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Pain is not uncommon in older adult patients with heart failure (HF) and has been identified as a risk factor for rehospitalization of homebound patients with HF. Little is known about the pain experiences and management of older adults with HF after hospital discharge. We sought to describe pain and other symptoms among homebound older adults with HF using a qualitative and descriptive approach. We conducted semistructured interviews to obtain qualitative data and used the Brief Pain Instrument-Short Form and the Edmonton Symptom Assessment Scale to obtain descriptive data on symptom burden. We interviewed 18 participants within 10 days after hospital discharge. Participants’ mean age was 75.8 ± 9.0 years; 78% were White. The mean pain score at its worst was 5.2 ± 3.1, and for pain interfering with sleep was 4.3 ± 3.41. Most participants managed pain with medications. Using thematic analysis of qualitative data, we identified three distinct categories: (1) the diversity of patients’ pain experiences, (2) the diversity of pain management routines, and (3) patients’ experiences with healthcare providers’ pain assessment and management practices. Our findings show that homebound older adults with HF experience various pain symptoms and receive inconsistent education about how to manage pain from healthcare providers. This study supports the need for better pain assessment and education about the appropriate use of pain medications and nonpharmacologic approaches to pain control for homebound older adults with HF.

Heart failure (HF) is one of the leading causes of rehospitalization in the United States. Due to the complex nature of HF, the provision of Medicare-certified home healthcare services has increased. Medicare-certified home healthcare agencies measure and report patients' outcomes such as functional status, activities of daily living (ADL), and instrumental activities of daily living to the Centers for Medicare and Medicaid Services. These metrics are assessed using the Outcome and Assessment Information Set (OASIS). As a large data set, OASIS has been used to advance care quality in multiple ways including identifying risk factors for negative patient outcomes. However, there is a lack of OASIS analyses to assess the relationship between functional status and the role of other factors, such as pain, in impeding recovery after hospitalization among HF patients. Therefore, the purpose of this study is to identify the relationship between functional status and pain using the OASIS database. Among 489 HF patients admitted to home healthcare, 83% were White, 57% were female, and the median age was 80. Patients who reported daily but not constant activity-interfering pain at discharge demonstrated the least improvement in functional performance as measured by ADLs, whereas patients without activity-interfering pain demonstrated the greatest improvement in ADL performance (p value = 0.0284). Tracking individual patient ADL scores, particularly the frequency of activity-interfering pain, could be a key indicator for clinical focus for patients with HF in the home healthcare setting.

Frequent rehospitalizations among patients with heart failure (HF) result in patient burden and cost. Homebound patients with HF qualify for home healthcare after hospital discharge. Whether nonhomebound ambulatory patients with HF could also benefit from home healthcare nursing (HHN) visits to improve the transition from hospital to home has not been tested. The purpose of our quality-improvement pilot study was to assess the impact of HHN visits provided to ambulatory patients after hospital discharge on the 30-day rehospitalization rate. We included patients with HF ineligible for home healthcare services at hospital discharge due to their nonhomebound status. Home healthcare nurses followed a modified version of the Discharge Checklist from the American Heart Association’s Rise Above Heart Failure materials. Home healthcare nurses provided education as appropriate based on patients’ responses. We enrolled 68 patients in the study. The mean age was 60 years; 61% were male and 80% were White. Based on patient responses to the Checklist, key areas addressed during HHN visits were medication management, self-care, and adherence to HF behaviors. The 30-day rehospitalization rate of the study patients was 15%, compared with 23% among 540 patients discharged in the same time frame who met the inclusion criteria but were not enrolled in the study (p = .12). Our pilot data show that HHNs in ambulatory patients are feasible and result in a numerically lower 30-day rehospitalization rate after discharge. Further study is needed to confirm the clinical efficacy of this approach.

Cardiopulmonary rehabilitation (CR) improves physical function and quality of life (QoL) in chronic obstructive pulmonary disease (COPD) and heart failure (HF), but it is unknown if CR improves outcomes in very severe disease. This study’s purpose was to describe functional capacity (6-min walk distance [6MWD], steps/day), symptoms (dyspnea, depression), QoL (Short-Form Health Survey–Veterans [SF-36 V]) and cardiopulmonary function ( N-terminal pro-brain natriuretic peptide [NT-proBNP], forced expiratory volume in 1 s [FEV1]), and derive predictors of mortality among patients with severe COPD and HF who participated in CR.Methods and Results:In this secondary analysis of a randomized controlled trial comparing two CR methods in severe COPD and HF, 90 (COPD = 63, HF = 27) male veterans, mean age 66 ± 9.24 years, 79% Caucasian, and body mass index 31 kg/m2, were followed for 12 months after CR. The COPD group had greater functional decline than the HF group (6MWD, p = .006). Dyspnea was lower ( p = .001) and QoL higher ( p = .006) in the HF group. Mean NT-proBNP was higher in the HF group at all time points. FEV1improved over 12 months in both groups ( p = .01). Mortality was 8.9%, 16.7%, and 37.8% at 12, 24, and 60 months, respectively. One-year predictors of mortality were baseline total steps (2,000 mg/pg).Conclusions:In very severe COPD and HF, risks of mortality over 12 months can predict patients unlikely to benefit from CR and should be considered at initial referral.

The availability of smartphone applications has increased rapidly including applications related to palliative care. The scope of these available apps has not been synthesized.The purpose of this study was to identify and review available palliative care-related smartphone applications for clinicians.Smartphone application platform stores, for example, App Store iOS, Google Play Store, Windows App-Microsoft Store, and Blackberry World App store were searched (December 2016) using relevant key words.Forty-six palliative care applications targeting clinicians were identified, including clinical guidelines (n = 17), advance care planning (n = 9), training materials in palliative care (n = 7), and pharmaceutical tools (n = 7), and platforms for distributing current palliative care news, articles, and opinions (n = 6). The majority of the applications were free and available in English. The most common platforms were Android and iOS.The number of palliative care apps targeting clinicians has increased dramatically for the past five years. However, many apps did not report adequate information to judge the evidence upon which the apps were based.

Objective: To identify potential risk factors associated with rehospitalization among Medicare recipients with heart failure (HF) receiving telehomecare. Materials and Methods: This study is a nonexperimental, cross-sectional secondary data analysis of the Centers for Medicare and Medicaid (CMS) mandated assessment called the Outcome and Assessment Information Set (OASIS)–C, provided by a large home care company. A total of 526 patients who received telehomecare from January 1, 2011 to August 31, 2013 were included in the analyses, which used multiple logistic regression. Results: The overall rate of rehospitalization was 36% while patients were receiving telehomecare. Moderately frail health status (p = 0.01), the presence of severe pain (p = 0.01), the presence of dermatologic problems (p = 0.03), and independence in dressing one's lower body (compared to slightly dependent [p = 0.01] or mostly dependent patient groups [p = 0.02]) were identified as risk factors for rehospitalization. Conclusions: The risk factors identified from this study may be used to drive more effective telehomecare placements, and referrals for additional services among telehomecare patients with HF.

Pain symptoms are underreported in older adults (i.e., those ages ≥65), because many consider it a part of aging. Pain is highly prevalent in patients with heart failure (HF). HF is increasing in incidence with the aging population. Pain is also an important risk factor for rehospitalization among home healthcare patients with HF. However, little is known about the pain experiences of older adults with HF after hospital discharge. Accordingly, this study sought to describe pain and other symptoms among older adults with HF in the home healthcare setting using a mixed-methods approach. We conducted semi-structured interviews. We used the Edmonton Symptom Assessment Scale and Brief Pain Instrument on older adults (N=17) with HF in the home healthcare setting within 10 days of hospital discharge. The mean age was 76±9.25 years, nearly 50% were female, and most (90%) were White. The majority of participants managed pain with medications. Loss of appetite had the highest mean severity score (3.88±2.50) of symptoms measured. The mean score for pain at its worst was 4.94±3.07. Pain interfering with sleep had the highest mean score (4.24±3.36). Using content analysis we identified 4 distinct themes regarding the pain experience: (1) differences in the pain experiences before and after being diagnosed of HF, (2) symptoms accompanied with pain, (3) health care providers’ pain assessment, and (4) knowledge about pain management. These findings will contribute to the development and evaluation of a pain assessment and management protocol targeting older adults with HF in the home healthcare setting.

Activities of daily living (ADL) and instrumental activities of daily living (IADL) are often used as indicators of a patient’s functional status. For example, the items of ADL and IADL are assessed using Outcome Assessment Information Set (OASIS), which is a system of electronic health records (

Purpose Renal impairment is highly prevalent among patients with cancer, and many patients have undiagnosed chronic kidney disease (CKD) from underlying disease, treatment, or both. African American individuals have disproportionate risk factors (diabetes, hypertension) predisposing them to CKD. We investigated whether African American patients are more likely than white patients to receive morphine with 3- and 6-glucuronide metabolites, which are known to be neurotoxic and accumulate in CKD; whether insurance type mediates the relationship between race and the prescriber's opioid selection; and whether the chosen opioid has a resultant negative effect according to race. Patients and Methods Patients (N = 182) were recruited from oncology clinics within the University of Pennsylvania Health System. Inclusion was based on self-identified African American or white race, age older than 18 years, and the presence of cancer-related pain plus a prescription for morphine or oxycodone. Kidney function was estimated using the abbreviated Modification of Diet in Renal Disease formula. Results Patients with CKD who received morphine reported a greater severity of analgesic-related adverse effects than patients with CKD who received oxycodone (P = .010). Controlling for health insurance type, African American patients had 71% lower odds of receiving a prescription of oxycodone than white patients (P < .001). Limiting analysis to those with CKD, the effect of private insurance became insignificant. However, race still remained a significant predictor of the prescribed opioid selection. Race was a strong predictor of adverse effect severity in the presence of CKD, and the type of opioid selection partially mediated this relationship. Conclusion Reducing racial disparities in the type of opioid prescription and understanding mechanisms of disproportionate opioid-related adverse effects in African American patients might decrease the clinical disparities in cancer pain outcomes.

The energy intake goal is important to achieving energy intake in critically ill patients, yet clinical outcomes associated with energy goals have not been reported.This secondary analysis used the Improving Nutrition Practices in the Critically III International Nutrition Surveys database from 2007-2009 to evaluate whether mortality or time to discharge alive is related to use of complex energy prediction equations vs weight only. The sample size was 5672 patients in the intensive care unit (ICU) ≥ 4 days and a subset of 3356 in the ICU ≥ 12 days. Mortality and time to discharge alive were compared between groups by regression, controlling for age, sex, admission type, Acute Physiology and Chronic Health Evaluation II score, ICU geographic region, actual energy intake, and obesity.There was no difference in mortality between the use of complex and weight-only equations (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.86-1.15), but obesity (OR, 0.83; 95% CI, 0.71-0.96) and higher energy intake (OR, 0.65; 95% CI, 0.56-0.76) had lower odds of mortality. Time to discharge alive was shorter in patients fed using weight-only equations (hazard ratio [HR], 1.11; 95% CI, 1.01-1.23) in patients staying ≥ 4 days and with greater energy intake (HR, 1.19; 95% CI, 1.06-1.34) in patients in the ICU ≥ 12 days.These data suggest that higher energy intake is important to survival and time to discharge alive. However, the analysis was limited by actual energy intake70% of goal. Delivery of full goal intake will be needed to determine the relationship between the method of determining energy goal and clinical outcomes.

Clinicians working with patients who undergo bariatric surgery have found loss to follow-up challenging; however, the impact of this factor on postsurgical weight loss has not been adequately examined. The purpose of this study was to determine whether patients who returned for office visits after their gastric bypass (GBP) lost more weight than those who did not. All patients treated with GBP by a single surgeon during 2003 were eligible. Measured weights were obtained from surgical and local physician records over 24 months after GBP. Attender status was defined by whether patients attended the 12-month post-GBP visit, and number of visits attended was recorded. When measured weights were not available at 1.5, 6, 12, or 24 months, the previous measured weight was carried forward. Weight loss over time was compared by attender group and by visit number using mixed models and ≥50% excess weight loss (EWL) by logistic regression. Weight loss was greater in attenders and men (both p

Aims: A low-sodium diet is important for HF management to prevent fluid retention. Prior studies have found that patients have trouble judging their adherence to a low salt diet. Concordance between self-reported and objectively measured sodium levels was assessed and predictors of nonadherence to sodium recommendations were identified. Methods and Results: This was a secondary analysis of data collected from a prospective observational study. The Self Care of Heart Failure Index and 24hour urine sodium excretion were used to measure self-reported and objective adherence to a low-sodium diet in 280 Stage C HF patients. Mixed effect models were used to quantify the correlation between self-reported and objective measures at enrollment, 3and 6-months. There was no association between self-reported low-sodium diet and urinary sodium levels after controlling for age, gender, race, perceived health, income, comorbid conditions, data collection site, NYHA functional class, cognitive status, HF etiology, left ventricular ejection fraction, body mass index and diuretic use. Logistic regression was used to identify predictors of nonadherence. The odds of nonadherence to a low-sodium diet was about double for people who are obese (1.1-3.5, p50.028), male (1.13.6, p50.017), or have a low self-reported income (1.21-6.35, p50.016). The odds of non-adherence declined 3% for each year of age (1.0-5.0, p50.005). Conclusion: Clinicians should be cautious about basing clinical decisions on self-reported sodium intake without objective verification. Patient predictors of nonadherence such as male gender, obesity, lower income levels and younger age may help clinicians identify patients at risk for poor dietary adherence.