary effort required to produce symptoms). The theoretical range of the instrument is 0 (indicating the worst possible symptom status) to 12. Reliability and validity of this instrument have been established.19

Functional status was assessed using New York Heart Association [NYHA] functional class. To enhance reliability and validity of assessments, the same trained cardiovascular nurse performed all assessments, and the questioning used to assign a class was more extensive and structured than usually used in clinical practice.

Adherence to self-care recommendations was measured by analyzing the logs kept by the intervention nurses of the details of their first home visit. Adherence to the following recommendations was assessed: taking medications as prescribed at hospital discharge, following a low-sodium diet, weighing self daily, and symptom monitoring. Adherence to prescribed medications was assessed by having the patient show the nurse all medications taken each day and describe how often and how much of each were taken. Adherence to the sodium-restricted diet was assessed by having the patient review all foods and amounts eaten in the last 48 hours and then asking for a demonstration of how sodium content of selected foods eaten were calculated. Adherence to symptom monitoring was assessed by asking patients to describe the symptoms of worsening HF and how often and how they assessed for them. In addition, patients were asked how often they weighed themselves, if they planned to weigh themselves in the future, and to show their weight log.

Data analysis 

Descriptive statistics were used in this study, and data are presented as mean ± SD, medians or frequencies, and percentages, depending on the level of measurement. Data on adherence were abstracted from the patient logs of nurses caring for each patient. Reasons for medication nonadherence were abstracted first as individual items and then categorized by an expert HF clinician. Categorization was confirmed by 2 additional investigators.

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Results 

Sample characteristics 

A total of 206 patients with HF were enrolled. Four patients dropped from the study before the initial data collection period; thus, the final sample size was 202 (Table I). The sample included patients with both preserved (49%) and nonpreserved systolic function (51%). Most patients (88%) were under the care of a cardiologist during their hospitalization because of a consultation. Medication prescription patterns reflected use of evidence-based medicine (Table II).

Table I. Sociodemographic and clinical characteristics of 202 patients newly discharged from a hospitalization for exacerbation of chronic HF
Characteristic
Age (y)70 ± 12
Women (%)51
Marital status (%)
Married or cohabitate54
Widowed30
Single/divorced19
Living alone (%)28
Race (%)
White88
African American12
Heart failure etiology (%)
Ischemic63
Hypertension22
Idiopathic cardiomyopathy9
Others6
NYHA functional class (%)
I1
II30
III44
IV26
Diabetes mellitus (%)42
Chronic obstructive pulmonary disease (%)19
Stroke (%)10
Peripheral vascular disease (%)17
Prior myocardial infarction (%)30
Prior revascularization (%)30
Chronic renal failure (%)9
Hypertension (%)64
Discharge medications (%)
Diuretics94
Angiotensin converting enzyme inhibitors69
Angiotensin receptor blocking agents12
Digoxin58
β-Adrenergic blocking agents69
Aldosterone antagonists15
Nitrates28
Amiodarone12
Cholesterol-lowering agents37

Entries are mean ± SD or percentages.

Table II. Percentage of patients adhering to selected recommendations
Weighing behavior (%)
Daily14
Weekly17
Monthly22
Never47
Knowledge of symptoms of worsening HF (%)
Knew ≥2 symptoms16
Knew at least 1 symptom53
Did not know any symptoms31
Monitored for symptoms of worsening HF (%)9
Medication adherence (%)
Taking all medications as prescribed and not taking unprescribed medications34
Taking all prescribed medications plus ≥1 not prescribed12
Not taking all prescribed medications and not taking unprescribed medications28
Not taking all prescribed medications and taking medications not prescribed26
Low-sodium diet adherence (%)
Stated their physician did not prescribe a low-sodium diet20
Followed a low-sodium diet and could calculate sodium content8
Followed a low-sodium diet but could not calculate sodium content5
Did not follow a low-salt diet, but could calculate sodium content12
Did not follow a low-salt diet and could not calculate sodium content55

Functional status, comorbidities, marital status, and living alone 

Most patients were functionally impaired (70% NYHA class III/IV). Eighty-nine percent of patients had ≥1 of the comorbidities examined, and of these, 48% had ≥2 comorbidities. Of the 28% of patients who lived alone, 56% were widowed, 29% were single or divorced, and the remaining 15% were married. Of the 88 NYHA class III patients and the 52 NYHA class IV patients, 49% were living alone (Figure 1).

Depression and anxiety 

Patients' mean anxiety level was 7.8 ± 4.6 (median 7.0, range 0-21) and mean depression level was 15.6 ± 8.4 (median 16, range 1-37). Fifty percent of patients had symptoms of anxiety, whereas 69% of patients had depressive symptoms. Of the 50% of patients who were anxious, 5% had anxiety levels that were at least twice as high as the minimum cut-off point for anxiety. Of the 69% of patients who were depressed, 15% had depression levels that were at least twice as high as the minimum cut-off point for depression.

Health-related quality of life 

As measured by the total score of the MLHFQ, health-related quality of life was substantially impaired. The total score was 52 ± 24 with a median of 56, and a range of 2 to 95. Although there are no normative scores for this instrument, perspective can be gained by considering instrument scoring. If a respondent reported no negative impact of HF for the 21 items composing the MLHFQ, the score would be zero. If they indicated a moderately negative impact of HF for the 21 items, the score would be 63.

Symptom status 

The mean score on the Dyspnea/Fatigue Index was 5 ± 2.3 (median 5, range 0-11). Of the sample, 25% scored 3 or less, whereas 75% scored 6 or less. These numbers indicate that patients were experiencing substantial symptom burden.

Adherence 

Adherence with recommended self-care strategies is presented in Table II. With regard to daily weighing, only 14% weighed themselves daily. Only 9% of patients reported monitoring for symptoms of worsening HF. Although 53% of patients knew at least 1 symptom of worsening HF, 31% could not name any symptom.

Medication adherence was poor, with only 34% of patients taking all medications as prescribed and not taking unprescribed medications. The remaining patients either were not taking all prescribed medications or were taking unprescribed medications or both. Of those not taking medications as prescribed, the following reasons were seen (patients could have more than 1 reason): not understanding discharge instructions (57%), confused about apparently conflicting instructions between discharging physician and primary care physician (22%), unable to afford filling the prescription (18%), not being convinced of the utility of the medication (9%), and worried about potential side effects (7%). Patients took unprescribed medications for the following reasons: continued to take previously prescribed medications although not included on discharge instructions (68%), lack of confidence in new prescriptions so continued taking old ones (19%), had previous prescriptions of the same prescribed medication filled under a different drug name (eg, 1 prescription filled with generic name and 1 with the trade name) (8%), and confused medications of others in the household with their own (7%).

Regarding low-sodium diet adherence, 20% of patients reported that they had not received instructions from their physicians to follow a low-sodium diet or that their physician had specifically told them one was not necessary. Of the remaining 80%, 55% did not follow a low-sodium diet and could not calculate the sodium content of foods.

Composite risk factor status 

A total of 23% of patients had all of the following risk factors: NYHA class III or IV, lived alone, ≥1 comorbidities, and were depressed or anxious. A total of 14% of patients enrolled in this study had all of those risk factors and, in addition, were ≥70 years of age.

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Discussion 

Many health care providers hold the common belief that patients discharged from a hospitalization for an exacerbation of HF have reached an acceptable level of stability. Some investigators have challenged this assumption,20, 21 and findings from the current study indicate that not only are many discharged patients clinically unstable, but also, they are vulnerable to rehospitalization because they have several modifiable risk factors that place them at jeopardy for further decompensation. Among the patients enrolled in this study, the majority was functionally impaired and suffering significant symptom burden, depressed or anxious, and reported poor quality of life. Most patients had multiple comorbidities that complicate self-care, and many of the most impaired patients were living alone. In addition, most patients were not performing fundamental aspects of self-care that promote stability, and most were not adherent to the prescribed drug regimen despite receiving written discharge medication instructions. These data suggest that assessment of such risk factors be conducted in a thorough and systematic manner for patients being discharged after a hospitalization for HF, and the education and counseling about self-care strategies continue early after discharge.

A major question that arises when examining such findings is about the quality of care delivered to patients. It could be argued that the problems seen in this patient cohort were the result of poor care and do not reflect problems commonly seen in patients with HF newly discharged from a hospitalization for an exacerbation of HF. However, several points dispute this argument. First, patients in this study came from 3 different community hospitals in a large metropolitan city, so the findings are reflective of care delivered by a variety of different health care providers in 3 different hospital settings to patients from different social and economic backgrounds. Second, the usual discharge practice at each of these hospitals includes patient education about prescribed medications, following a low-salt diet, and monitoring for symptoms of worsening HF, including performance of daily weights. Each patient was given a written discharge instruction sheet that included delineation of each medication to be taken, diet to be followed, activity recommendations, and recommendations for daily weights. Third, 88% of patients received consultation from a cardiologist while they were in the hospital, a practice known to improve outcomes in patients with HF.22 Finally, discharge HF medications prescribed for patients participating in this study reflected recent recommendations by expert panels based on evidence-based medicine.23

Why then were patients so emotionally and physically impaired although they were judged physically stable and ready to return home? Accumulating evidence suggests a higher-than-normal rate of depression and anxiety among patients with HF.13, 24, 25, 26, 27, 28, 29 Moreover, the prevalence of poor health–related quality of life also is high among patients with HF30 and is at its worst when measured during or immediately after a hospitalization.8 Thus, it is likely that our findings reflect the prevalence of anxiety, depression, and poor health–related quality of life seen in patients with HF, particularly after the disruption of rehospitalization. Yet, because these factors rarely are measured clinically and health care providers do not consider their assessment part of the risk assessment process, clinicians commonly are unaware of the severity of negative emotions and poor quality of life. Emphasis during hospitalization on achieving physiological stability can lead to inadequate treatment of anxiety and depression and failure to address poor quality of life.31 Furthermore, clinicians are not adept at recognizing anxiety or depression without formal screening measures that are rarely used in clinical practice.31, 32 As a result, it appears patients often are discharged suffering significant psychological problems without appropriate referral or treatment.

With regard to patients' impaired physical status on discharge, there are 2 reasons that clinicians likely fail to appreciate the severity of symptoms and functional disability and discharge patients while they are still symptomatic. First, when patients are admitted for decompensated HF, they commonly are suffering extreme and often dramatic dyspnea and other symptoms.33, 34 Under these circumstances, the appreciable improvements that occur with therapy can obscure the intensity of symptoms and functional impairment remaining. Second, most hospitalized patients do not exert themselves at a level approximating the performance of usual daily activities. As a result, their symptom burden and functional status may not be clear to clinicians making discharge decisions.

The number of people discharged with serious functional impairment who lived alone is of concern. Such individuals are at high risk for a variety of poor outcomes, including falls, worsening functional status, nonadherence, and depression. Only patients who were not referred for home health care or other intervention were enrolled in this study. These data suggest the importance of thoroughly assessing functional status in patients about to be discharged. This is not to suggest that patients remain hospitalized until their functional status or other risk factors are improved but that clinicians need to fully assess for these risk factors and appropriately manage them. Seriously impaired patients, particularly those with other risk factors, can benefit from home health care early after discharge.

The low level of adherence to self-care activities seen among these patients is, on the surface, surprising, given the discharge instructions they received. However, adherence among HF patients generally is poor,6, 7, 11, 35, 36, 37, 38 and closer examination of the problems patients face as they attempt to cope with a chronic illness and complicated treatment regimen39 suggests that it is imprudent of health care providers to assume that simple educational methods will result in adherence. Like many health care providers who do not appreciate the chronicity of HF, patients have an “acute model” of chronic HF and often do not understand the relationship between their symptoms and the diagnosis of HF.40 Patients with HF have difficulty recognizing escalation of their own symptoms and do not make the link between symptom monitoring and actions that can be taken to prevent or manage worsening symptoms.39, 40, 41, 42 Knowledge of self-care strategies is poor,38, 42, 43 patient understanding of the purpose of medications is limited,44, 45 many patients can not differentiate symptoms of HF from what they believe are medication side effects,45 and knowledge frequently does not translate into behavior.39, 46 Educational efforts that rely on traditional methods using, short, one-time delivery of information, such as those used during a hospitalization, are ineffective.47, 48, 49

Several other factors likely contributed to the low adherence seen in this study. Patients in this study had a high rate of depression, and depression is linked to poor adherence in cardiac patients.50, 51 Depression and anxiety also limit the ability of individuals to learn and retain educational content. Having ≥1 comorbid conditions contributes to confusion about managing each condition.40 Living alone and lacking a source of support adversely affects adherence.52 The many factors common to newly discharged patients can accumulate to produce vulnerability to rehospitalization and other poor outcomes. Given the relationship between poor adherence and poor outcomes,53, 54 it is imperative that attention be given to addressing the psychosocial and behavioral risk factors identified.

One could argue that it would be natural for patients newly discharged from a hospitalization for HF to be anxious or depressed and have poor quality of life and that these will improve over time, thus decreasing patients' risk. Indeed, there is ample evidence that quality of life, in general, improves as time from discharge increases.55 However, despite improving after hospital discharge, quality of life remains poor and is worse than that seen in most patients with other chronic conditions.56 There is little research describing the natural course of anxiety or depression after discharge, but current evidence suggests that these persist in patients with HF, particularly when not diagnosed or treated.57, 58 Moreover, the high rate of 30- to 60-day hospital readmissions suggests that even if quality of life, anxiety, and depression improved in the long term, early unrecognized and untreated dysphoria and poor quality of life place patients at substantial risk.

This study is limited by our method of measuring adherence, which is based on self-report. There is no gold standard for assessing adherence, and even so-called objective methods are subject to many sources of error.59 However, the steps we took to confirm patients' reports and the details we assessed add to the validity of our measurement.

Summary 

Patients newly discharged from a hospitalization for exacerbation of HF are vulnerable to rehospitalization. The number of psychological, social, and behavioral risk factors that challenge many patients adds substantially to the risk burden conferred by physiological factors. Depression, anxiety, poor quality of life, functional impairment, poor symptom status, suboptimal living situation, comorbidities, and poor adherence are common among discharged HF patients. Healthcare providers must develop more aggressive strategies to assess these risk factors so that they can be appropriately managed after discharge. Earlier follow-up appointments and greater vigilance are warranted to detect patients at risk so that they can be treated before risk factors escalate.

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PII: S0002-8703(05)00756-8

doi:10.1016/j.ahj.2005.07.028

American Heart Journal
Volume 150, Issue 5 , Pages 984.e7-984.e13, November 2005

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