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Aims and objectivesTo determine whether a single-item self-report medication adherence question predicts hospitalisation and death in patients with heart failure.BackgroundPoor medication adherence is associated with increased morbidity and mortality. Having a simple means of identifying suboptimal medication adherence could help identify at-risk patients for interventions.DesignWe performed a prospective cohort study in 592 participants with heart failure within a four-site randomised trial.MethodsSelf-report medication adherence was assessed at baseline using a single-item question: 'Over the past seven days, how many times did you miss a dose of any of your heart medication?' Participants who reported no missing doses were defined as fully adherent, and those missing more than one dose were considered less than fully adherent. The primary outcome was combined all-cause hospitalisation or death over one year and the secondary endpoint was heart failure hospitalisation. Outcomes were assessed with blinded chart reviews, and heart failure outcomes were determined by a blinded adjudication committee. We used negative binomial regression to examine the relationship between medication adherence and outcomes.ResultsFifty-two percent of participants were 52% male, mean age was 61 years, and 31% were of New York Heart Association class III/IV at enrolment; 72% of participants reported full adherence to their heart medicine at baseline. Participants with full medication adherence had a lower rate of all-cause hospitalisation and death (0·71 events/year) compared with those with any nonadherence (0·86 events/year): adjusted-for-site incidence rate ratio was 0·83, fully adjusted incidence rate ratio 0·68. Incidence rate ratios were similar for heart failure hospitalisations.ConclusionA single medication adherence question at baseline predicts hospitalisation and death over one year in heart failure patients.Relevance to clinical practiceMedication adherence is associated with all-cause and heart failure-related hospitalisation and death in heart failure. It is important for clinicians to assess patients' medication adherence on a regular basis at their clinical follow-ups.

BackgroundAssessing depression in patients hospitalized with coronary heart disease is clinically challenging because depressive symptoms are often confounded by poor somatic health.ObjectiveTo identify symptom clusters associated with clinical depression in patients hospitalized with coronary heart disease.MethodSecondary analyses of 3 similar data sets for hospitalized patients with coronary heart disease who had diagnostic screening for depression (99 depressed, 224 not depressed) were done. Depressive symptoms were assessed by using the Hamilton Depression Rating Scale or the Beck Depression Inventory. Hierarchical cluster analysis was performed on 11 symptom variables: anhedonia, dysphoria, loss of appetite, sleep disturbance, fatigue, guilt, suicidal symptoms, hypochondriasis, loss of libido, psychomotor impairment, and nervous irritability. Associations between symptom clusters and presence or absence of clinical depression were estimated by using logistic regression.ResultsFatigue (69%) and sleep disturbance (55%) were the most prevalent symptoms. Guilt (25%) and suicidal symptoms (9%) were the least common. Three symptom clusters (cognitive/affective, somatic/affective, and somatic) were identified. Compared with patients without cognitive/affective symptoms, patients with the cognitive/affective symptom cluster (anhedonia, dysphoria, guilt, suicidal symptoms, nervous irritability) had an odds ratio of 1.41 (P

BackgroundLow literacy increases the risk for many adverse health outcomes, but the relationship between literacy and adverse outcomes in heart failure (HF) has not been well studied.MethodsWe studied a cohort of ambulatory patients with symptomatic HF (NYHA Class II-IV within the past 6 months) who were enrolled in a randomized controlled trial of self-care training recruited from internal medicine and cardiology clinics at four academic medical centers in the US. The primary outcome was combined all-cause hospitalization or death, with a secondary outcome of hospitalization for HF. Outcomes were assessed through blinded interviews and subsequent chart reviews, with adjudication of cause by a panel of masked assessors. Literacy was measured using the short Test of Functional Health Literacy in Adults. We used negative binomial regression to examine whether the incidence of the primary and secondary outcomes differed according to literacy.ResultsOf the 595 study participants, 37 % had low literacy. Mean age was 61, 31 % were NYHA class III/IV at baseline, 16 % were Latino, and 38 % were African-American. Those with low literacy were older, had a higher NYHA class, and were more likely to be Latino (all p

BackgroundHeart failure (HF) is common, costly and associated with significant morbidity and poor quality of life, particularly for patients with low socioeconomic status. Self-management training has been shown to reduce HF related morbidity and hospitalization rates, but there is uncertainty about how best to deliver such training and what patients benefit. This study compares a single session self-management HF training program against a multiple session training intervention and examines whether their effects differ by literacy level.Methods/designIn this randomized controlled multi-site trial, English and Spanish-speaking patients are recruited from university-affiliated General Internal Medicine and Cardiology clinics at 4 sites across the United States. Eligible patients have HF with New York Heart Association class II-IV symptoms and are prescribed a loop diuretic. Baseline data, including literacy level, are collected at enrollment and follow-up surveys are conducted at 1, 6 and 12 months. Upon enrollment, both the control and intervention groups receive the same 40 minute, literacy-sensitive, in-person, HF education session covering the 4 key self-management components of daily self assessment and having a plan, salt avoidance, exercise, and medication adherence. All participants also receive a literacy-sensitive workbook and a digital bathroom scale. After the baseline education was completed, patients are randomly allocated to return to usual care or to receive ongoing education and training. The intervention group receives an additional 20 minutes of education on weight and symptom-based diuretic self-adjustment, as well as periodic follow-up phone calls from the educator over the course of 1 year. These phone calls are designed to reinforce the education, assess participant knowledge of the education and address barriers to success.The primary outcome is the combined incidence of all cause hospitalization and death. Secondary outcomes include HF-related quality of life, HF-related hospitalizations, knowledge regarding HF, self-care behavior, and self-efficacy. The effects of each intervention will be stratified by patient literacy, in order to identify any differential effects.DiscussionEnrollment of the proposed 660 subjects will continue through the end of 2009. Outcome assessments are projected to be completed by early 2011.Trial registrationClinicalTrials.gov (http://www.clinicaltrials.gov/) NCT00378950.

Low-income, uninsured individuals with multiple cardiovascular risk factors (CRFs) are at risk of heart failure (HF). B-type natriuretic peptide (BNP) screening for asymptomatic left ventricular dysfunction (ALVD) has not been tested specifically in this group. The purposes of this study were to describe BNP levels in asymptomatic low-income, uninsured individuals with multiple CRFs and determine the correlation between BNP levels and echocardiography for identifying ALVD. Methods: This correlational study included 53 patients (age 55 ± 10 years, 83% non-White, 64% female). BNP testing and echocardiogram (ECHO) were performed. Results: Of the 30 patients (57%) diagnosed with ALVD by ECHO, 21 (40%) had diastolic and 9 (17%) systolic dys-function. BNP levels were lower among those with normal left ventricular (LV) function (29.6 ± 24 pg/mL) than those with diastolic (80.2 ± 69 pg/mL, p = .01) and systolic dysfunction (337.1 ± 374 pg/mL, p = .009). sParticipants with BNP ≥50 pg/ mL were 5.75 times more likely to exhibit diastolic dysfunction (odds ratio [OR] = 5.75, 95% confidence interval [CI] 1.29-25.51; p < .01) and those with BNP ≥100 pg/mL were 7.80 times more likely to have systolic dysfunction (OR = 7.8, 95% CI 1.60-37.14; p < .005) than those with lower levels. With BNP cut point of 50 pg/mL, area under the curve (AUC) was 0.82 (95% CI 0.63-1.00) with sensitivity of 88% and specificity of 67%. Conclusion: BNP is a low-cost method to detect ALVD in high-risk, uninsured, low-income individuals. Elevated BNP levels should prompt initiation of further diagnostic testing and early treatment. [ABSTRACT FROM AUTHOR]