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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.

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.

Introduction Heart failure (HF) is one of the leading causes of rehospitalization in the United States. Rehospitalizations are a costly outcome and are challenging to reduce due to multiple factors. Some interventions for reducing readmissions utilize predictive models to forecast adverse events such as mortality and rehospitalizations. Many rehospitalization risk scores were developed using hospital-based data from electronic health records (EHR). However, no rehospitalization risk score uses home healthcare EHR data. This study evaluated the production of a rehospitalization risk score using data from the Outcome and Assessment Information Set (OASIS) among home healthcare patients with HF after hospital discharge. Aim To produce a risk score for rehospitalization using OASIS among home healthcare patients with HF after hospital discharge. Methods This study was a secondary data analysis of the OASIS C version that was collected from January 1, 2011 to August 31, 2013. The dataset included N=836 patients. A multivariable logistic regression model was fitted to the rehospitalization outcome, using interactive backwards elimination variable selection. The final model included 9 predictor variables in a simple-to-use risk score that has a possible range (0 to 41). Regression coefficients were divided by the smallest regression coefficient and rounded to the nearest integer. For each patient risk factor, the integer weightings were summed to obtain the risk score. The predictive accuracy of the risk score was measured using the area under the receiver operating characteristic curve (i.e., c-statistic). The model was then internally validated using 10-fold cross validation. Results The median age was 79.5 years old, 43% were male, and 82% were white. We identified 9 significant risk factors: multiple hospitalization in the past 12 months, frequency of pain interfering, urinary incontinence, ability to grooming, ability to dress lower body, ability to feed, prior ability with everyday activities, the level of assistance, and Charlson comorbidity index score. For example, patients with grooming utensils must be placed within reach was a significantly greater risk compared to being able to groom self-unaided. The clinical prediction score which combined the patient's risk factors achieved a c-statistic of 0.64 (95%CI: 0.61 to 0.68). In the 10-fold cross-validation, the risk score had a c-statistic of 0.62 (95%CI: 0.58 to 0.65), which is the validated prediction accuracy expected in future home healthcare patients with HF. Conclusions This study developed a risk score for rehospitalization using OASIS among home healthcare patients with HF after hospital discharge. The risk scores of specific items such as the identified risk factors in this study could be an indicator of decision-making for personalized care.

Background Standardized pain-intensity measurement across different tools would enable practitioners to have confidence in clinical decision making for pain management. Objectives The purpose was to examine the degree of agreement among unidimensional pain scales and to determine the accuracy of the multidimensional pain scales in the diagnosis of severe pain. Methods A secondary analysis was performed. The sample included a convenience sample of 480 cancer patients recruited from both the Internet and community settings. Cancer pain was measured using the Verbal Descriptor Scale (VDS), the visual analog scale (VAS), the Faces Pain Scale (FPS), the McGill Pain Questionnaire-Short Form (MPQ-SF), and the Brief Pain Inventory-Short Form (BPI-SF). Data were analyzed using a multivariate analysis of variance and a receiver operating characteristic curve. Results The agreement between the VDS and VAS was 77.25%, whereas the agreement was 71.88% and 71.60% between the VDS and FPS, and VAS and FPS, respectively. The MPQ-SF and BPI-SF yielded high accuracy in the diagnosis of severe pain. Cutoff points for severe pain were more than 8 for the MPQ-SF and more than 14 for the BPI-SF, which exhibited high sensitivity and relatively low specificity. Conclusion The study found substantial agreement between the unidimensional pain scales and high accuracy of the MPQ-SF and the BPI-SF in the diagnosis of severe pain. Implications for practice Use of 1 or more pain screening tools that have validated diagnostic accuracy and consistency will help classify pain effectively and subsequently promote optimal pain control in multiethnic groups of cancer patients.

Pain is common among older adults, and is often underreported because it is considered as part of the normal physiological changes that come with aging. Since self-report of pain is the gold standard in research and practice, it is important to use the appropriate pain assessment tools to facilitate self-report. Little is known which self-report pain assessment tools are most appropriate to use in cognitively intact older adults. Thus, the purpose of this review is to identify which tools have been recognized as appropriate tools for this population. A systematic search was conducted through indexed databases from January 1990 to December 2015. Two raters independently evaluated 35% of abstracts based on inclusion/exclusion criteria. A final set of 43 full articles was reviewed. There were 23 self-reported pain assessment tools including non-dimensional, unidimensional, and multidimensional tools. In this review, the Iowa Pain Thermometer, the 6-point Verbal Descriptor Scale, and the 11-point Verbal Numeric Rating Scale, the short form Brief Pain Inventory and the Geriatric Pain Measure were recognized as more suitable tools than any other tools in cognitively intact older adults across different settings. Only the Geriatric Painful Event Inventory and the Geriatric Pain Measure were developed specifically for older adults. Since 80% of older adults have at least one chronic disease, multidimensional tools such as the Geriatric Pain Measure may be more appropriate. More studies are needed to evaluate the psychometric tests of the Geriatric Pain Measure in different settings, racially diverse populations and diseases or clinical conditions.

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.

Demand for home health care services for older adults is rapidly increasing. Older adults have the greatest number of chronic diseases and consequently are the largest consumers of home health care services in the US. Patient-centered technologies that support personal health information management for patients, such as patient portals, are being developed; however, little is known about how older adults and their caregivers use patient portals and whether health information is exchanged between patients and home health care providers. Home health care nurses represent the largest group of home health care providers. The purpose of our qualitative study is to gain insight into the health information exchange between older adults and home health care nurses. We are conducting semi-structured interviews with approximately 15–20 home health care nurses employed by two home health care agencies located in Philadelphia and in Seattle. We have completed nine interviews and intend to continue enrolling participants until we reach saturation. We will discuss the results of our qualitative interviews including the role of home health care nurses in personal health information management of older adults, specifically with regard to patient portal use. We will analyze barriers and facilitators to health information exchange between older adults and home health care nurses. These findings will contribute to the development of design criterial for a tool to support the health information management needs of older adults, their caregivers, and their providers.

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.