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Background: Weight monitoring is an important element of HF self-care, yet the most clinically meaningful way to evaluate weight monitoring adherence is uncertain. We conducted this study to evaluate the association of (1) self-reported recall and (2) dail

Objective: Little is known about how best to target cardiovascular health promotion messages to minorities. This study describes key lessons that emerged from a community and culture-centered approach to developing a multimedia, coronary heart disease (CHD) patient education program (PEP) for medically underserved South Asian immigrants.Methods: The prototype PEP integrated the surface structures (e.g. language) and deeper structures (e.g. explanatory models (EMs), values) of South Asians' socio-cultural context. Seven focus groups and 13 individual interviews were used to investigate South Asians' reactions and obtain qualitative feedback after viewing the culturally targeted PEP. Qualitative data were organized into emergent thematic constructs.Results: Participants (n=56) mean age was 51 years and 48 % were Hindi speakers. Community members had a strong, negative reaction to some of the targeted messages, "This statement is a bold attack. You are pin-pointing one community." Other important themes emerged from focus groups and interviews about the PEP: 1) it did not capture the community's heterogeneity; 2) did not sufficiently incorporate South Asians' EMs of CHD; and 3) did not address economic barriers to CHD prevention. Feedback was used to revise the PEP.Conclusion: A community and culture-centered approach to developing cardiovascular health promotion messages revealed tensions between the researcher's vantage point of "cultural targeting" and the community's perceptions and reactions to these messages. Engaging communities in every phase of message design, incorporating their EMs, recognizing community heterogeneity, and addressing economic and structural barriers, are critical steps to ensuring that health promotion messages reach their intended audience and achieve true cultural appropriateness. [ABSTRACT FROM AUTHOR]

Background: Emerging evidence suggests the relationship between health literacy and health outcomes could be explained by cognitive abilities.Objective: To investigate to what degree cognitive skills explain associations between health literacy, performance on common health tasks, and functional health status.Design: Two face-to-face, structured interviews spaced a week apart with three health literacy assessments and a comprehensive cognitive battery measuring 'fluid' abilities necessary to learn and apply new information, and 'crystallized' abilities such as background knowledge.Setting: An academic general internal medicine practice and three federally qualified health centers in Chicago, Illinois.Patients: Eight hundred and eighty-two English-speaking adults ages 55 to 74.Measurements: Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy in Adults (TOFHLA), and Newest Vital Sign (NVS). Performance on common health tasks were globally assessed and categorized as 1) comprehending print information, 2) recalling spoken information, 3) recalling multimedia information, 4) dosing and organizing medication, and 5) healthcare problem-solving.Results: Health literacy measures were strongly correlated with fluid and crystallized cognitive abilities (range: r=0.57 to 0.77, all p<0.001). Lower health literacy and weaker fluid and crystallized abilities were associated with poorer performance on healthcare tasks. In multivariable analyses, the association between health literacy and task performance was substantially reduced once fluid and crystallized cognitive abilities were entered into models (without cognitive abilities: β= -28.9, 95 % Confidence Interval (CI) -31.4 to -26.4, p; with cognitive abilities: β= -8.5, 95 % CI -10.9 to -6.0).Limitations: Cross-sectional analyses, English-speaking, older adults only.Conclusions: The most common measures used in health literacy studies are detecting individual differences in cognitive abilities, which may predict one's capacity to engage in self-care and achieve desirable health outcomes. Future interventions should respond to all of the cognitive demands patients face in managing health, beyond reading and numeracy. [ABSTRACT FROM AUTHOR]

Rationale: Checklists may reduce errors of omission for critically ill patients.Objectives: To determine whether prompting to use a checklist improves process of care and clinical outcomes.Methods: We conducted a cohort study in the medical intensive care unit (MICU) of a tertiary care university hospital. Patients admitted to either of two independent MICU teams were included. Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting.Measurements and Main Results: One hundred and forty prompted group patients were compared with 125 control and 1,283 preintervention patients. Compared with control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of deep vein thrombosis and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared with the control group (odds ratio, 0.36; 95% confidence interval, 0.13-0.96; P = 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P = 0.014), which remained significant after risk adjustment (odds ratio, 0.34; 95% confidence interval, 0.15-0.76; P = 0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared with control (0.59 vs. 0.87; P = 0.02). Checklist availability alone did not improve mortality or length of stay compared with preintervention patients.Conclusions: In this single-site, preliminary study, checklist-based prompting improved multiple processes of care, and may have improved mortality and length of stay, compared with a stand-alone checklist. The manner in which checklists are implemented is of great consequence in the care of critically ill patients. [ABSTRACT FROM AUTHOR]

Self-administration of a multimedia health literacy measure in clinic settings is a novel concept. Demonstrated ease of use and acceptability will help predicate the future value of this strategy. We previously demonstrated the acceptability of a "Talking Touchscreen" for health status assessment. For this study, we adapted the touchscreen for self-administration of a new health literacy measure. Primary care patients (n = 610) in clinics for underserved populations completed health status and health literacy questions on the Talking Touchscreen and participated in an interview. Participants were 51% women, 10% age 60+, 67% African American, 18% without a high school education, and 14% without any prior computer experience. The majority (93%) had no difficulty using the touchscreen, including those who were computer-naive (87%). Most rated the screen design as very good or excellent (72%), including computer-naive patients (71%) and older patients (75%). Acceptability of the touchscreen did not differ by health literacy level. The Talking Touchscreen was easy to use and acceptable for self-administration of a new health literacy measure. Self-administration should reduce staff burden and costs, interview bias, and feelings of embarrassment by those with lower literacy. Tools like the Talking Touchscreen may increase exposure of underserved populations to new technologies. [ABSTRACT FROM AUTHOR]

Background: Dyspnea is a common symptom among patients with heart failure. Currently, there is no standardized, rapid, precise method to assess dyspnea.Methods and Results: From a review of the literature, we pooled questions from various questionnaires assessing dyspnea. A total of 201 patients with heart failure completed all questions in the preliminary item bank. Each item asks how much shortness of breath the patient had when doing an activity. Medical charts were reviewed for hospitalization within 1 or 3 months of completing the questions. We created a dyspnea item bank of 44 items. Computer adaptive tests (CAT) generated from this item bank can assess dyspnea by administering on average 10 questions. Simulation CAT scores were generated to compare with the item bank scores. The CAT scores had a correlation of 0.98 with item bank scores. Logistic regression models predicting the probability of being hospitalized from the dyspnea score were statistically significant (P < .05). A 5-point score increase was associated with a 32% increased odds of hospitalization in 1 month and a 20% increased odds of hospitalization in 3 months.Conclusions: This computer-based tool for dyspnea assessment obtains similar precision to that of answering the entire dyspnea item bank with less patient burden. [ABSTRACT FROM AUTHOR]

BACKGROUND: Interdisciplinary communication is critically important to provide safe and effective care, yet it has been inadequately studied for hospitalised medical patients. Our objective was to characterise nurse-physician communication and their agreement on patients' plan of care. METHODS: During a one-month period, randomly selected hospitalised patients, their nurses and their physicians were interviewed. Nurses and physicians were asked to identify one another, whether communication had occurred, and about six aspects of the plan of care. Two internists rated nurse-physician agreement on aspects of the plan of care as none, partial or complete agreement. Measures included the percentage of nurses and physicians able to identify one another and reporting communication and the percentage of nurse-physician pairs in agreement on aspects of the plan of care. RESULTS: 310 (91%) and 301 (88%) of 342 eligible nurses and physicians completed interviews. Nurses correctly identified patients' physicians 71% of the time and reported communicating with them 50% of the time. Physicians correctly identified the patients' nurses 36% of the time and reported communicating with them 62% of the time. Physicians and nurses showed no agreement on aspects of the plan of care ranging from 11% for planned procedures to 42% for medication changes. CONCLUSIONS: Nurses and physicians did not reliably communicate with one another and were often not in agreement on the plan of care for hospitalised medical patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Studies demonstrating the value of hospitalists to medical student education have been performed in traditional resident covered ward service settings (RCWS). PURPOSE: To compare medical subinterns' experiences on an RCWS to that on a resident uncovered hospitalist service (RUHS). METHODS: We assessed students' overall experience and knowledge learned on the two services using a 5-point Likert scale. We also assessed learning environment characteristics, workload, and time spent at the hospital on each service. RESULTS: The mean rating for knowledge learned was higher on the RCWS. Subinterns rated the two services equivalent on measures of educational value of patient problems, faculty assessment, supervision, and number and value of teaching sessions. The RCWS received higher ratings on variety of patient problems and frequency of intellectual discussion. CONCLUSIONS: The RCWS provided a superior learning experience for subinterns. Academic medical centers should take these findings into consideration before placing medical students on an RUHS. [ABSTRACT FROM AUTHOR]

Context: Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events.Objectives: To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process.Data Sources: MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies.Study Selection: Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18).Data Extraction: Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer.Data Synthesis: Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents.Conclusions: Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although individuals' health insurance coverage changes frequently, previous analyses have not accounted for changes in insurance coverage over time. OBJECTIVE: We sought to determine the independent association between lack of insurance and the risk of a decline in self-reported overall health and death from 1992 to 2002, accounting for changes in self-reported overall health and insurance coverage. METHODS: We analyzed data from the Health and Retirement study, a prospective cohort study of a national sample of community-dwelling adults age 51-61 years old at baseline. Major decline in self-reported overall health and mortality was determined at 2-year intervals. RESULTS: People who were uninsured at baseline had a 35% (95% confidence interval [CI] 12-62%) higher risk-adjusted mortality from 1992 to 2002 compared with those with private insurance. However, when we analyzed outcomes over 2-year intervals, individuals who were uninsured at the start of each interval were more likely to have a major decline in their overall health (pooled adjusted relative risk 1.43, 95% CI 1.28-1.63), but they were equally likely to die (pooled adjusted relative risk 0.96, 95% CI 0.73-1.27). Of the 1512 people who were uninsured at baseline, 220 (14.6%) died; of those who died, only 70 (31.8%) were still uninsured at the HRS interview prior to death. CONCLUSIONS: Death does not appear to be a short-term consequence of being uninsured. Instead, higher long-term mortality among the uninsured results from erosion in this population's health status over time and the attendant higher mortality associated with this. Most deaths among the uninsured occur after individuals have gained either public or private health insurance. [ABSTRACT FROM AUTHOR]

Background: Organizationally based, disease-targeted collaborative quality improvement efforts are widely applied but have not been subject to rigorous evaluation. We evaluated the effects of the Institute of Healthcare Improvement's Breakthrough Series (IHI BTS) on quality of care for chronic heart failure (CHF).Research Design: We conducted a quasi-experiment in 4 organizations participating in the IHI BTS for CHF in 1999-2000 and 4 comparable control organizations. We reviewed a total of 489 medical records obtained from the sites and used a computerized data collection tool to measure performance on 23 predefined quality indicators. We then compared differences in indicator performance between the baseline and post-intervention periods for participating and non-participating organizations.Results: Participating and control patients did not differ significantly with regard to measured clinical factors at baseline. After adjusting for age, gender, number of chronic conditions, and clustering by site, participating sites showed greater improvement than control sites for 11 of the 21 indicators, including use of lipid-lowering and angiotensin converting enzyme inhibition therapy. When all indicators were combined into a single overall process score, participating sites improved more than controls (17% versus 1%, P < 0.0001). The improvement was greatest for measures of education and counseling (24% versus -1%, P < 0.0001).Conclusions: Organizational participation in a common disease-targeted collaborative provider interaction improved a wide range of processes of care for CHF, including both medical therapeutics and education and counseling. Our data support the use of programs like the IHI BTS in improving the processes of care for patients with chronic diseases. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We examined the relation between body mass index, exercise, overall health, and physical functioning. METHODS: We studied 7867 adults aged 51 to 61 years in 1992 to 1996. Adjusted relative risks for health decline and new physical difficulties were determined with logistic regression. RESULTS: Overweight and obesity were independently associated with health decline (adjusted relative risk [ARR] = 1.29 and 1.36) and development of a new physical difficulty (ARR = 1.27 and 1.45). Regular exercise significantly reduced the risk of health decline and development of a new physical difficulty, even among obese individuals. CONCLUSIONS: Maintaining ideal body weight is important in preventing decline in overall health and physical functioning. However, regular exercise can reduce the risk of health decline even among individuals who cannot achieve ideal weight. [ABSTRACT FROM AUTHOR]

Review of: ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). Hunt SA, Baker DW, Chin MH et al. American College of Cardiology/American Heart Association. J Am Coll Cardiol 2001;38:2101-2113. BACKGROUND: Heart failure (HF) is the only cardiovascular disease with increasing incidence and prevalence. Most HF patients are older adults. With the aging of the population and effective treatment of hypertension and coronary artery disease, the two major underlying causes of HF, the number of older Americans with HF is expected to rise significantly in the coming decades. HF is the number one hospital discharge diagnosis for older adults. It is one of the causes of frequent hospital readmissions, reflecting acute decompensation and compromised quality of life for patients and increased cost and resource use for the healthcare system. It is also associated with approximately 300,000 deaths annually, most in older adults. Advances in the management of HF in the past several decades have significantly decreased the mortality and morbidity associated with this condition. Randomized controlled trials have demonstrated the beneficial effects of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers, and spironolactone on survival and quality of life of HF patients, but there is evidence of underuse of evidence-based care for HF. Several national guidelines have been published since 1994 that recommended evidence-based evaluation and management of HF. In 1995, the American College of Cardiologists (ACC) and the American Heart Association (AHA) published their first HF guidelines that recommended left ventricular (LV) function evaluation for all patients presenting with HF and use of ACE inhibitors for... [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare the effect of 2 feedback strategies on the adherence to congestive heart failure (CHF) guidelines. Thirty-two hospitals in 4 states were randomized to receive either a written feedback intervention (low-intensity intervention [LII]) or an intervention involving feedback, a physician liaison, and quality improvement tools (high-intensity intervention [HII]). CHF quality indicators were assessed, and quality managers were interviewed at baseline and remeasurement. No significant changes in quality indicators were found as a result of either intervention. Seventy-eight percent of quality managers indicated that hospital project implementation had not begun until shortly before remeasurement. HII quality managers perceived the CHF project as significantly more successful compared with LII quality managers (63% versus 13%, P < .01). Evaluation of the effects of external feedback on practice behavior requires sufficient time for organizational and individual clinician change to occur. Physician liaisons may play a role in facilitating this change. [ABSTRACT FROM AUTHOR]

The objective was to determine physicians' ratings of the clinical importance of common adult symptoms and to use these ratings to develop a new measure of symptom-specific use of health care services. We developed a list of common symptoms using the National Ambulatory Medical Care survey. We surveyed a random sample of internists, family physicians, general practitioners and emergency medicine physicians from the American Medical Association's Physician Masterfile and asked them to rate symptoms' seriousness, impact on quality of life and urgency of need for medical attention. The symptoms' prevalences were determined in a general population survey (National Access to Care Survey). Eleven items were classified as 'serious' (median seriousness ratings of 7 or higher on scale from 1 to 10); most of these also were judged to have high impact on quality of life. Another 12 items that were not judged 'serious' had median quality of life impact scores of 7 or higher and were classified as 'morbid'. Sixteen items did not meet criteria for either 'serious' or 'morbid' symptoms and were classified as 'intermediate'. Six other items had median seriousness and quality of life impact scores of 3 or less and were classified as 'benign'. A total of 24 of these items (7 'serious', 8 'morbid', 8 'intermediate' and 1 'benign') were selected to form the symptom-response measure. In the national survey, 26.3% reported one or more serious symptom, 30.6% reported one or more morbid symptom and 29.6% reported one or more intermediate symptom. This new instrument expands on earlier 'symptom-response' measures by including a larger number and a broader spectrum of symptoms. This measure should be useful to assess differences in patterns of health care use for particularly serious or morbid conditions; such variations may indicate problems with access to medical care. [ABSTRACT FROM AUTHOR]

Objective: This article reviews the benefits and risks of coronary artery bypass grafting and angioplasty for patients with moderate or severe left ventricular systolic dysfunction and summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline.Data Sources: Data were obtained from studies published in English and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass grafting and angioplasty.Study Selection: All cohort studies and case series that provided separate outcomes data on a subgroup of patients with a left ventricular ejection fraction less than 0.40 were reviewed.Data Extraction and Synthesis: Studies were reviewed for inclusion and exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of study quality using a defined list of study flaws.Conclusion: Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart Association class in patients with moderate to severe left ventricular dysfunction and limiting angina. However, the operative mortality ranges from 5% to 30% depending on patients' ejection fractions and comorbidity. It is not clear whether patients whose predominant symptom is heart failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outcomes after angioplasty have not been adequately studied to determine the relative risks and benefits compared with bypass grafting. [ABSTRACT FROM AUTHOR]

Objective: This article reviews the role of counseling, education, dietary modifications, and exercise for patients with heart failure due to left ventricular systolic dysfunction.Data Source: We reviewed studies published in English between 1966 and 1993 and referenced in MEDLINE or EMBASE. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific areas of interest. Where data were lacking, we relied on opinions of panel members and peer reviewers. STUDY SELECTION AND DATA SYNTHESIS: Studies were reviewed to determine whether patients had heart failure due to systolic dysfunction (left ventricular ejection fraction, < 0.35 to 0.40) and whether clinical outcomes were reported. Studies that reported only intermediate outcomes (eg, hemodynamics) were not reviewed.Conclusion: Counseling and education can improve patient outcomes and decrease unnecessary hospitalizations. Patients with mild to moderate heart failure should be restricted to 3 g/d of sodium initially. Those who are unresponsive to this dosage or who have more severe disease should be advised to consume 2 g/d or less. Patients should be strongly advised to drink no more than 30 mL/d of alcohol or, preferably, to abstain completely. Exercise training is safe and can improve exercise duration and symptoms. Adherence to the treatment plan should be stressed and monitored at each visit. Clinicians should inform patients of the seriousness of their disease and their prognosis, but they should emphasize that patients can continue to remain active and enjoy a reasonable quality of life. [ABSTRACT FROM AUTHOR]

Objective: This review of the pharmacologic treatment of heart failure due to left ventricular systolic dysfunction summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. It provides specific advice to help guide practitioners through clinical decision making.Data Sources: Data were obtained from English-language studies and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific treatments. Where data were lacking, we relied on opinions of panel members and peer reviewers.Study Selection: Only large prospective trials were used to estimate treatment efficacy. Smaller trials, case series, and case reports were reviewed for the incidence of adverse effects.Data Extraction and Synthesis: Randomized clinical trials were reviewed for inclusion and exclusion criteria, patient outcomes, adverse effects, and eight categories of study quality using a defined list of study flaws.Conclusion: Angiotensin-converting enzyme (ACE) inhibitors should be given to all patients unless specific contraindications exist. Diuretics should be used judiciously early in treatment to prevent excessive diuresis that could prevent titration of ACE inhibitors to target doses. Digoxin has not been shown to affect the natural history of heart failure and should be reserved for patients who remain symptomatic after treatment with ACE inhibitors and diuretics. Isosorbide dinitrate and hydralazine hydrochloride should be tried in patients who cannot tolerate ACE inhibitors or who have refractory symptoms. [ABSTRACT FROM AUTHOR]

Background: Inadequate functional health literacy is common, but its impact on patients with chronic diseases is not well described. Objective: To examine among patients with hypertension or diabetes the relationship between their functional health literacy level and their knowledge of their chronic disease and treatment. Methods: We conducted a cross-sectional survey of patients with hypertension and diabetes presenting to the general medicine clinics at 2 urban public hospitals. Literacy was measured by the Test of Functional Health Literacy in Adults. Knowledge of their illness was assessed in patients with diabetes or hypertension using 21 hypertension and 10 diabetes questions based on key elements in educational materials used in our clinics. Results: A total of 402 patients with hypertension and 114 patients with diabetes were enrolled. Mean (±SD) knowledge scores for patients with hypertension with inadequate (n=189), marginal (n=49), or adequate (n=155) literacy were 13.2±3.1, 15.3±2.2, and 16.5±2.3, respectively (range, 4-20; P,.001). A total of 92% of patients with hypertension and adequate literacy levels knew that a blood pressure reading of 160/100 mm Hg was high compared with 55% of those in the lowest reading level (P,.001). Mean (±SD) knowledge scores for patients with diabetes with inadequate (n=50), marginal (n=13), or adequate (n=51) literacy were 5.8±2.1, 6.8±1.9, and 8.1±1.6, respectively (range, 1-10; P,.001). A total of 94% of patients with diabetes and adequate functional health literacy knew the symptoms of hypoglycemia compared with 50% of those with inadequate literacy (P,.001). Conclusions: Inadequate functional health literacy poses a major barrier to educating patients with chronic diseases, and current efforts to overcome this appear unsuccessful. [ABSTRACT FROM AUTHOR]