Predictors of hospitalization and quality of life in heart failure: A model of comorbidity, self-efficacy and self-care
Introduction
Comorbidity, defined as two or more chronic conditions, is associated with longer lengths of hospital stay, more hospital stays per year, and higher overall costs of care (Rijken et al., 2013, Steiner and Friedman, 2013). In Italy, where this study was conducted, approximately 50% of the general population between the ages of 65–74 has at least two chronic conditions (I. Stat, 2015). This number jumps to 68% in heart failure populations (Cocchieri et al., 2015) with hospitalization accounting for 53% of the average costs (Valle et al., 2006). It has been estimated that comorbidity is responsible for 70–80% of heath care costs in Europe or approximately 700 billion Euros in 2013 (Rijken et al., 2013). In comorbid heart failure populations the need for concurrent adherence to multiple self-care regimens and management of overlapping symptom profiles is common (Dickson et al., 2013). Failures in self-care result in health system utilization and increased health care costs (Ditewig et al., 2010).
Heart failure self-care is a 2 stage process (Riegel and Dickson, 2008). First, self-care maintenance captures the day-to-day treatment adherence and monitoring behaviors. Then self-care management includes recognition of a change in homeostasis and response mobilization. The self-care process is influenced by self-efficacy (Peters-Klimm et al., 2013, Riegel and Dickson, 2008). Heart failure patients derive event-free survival benefits from above average self-care and decreased hospitalization rates and improved quality of life from adequate self-care (Buck et al., 2012, Lee et al., 2011, Vellone et al., 2014) suggesting that the cost of heart failure may be mitigated by improving self-care.
However, recent attempts to decrease hospitalizations using self-care interventions have resulted in mixed outcomes (Davis et al., 2012, Delaney et al., 2013, Dracup et al., 2014, Inglis et al., 2011). In two, single site small RCTs, an in-person self-care intervention did not change readmission rates in the first study (Davis et al., 2012) and in the second, a technology intervention reduced 90 day hospital readmissions (Delaney et al., 2013). In a larger, multi-site three-arm RCT testing the impact of stepped self-care interventions on readmission, no significant differences were found when either intervention arm was compared with usual care (Dracup et al., 2014). Furthermore, a large meta-analysis of heart failure education and monitoring studies conducted in 10 countries found significant improvement in hospitalizations in 30 studies but also found a bias toward positive outcomes (Inglis et al., 2011). One possible explanation for this outcome heterogeneity may be the role of comorbidity in the study. In each of these studies comorbidity functioned, if measured, as a sample descriptor rather than an independent variable in multivariate analysis. So it is unclear what part, if any, comorbidity may have played in the response to the interventions. Our study seeks to clarify this important point.
In earlier work, we established that there is interaction between comorbidity, self-efficacy and heart failure self-care in smaller samples (Dickson et al., 2011, Dickson et al., 2013). Specifically, we found that comorbidity decreases self-efficacy. Self-efficacy, in turn, decreases self-care behaviors. Yet the manner in which comorbidity and self-efficacy interact to influence self-care remains unclear. Building on this earlier work, our goal in this study was to create an explanatory model for the manner in which comorbidity, self-efficacy and heart failure self-care interact and test it structurally with meaningful outcomes – hospitalization and quality of life.
Therefore, the specific aim of this study was to test an explanatory model of known predictors of hospitalization and quality of life. The research questions were (1) What is the contribution of comorbidity to heart failure self-care behaviors and outcomes (i.e. hospitalization, quality of life) adjusting for age and gender? and (2) Is comorbidity a moderator of the relationship between self-efficacy and heart failure self-care behaviors? Knowing the interaction among self-efficacy, comorbidity and self-care would clarify the mechanism by which hospitalization and quality of life are affected. This is important as self-efficacy is potentially modifiable and interventions designed to improve self-efficacy may differ when patients have different levels of comorbidity.
Section snippets
Study design and setting
This was a secondary analysis of a large cross-sectional database that described self-care in Italian heart failure patients (Cocchieri et al., 2015). In the parent study, a convenience sample of 1192 adults with heart failure was enrolled from cardiovascular centers located across 28 provinces in northern, central, and southern Italy. Data were collected between January 2011 and November 2012.
Sample
The inclusion criteria parent study were (1) adults over age 18; (2) diagnosis of heart failure by a
Sample
Table 1 presents the sociodemographic, family and clinical characteristics of the total sample. The sample (n = 628) was predominantly older (mean age = 72.98, SD = 11.34), male (57.6%) and married (54.9%). Patients had lived with heart failure more than 4 years on average and 75% of the sample was functionally compromised (NYHA classes II and III).
Descriptive statistics (Table 2)
Most (75.6%) had at least one other comorbid condition in addition to heart failure (CCI = 2.98; SD = 1.1). The most commonly reported comorbidities were
Discussion
The specific aim of this study was to test an explanatory model of known predictors of hospitalization and quality of life by identifying the contribution of comorbidity to heart failure self-care and then testing comorbidity as a moderator of the relationship between self-efficacy and heart failure self-care behaviors. To our knowledge, this is the first study describing the manner in which comorbidity, self-efficacy, and heart failure self-care interact to influence hospitalization and
Conclusion
This study presented an explanatory model of variables known to be associated with hospitalization and quality of life in heart failure and identified the contribution of comorbidity. It was found that comorbidity differentially moderated the relationship between self-care self-efficacy and self-care maintenance but did not moderate the relationship with self-care management. Given what is known about comorbidity's association with longer lengths of hospital stay, more hospital stays per year,
Acknowledgements
The team of investigators would like to acknowledge Donna Fick, PhD, GCNS-BC, FGSA, FAAN; Distinguished Professor of Nursing and Professor of Medicine at Penn State for her careful review of this analysis and paper and her comments.
Conflict of interest: None declared.
Funding: This work was supported by the Center of Excellence for Nursing Scholarship, Rome, Italy.
Ethical approval: The investigation confirmed to the principles outlined in the Declaration of Helsinki obtaining ethical review of
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