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Confidence in self-care after heart failure hospitalization

Published:October 24, 2022DOI:https://doi.org/10.1016/j.jjcc.2022.10.001

      Highlights

      • Heart failure (HF) patients had low confidence about exercise, salt restriction, and flu vaccination.
      • Patients lacked confidence in the distinction between HF and other disease symptoms.
      • Patient-physician communication was associated with confidence levels in self-care.
      • Medical providers should focus more on improving patient-physician communication.

      Abstract

      Background

      Understanding patient perspectives of self-care is critical for improving multidisciplinary education programs and adherence to such programs. However, perspectives of self-care for patients with heart failure (HF) as well as the association between patient perspectives and patient-physician communication remain unclear.

      Methods

      Confidence levels regarding self-care behaviors (eight lifestyle behaviors and four consulting behaviors) and self-monitoring were assessed using a self-administered questionnaire survey, which was directly distributed by dedicated physicians and nurses to consecutive patients hospitalized with HF in a tertiary-level hospital. Patient-physician communication was evaluated according to the quality of physician-provided information regarding “treatment and treatment choices” and “prognosis” using the Prognosis and Treatment Perception Questionnaire. Out of 202 patients, 187 (92.6 %) agreed to participate, and 176 completed the survey [valid response rate, 87.1 %; male, 67.0 %; median age, 73 (63–81) years]. Multivariate logistic regression analyses were conducted to predict low confidence in self-care (score in the lowest quartile).

      Results

      High confidence (confident or completely confident >75 % of patients) was observed for all self-care behavior categories except low-salt diet (63.1 %), regular exercise (63.1 %), and flu vaccination (65.9 %). Lower confidence in self-care behavior was associated with low quality of patient-physician communication. With regard to self-monitoring, 62.5 % of patients were not confident in distinguishing worsening symptoms of HF from other diseases; non-confidence was also associated with low quality of patient-physician communication.

      Conclusions

      Hospitalized patients with HF had low confidence regarding regular exercise, salt restriction, and flu vaccination. The results also suggest patient-physician communication affects patient confidence.

      Graphical abstract

      Keywords

      Introduction

      Heart failure (HF) is a major global health concern due to its association with repeated hospitalizations and high mortality [
      • Roth G.A.
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      • Moran A.E.
      • Barber R.
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      Demographic and epidemiologic drivers of global cardiovascular mortality.
      ]. To improve the poor outcomes of HF, patients' understanding of the disease, as well as lifestyle interventions, are essential. The implementation of self-care behavior (lifestyle and counseling behaviors) and monitoring (recognition of worsening HF) is associated with better quality of life and lower mortality and readmission rates [
      • Jaarsma T.
      • Hill L.
      • Bayes-Genis A.
      • La Rocca H.B.
      • Castiello T.
      • Čelutkienė J.
      • et al.
      Self-care of heart failure patients: practical management recommendations from the heart failure Association of the European Society of cardiology.
      ,
      • Riegel B.
      • Moser D.K.
      • Buck H.G.
      • Dickson V.V.
      • Dunbar S.B.
      • Lee C.S.
      • et al.
      Self-care for the prevention and management of cardiovascular disease and stroke: a scientific statement for healthcare professionals from the American Heart Association.
      ,
      • Riegel B.
      • Moser D.K.
      • Anker S.D.
      • Appel L.J.
      • Dunbar S.B.
      • Grady K.L.
      • et al.
      State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association.
      ,
      • van der Wal M.H.
      • van Veldhuisen D.J.
      • Veeger N.J.
      • Rutten F.H.
      • Jaarsma T.
      Compliance with non-pharmacological recommendations and outcome in heart failure patients.
      ]. In addition, self-care education is recognized as a quality measure for HF [
      • Heidenreich P.A.
      • Fonarow G.C.
      • Breathett K.
      • Jurgens C.Y.
      • Pisani B.A.
      • Pozehl B.J.
      • et al.
      2020 ACC/AHA clinical performance and quality measures for adults with heart failure: a report of the American College of Cardiology/American Heart Association task force on performance measures.
      ], and improving self-care is a major focus of multidisciplinary HF management programs worldwide [
      • Jaarsma T.
      • Hill L.
      • Bayes-Genis A.
      • La Rocca H.B.
      • Castiello T.
      • Čelutkienė J.
      • et al.
      Self-care of heart failure patients: practical management recommendations from the heart failure Association of the European Society of cardiology.
      ,
      • Riegel B.
      • Moser D.K.
      • Buck H.G.
      • Dickson V.V.
      • Dunbar S.B.
      • Lee C.S.
      • et al.
      Self-care for the prevention and management of cardiovascular disease and stroke: a scientific statement for healthcare professionals from the American Heart Association.
      ,
      • Riegel B.
      • Moser D.K.
      • Anker S.D.
      • Appel L.J.
      • Dunbar S.B.
      • Grady K.L.
      • et al.
      State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association.
      ]. The current European Society of Cardiology/European Heart Journal guidelines recommend that physicians provide self-care advice prior to discharge, which enables patients to engage in continuous self-care management, especially in in-home settings [
      • McDonagh T.A.
      • Metra M.
      • Adamo M.
      • Gardner R.S.
      • Baumbach A.
      • Böhm M.
      • et al.
      2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure.
      ].
      Identifying patient perspectives on self-care behavior and monitoring is a topic of growing interest in the field of cardiovascular diseases [
      • Vellone E.
      • Pancani L.
      • Greco A.
      • Steca P.
      • Riegel B.
      Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: testing a mediation model.
      ,
      • Kitakata H.
      • Kohno T.
      • Kohsaka S.
      • Fujino J.
      • Nakano N.
      • Fukuoka R.
      • et al.
      Patient confidence regarding secondary lifestyle modification and knowledge of 'heart attack' symptoms following percutaneous revascularisation in Japan: a cross-sectional study.
      ], and is thought to be an essential step in closing the perception gap. Confidence levels regarding self-care exert a powerful and consistent influence on self-care performance across patient populations and various self-care behaviors [
      • Riegel B.
      • Moser D.K.
      • Buck H.G.
      • Dickson V.V.
      • Dunbar S.B.
      • Lee C.S.
      • et al.
      Self-care for the prevention and management of cardiovascular disease and stroke: a scientific statement for healthcare professionals from the American Heart Association.
      ,
      • Vellone E.
      • Pancani L.
      • Greco A.
      • Steca P.
      • Riegel B.
      Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: testing a mediation model.
      ,
      • Jaarsma T.
      • Cameron J.
      • Riegel B.
      • Stromberg A.
      Factors related to self-care in heart failure patients according to the middle-range theory of self-care of chronic illness: a literature update.
      ]. Increased levels of self-efficiency promote greater adherence to daily weighting and dietary recommendations [
      • Schweitzer R.D.
      • Head K.
      • Dwyer J.W.
      Psychological factors and treatment adherence behavior in patients with chronic heart failure.
      ]. We previously reported substantial disparities in the confidence levels associated with lifestyle modifications and awareness of heart attack in patients with coronary artery disease [
      • Kitakata H.
      • Kohno T.
      • Kohsaka S.
      • Fujino J.
      • Nakano N.
      • Fukuoka R.
      • et al.
      Patient confidence regarding secondary lifestyle modification and knowledge of 'heart attack' symptoms following percutaneous revascularisation in Japan: a cross-sectional study.
      ], identifying imbalances in the composition of patient education programs for the management of HF. Thus, a comprehensive understanding of patient confidence in self-care can similarly highlight issues in providing a multidisciplinary HF management program, which may result in the improvement of adherence and self-care behavior. In general, patient-physician communication is one of the important factors that influences self-care behavior [
      • Bukstein D.A.
      Patient adherence and effective communication.
      ,
      • Chang T.J.
      • Bridges J.F.P.
      • Bynum M.
      • Jackson J.W.
      • Joseph J.J.
      • Fischer M.A.
      • et al.
      Association between patient-clinician relationships and adherence to antihypertensive medications among Black adults: an observational study design.
      ].
      The relationship between patient-physician communication and self-care confidence in patients hospitalized with HF remains unclear. This constitutes a critical knowledge gap because self-care confidence may be associated with patient-physician communication in patients hospitalized with HF, highlighting actionable areas for interventions to improve clinical outcomes. Given the fact that the quality of physician-provided information is a key aspect of patient-physician communication [
      • Simpson M.
      • Buckman R.
      • Stewart M.
      • Maguire P.
      • Lipkin M.
      • Novack D.
      • et al.
      Doctor-patient communication: the Toronto consensus statement.
      ], this study aimed to elucidate the confidence levels of patients hospitalized with HF regarding their self-care behavior and monitoring and to explore the association between patients' confidence in self-care and the quality of information (QoI) provided by physicians.

      Methods

      Study population

      We performed a cross-sectional observational study that consecutively recruited patients hospitalized with HF who completed the study questionnaire between September 2017 and March 2020 at a single university hospital center (Keio University Hospital, Tokyo, Japan). Inclusion criteria were non-elective hospitalization for worsening HF and meeting Framingham criteria [
      • McKee P.A.
      • Castelli W.P.
      • McNamara P.M.
      • Kannel W.B.
      The natural history of congestive heart failure: the Framingham study.
      ], resulting in medication augmentation or the administration of new intravenous HF therapies.
      The study protocol was approved by the institutional review board prior to data collection, and research was conducted in accordance with the Declaration of Helsinki. All patients provided informed consent to participate.

      Sociodemographic and clinical variables

      Clinical data of patients were obtained from their electronic medical records and defined according to the West Tokyo Heart Failure (WET-HF) registry, an ongoing prospective multicenter cohort registry of patients hospitalized with HF in Japan [
      • Kitakata H.
      • Kohno T.
      • Kohsaka S.
      • Shiraishi Y.
      • Parizo J.T.
      • Niimi N.
      • et al.
      Prognostic implications of early and midrange readmissions after acute heart failure hospitalizations: a report from a Japanese multicenter registry.
      ,
      • Shiraishi Y.
      • Kohsaka S.
      • Nagai T.
      • Goda A.
      • Mizuno A.
      • Nagatomo Y.
      • et al.
      Validation and recalibration of Seattle heart failure model in Japanese acute heart failure patients.
      ]. We collected data on patients' background, etiology of HF, previous hospital admission for HF, ejection fraction on echocardiography, use of implantable cardioverter or cardiac resynchronization therapy, medication use at discharge, and laboratory results from close to discharge or at the time of discharge. The 13 comorbid conditions included in this analysis were chronic obstructive pulmonary disease, asthma, chronic kidney disease (estimated glomerular filtration rate < 60 mL/min per 1.73 m2) [
      • Levey A.S.
      • de Jong P.E.
      • Coresh J.
      • El Nahas M.
      • Astor B.C.
      • Matsushita K.
      • et al.
      The definition, classification, and prognosis of chronic kidney disease: a KDIGO controversies conference report.
      ], diabetes mellitus, anemia (hemoglobin concentration < 12.0 g/dL in women and < 13.0 g/dL in men) [
      • Cleland J.G.
      • Zhang J.
      • Pellicori P.
      • Dicken B.
      • Dierckx R.
      • Shoaib A.
      • et al.
      Prevalence and outcomes of anemia and hematinic deficiencies in patients with chronic heart failure.
      ], arthritis, hypertension, hyperlipidemia, obesity (body mass index >25 kg/m2), cancer, coronary artery disease, atrial fibrillation, and stroke.

      Procedure

      The procedure of the employment of the self-administered questionnaire has been described in detail previously [
      • Kitakata H.
      • Kohno T.
      • Kohsaka S.
      • Fujisawa D.
      • Nakano N.
      • Shiraishi Y.
      • et al.
      Prognostic understanding and preference for the communication process with physicians in hospitalized heart failure patients.
      ]. Briefly, after the stabilization of HF symptoms, our multidisciplinary HF team conducted a patient education program using written materials for guidance on HF, which was followed by face-to-face counseling by a nurse. After the education program and provision of discharge instructions, the investigators (O.S., H. K., T. K., and N.N.) distributed the survey questionnaire to patients. If required, patients were provided with assistance when completing the questionnaire.

      Survey questionnaire

      The 92-question survey comprised eight domains: (i) patient characteristics (socio-demographic factors, education history, living status, social isolation, and self-care behavior); (ii) health status (quality of life and depression); (iii) awareness of HF trajectory; (iv) perspectives on treatment goals; (v) decision-making style; (vi) prognostic understanding and preferences for information disclosure; (vii) emergency treatment preferences; and (viii) advance care planning and end-of-life care preferences. The present study analyzed domains (i), (ii), (iii), and (vi). For the health status domain, generic health-related quality of life and depression were evaluated using the 3-Level EuroQoL 5-Dimensions (EQ-5D-3L) [
      • Dyer M.T.D.
      • Goldsmith K.A.
      • Sharples L.S.
      • Buxton M.J.
      A review of health utilities using the EQ-5D in studies of cardiovascular disease.
      ] and Patient Health Questionnaire-2 (PHQ-2), respectively [
      • Jha M.K.
      • Qamar A.
      • Vaduganathan M.
      • Charney D.S.
      • Murrough J.W.
      Screening and management of depression in patients with cardiovascular disease: JACC state-of-the-art review.
      ,
      • Muramatsu K.
      • Miyaoka H.
      • Kamijima K.
      • Muramatsu Y.
      • Tanaka Y.
      • Hosaka M.
      • et al.
      Performance of the Japanese version of the patient health Questionnaire-9 (J-PHQ-9) for depression in primary care.
      ].
      Patients' perspectives toward information disclosure from physicians were adopted from three items of the Prognosis and Treatment Perception Questionnaire (PTPQ): 1) the QoI about treatment and treatment choices, 2) the QoI about prognosis provided by physicians, and 3) the frequency of conversations with the physician about prognosis [
      • El-Jawahri A.
      • Traeger L.
      • Kuzmuk K.
      • Eusebio J.
      • Vandusen H.
      • Keenan T.
      • et al.
      Prognostic understanding, quality of life and mood in patients undergoing hematopoietic stem cell transplantation.
      ]. Further details have been described previously [
      • Kitakata H.
      • Kohno T.
      • Kohsaka S.
      • Fujisawa D.
      • Nakano N.
      • Shiraishi Y.
      • et al.
      Prognostic understanding and preference for the communication process with physicians in hospitalized heart failure patients.
      ]. Briefly, the PTPQ is a well-established self-administered questionnaire focusing on patients' perspectives that has been employed in cancer research [
      • El-Jawahri A.
      • Traeger L.
      • Kuzmuk K.
      • Eusebio J.
      • Vandusen H.
      • Keenan T.
      • et al.
      Prognostic understanding, quality of life and mood in patients undergoing hematopoietic stem cell transplantation.
      ]. With regard to patients' perspectives toward the quality of information provided by their physician, patients answered using a five-point Likert scale (1: excellent, 2: good, 3: satisfactory, 4: fair, 5: poor). They were also instructed to rate the frequency of conversation on a five-point Likert scale (1: never, 2: rarely, 3: sometimes, 4: often, 5: very often). An answer of “poor” or “fair” was defined as low QoI, whereas an answer of “never” or “rarely” was defined as a low frequency of conversation.
      With regard to knowledge about HF trajectory, patients were instructed to choose the most typical trajectory of HF from four figures that represented trajectories of various illnesses (gradual, intermittent, rapid, or temporal decline), which were derived from previous studies, including ours [
      • Kitakata H.
      • Kohno T.
      • Kohsaka S.
      • Fujisawa D.
      • Nakano N.
      • Shiraishi Y.
      • et al.
      Prognostic understanding and preference for the communication process with physicians in hospitalized heart failure patients.
      ,
      • Murray S.A.
      • Kendall M.
      • Mitchell G.
      • Moine S.
      • Amblas-Novellas J.
      • Boyd K.
      Palliative care from diagnosis to death.
      ]. Patients were also questioned about the impact of HF on their life expectancy and were required to indicate their views on HF as follows: (i) will be cured completely, (ii) last for the rest of their lives without shortening life expectancy, (iii) shorten their life expectancy, and (iv) unclear how HF would impact their lives. Understanding regarding the typical HF trajectory and impact of HF on patients' life expectancy was defined as the choice of “intermittent decline” and “shorten their life expectancy”, respectively, based on the Japanese Cardiology Society/Japanese Heart Failure Society Guideline on Diagnosis and Treatment of Acute and Chronic Heart Failure [
      • Tsutsui H.
      • Isobe M.
      • Ito H.
      • Ito H.
      • Okumura K.
      • Ono M.
      • et al.
      JCS 2017/JHFS 2017 guideline on diagnosis and treatment of acute and chronic heart failure - digest version.
      ].

      Questionnaire regarding self-care behavior

      Questions regarding patients' confidence in self-care behavior and recognition of HF symptoms are presented in Table 1. The questionnaire items regarding confidence in self-care behavior were derived from items of the Japanese-validated translation of the European HF Self-care Behavior Scale (EHFScBS) [
      • Jaarsma T.
      • Strömberg A.
      • Mårtensson J.
      • Dracup K.
      Development and testing of the european heart failure self-care behaviour scale.
      ,
      • Kato N.
      • Ito N.
      • Kinugawa K.
      • Kazuma K.
      Validity and reliability of the japanese version of the european heart failure self-care behavior scale.
      ]. The EHFScBS is a validated and reliable scale used to measure the self-management performance of patients with HF [
      • Jaarsma T.
      • Strömberg A.
      • Mårtensson J.
      • Dracup K.
      Development and testing of the european heart failure self-care behaviour scale.
      ]. This scale consists of 12 items that are broadly divided into two components (eight items regarding lifestyle behavior and four items regarding consulting behavior) (Table 1). Patients were instructed to rate their confidence level for each lifestyle behavior item on a four-point Likert scale (1: completely confident, 2: confident, 3: less confident, 4: not confident). Further, patients were instructed to rate the agreement level for each consulting behavior item on a four-point Likert scale (1: absolutely agree, 2: agree, 3: disagree, 4: absolutely disagree). With regard to the recognition of HF symptoms, patients were instructed to rate their confidence levels in the perception of worsening HF symptoms and the distinction between worsening HF and other disease symptoms on a four-point Likert scale (1: completely confident, 2: confident, 3: less confident, 4: not confident). These questions were originally created based on our previous papers [
      • Kitakata H.
      • Kohno T.
      • Kohsaka S.
      • Fujino J.
      • Nakano N.
      • Fukuoka R.
      • et al.
      Patient confidence regarding secondary lifestyle modification and knowledge of 'heart attack' symptoms following percutaneous revascularisation in Japan: a cross-sectional study.
      ] and further developed via in-depth discussions among the investigators, including board-certified cardiologists (H.K. and T.K.), a nurse certified in chronic HF care (N.N.), and a behavioral scientist and board-certified psychologist (D.F.).
      Table 1Questionnaire on self-care for patients hospitalized with HF.
      Questions
      1. Confidence levels regarding self-care behavior
       Lifestyle behavior
      (Likert scale: 1 = completely confident to 4 = not confident)
      I feel confident that I weigh myself every day.
      I feel confident that I take it easy if I get short of breath.
      I feel confident that I limit the amount of fluids I drink (not >1–1.5 L/day).
      I feel confident that I take a rest during the day.
      I feel confident that I eat a low salt diet.
      I feel confident that I take my medication as prescribed.
      I feel confident that I get a flu shot every year.
      I feel confident that I exercise regularly.
       Consulting behavior
      (Likert scale: 1 = absolutely agree to 4 = absolutely disagree)
      If my shortness of breath increases, I contact a hospital or my doctor or nurse.
      If my feet/legs become more swollen than usual, I contact a hospital or my doctor or nurse.
      If I gain 2 kg in 1 week, I contact a hospital or my doctor or nurse.
      If I experience increased fatigue, I contact a hospital or my doctor or nurse.
      2. Confidence levels regarding self-monitoring
       (Likert scale: 1 = completely confident to 4 = not confident)
      I can recognize worsening symptoms of HF.
      I can distinguish worsening symptoms of HF from other diseases.
      HF, heart failure.

      Patient recruitment

      Among the 342 patients with HF admitted to our university hospital, we excluded patients who could not answer the questionnaire due to unconsciousness (n = 9, 2.6 %), severe cognitive impairment (n = 79, 23.1 %), other factors such as mental disorder and language barrier (n = 18, 5.3 %), other end-stage life-threatening diseases (n = 7, 2.0 %), or in-hospital death (n = 15, 4.4 %). For patients who had repeated admission to our hospital, subsequent surveys were eliminated (n = 12, 3.5 %). Consequently, 202 patients were included in our questionnaire survey. Of these, 15 declined to complete the questionnaire. In addition, 9 patients who were unable to complete the questionnaire due to early discharge, and two patients who did not respond to the questions of self-care behavior were excluded. Consequently, 176 patients were analyzed in the study.

      Statistical analysis

      Continuous variables were expressed as means ± standard deviations or medians with interquartile ranges (IQRs) depending on distribution characteristics. Categorical variables were expressed as numbers (percentages). Overall, missing data were ≤ 5 %, except for the percentage of lymphocytes (10.2 %). Data with missing responses to the major questionnaire were excluded from the analysis. To estimate the 1-year survival rate, the Seattle Heart Failure Model (SHFM) scores were calculated in accordance with previous reports in Japanese patients hospitalized with HF [
      • Shiraishi Y.
      • Kohsaka S.
      • Nagai T.
      • Goda A.
      • Mizuno A.
      • Nagatomo Y.
      • et al.
      Validation and recalibration of Seattle heart failure model in Japanese acute heart failure patients.
      ,
      • Levy W.C.
      • Mozaffarian D.
      • Linker D.T.
      • Sutradhar S.C.
      • Anker S.D.
      • Cropp A.B.
      • et al.
      The Seattle heart failure model: prediction of survival in heart failure.
      ].
      For questionnaire items regarding confidence levels, patients were divided into high confidence (1: completely confident or absolutely agree, 2: confident or agree) and low confidence (3: less confident or disagree, 4: not confident or absolutely disagree) groups. The total confidence score for self-care behavior was calculated from the sum of the 12 confidence/agreement levels in self-care behavior with a global score ranging from 12 to 48; higher scores represented lower confidence in self-care behavior. Patients scoring higher than the second tertile for total confidence (≥25 points) were defined as the low confidence levels regarding self-care behavior. Low confidence in distinguishing worsening symptoms of HF from other diseases was defined by an answer of “not confident” or “less confident”. Univariate and multivariate logistic regression analyses were conducted to elucidate the determinants of low confidence in self-care behavior and distinguishing between worsening HF and other disease symptoms. Covariates included in the multivariate models were age, sex, education status, SHFM-estimated 1-year survival rate, and QoI from physicians about treatment and treatment choices [Model 1] or QoI about prognosis instead of about treatment and treatment choices [Model 2]. We also compared the prevalence of each comorbidity depending on the confidence levels in self-care behavior as well as self-monitoring. Statistical significance was defined as p < 0.05 for all statistical analyses. Data were analyzed using SPSS version 26 (IBM Corp., Armonk, NY, USA).

      Results

      Patient characteristics

      The demographic data of the study participants are presented in Table 2. Enrolled patients were predominantly male (n = 118, 67.0 %), with a median age of 73.0 (IQR: 63.0–81.0) years and a median left ventricular ejection fraction of 44.2 % (31.4–59.1 %). Furthermore, 23.3 % (n = 41), 18.8 % (n = 33), and 23.9 % (n = 42) of patients had ischemic, dilated, and valvular etiologies for HF, respectively. Nearly half [47.7 % (n = 84)] of the study participants had previous HF admission. Online Table 1 presents the patients' understanding of the HF trajectory and perspectives toward information disclosure. Among the total number of patients, 54.1 % selected the typical HF trajectory (intermittent decline), and 39.9 % perceived that HF would limit their life expectancy. Furthermore, 72.7 % rated the QoI provided about their treatment and treatment choices as “excellent” or “good,” and 54.7 % provided these responses regarding the QoI about prognosis. In addition, 26.8 % of patients answered “never” or “rarely” to questions about the frequency of prognostic discussion.
      Table 2Demographic data of the study participants.
      Variablesn = 176
      Demographics
       Age, years73.0 (63.0–81.0)
       Female, n (%)58 (33.0 %)
       High school education or less, n (%)91 (51.7 %)
       Married, n (%)116 (65.9 %)
       Living alone, n (%)42 (23.9 %)
      Comorbidities, n (%)
       Hypertension92 (52.3 %)
       Diabetes mellitus66 (37.5 %)
       Dyslipidemia68 (38.6 %)
       Chronic obstructive pulmonary disease22 (12.5 %)
       Asthma11 (6.3 %)
       Stroke25 (14.2 %)
       Cancer44 (25.0 %)
       Anemia101(57.4 %)
       Obesity33 (18.8 %)
       Coronary artery disease48 (27.3 %)
       Atrial fibrillation112 (63.6 %)
       Chronic kidney disease145 (82.4 %)
       Arthritis18 (10.2 %)
      Previous HF admission, n (%)84 (47.7 %)
      NYHA class III and IV at discharge, n (%)54 (30.7 %)
      Vital signs at discharge
       Heart rate, bpm73.1 ± 12.9
       Systolic blood pressure, mmHg104.5 (94.0–116.0)
      Echocardiographic parameters
       Left ventricular ejection fraction, %44.2 (31.4–59.1)
      Laboratory data
       Creatinine, mg/dL1.2 (1.0–1.7)
       Hemoglobin, g/dL12.3 (10.4–13.6)
       BUN, mg/dL25.0 (19.6–35.3)
       Sodium, mEq/L139.4 (137.6–141.0)
       Uric acid, mg/dL7.1 (5.9–8.3)
       Total cholesterol, mg/dL160.0 (137.0–190.8)
       White blood cells, /μL5500 (4325–6875)
       Lymphocyte, %22.0 (17.9–27.0)
       Albumin, g/dL3.6 ± 0.5
       BNP, pg/mL401.5 (204.1–748.8)
      Medication or device therapy, n (%)
       Loop diuretics151 (85.8 %)
       Beta-blockers146 (83.0 %)
       RAS inhibitors103 (58.5 %)
       Mineralocorticoid receptor antagonists88 (50.0 %)
       Statin69 (39.2 %)
       Allopurinol or febuxostat77 (43.8 %)
       ICD15 (8.5 %)
       CRT10 (5.7 %)
      SHFM-estimated 1-year survival rate, %94.9 (92.2–96.7)
      Data are shown as mean ± standard deviation, median with interquartile range, or number and percentage.
      HF, heart failure; NYHA, New York Heart Association; BUN, blood urea nitrogen; BNP, brain natriuretic peptide; RAS, renin-angiotensin system; ICD, implantable cardioverter defibrillator; CRT, cardiac resynchronization therapy; SHFM, Seattle Heart Failure Model.
      The confidence levels regarding self-care behaviors are presented in Fig. 1. Overall, patients had a high level of confidence (confident or completely confident, >75 %) in the majority of lifestyle behaviors, such as proper medication use, getting sufficient rest in case of dyspnea/shortness of breath, taking a rest during the day, daily weighing, and fluid restriction. However, patients had relatively low levels of confidence (confident or completely confident, <75 %) in getting a flu vaccination (65.9 %), eating a low-salt diet (63.1 %), and exercising regularly (63.1 %). >75 % of patients “completely agreed” or “agreed” with consulting behavior (i.e. contacting the doctor or nurse in the case of dyspnea, edema, weight gain, and fatigue).
      Fig. 1
      Fig. 1Confidence levels regarding self-care behavior.
      Univariate logistic regression analysis revealed that low confidence in self-care behavior was associated with younger age [odds ratio (OR) = 0.97; 95 % confidence level (CI): 0.95–1.00], lower education status (OR = 2.49; 95 % CI: 1.29–4.81), and lower QoI from physicians about treatment and treatment choices (OR = 4.68; 95 % CI: 1.52–14.44) (Online Table 2). HF severity (i.e. New York Heart Association functional class, SHFM-estimated 1-year survival rate), comorbidities, and understanding of HF trajectory were not significantly associated with low confidence in self-care behaviors. No significant difference was observed in the prevalence of comorbidities between patients with high and low confidence levels in self-care behavior (Online Fig. 1). After adjustment, younger age (OR = 0.97; 95 % CI: 0.94–1.00), lower education status (OR = 2.74; 95 % CI: 1.31–5.73), and lower QoI from physicians about treatment and treatment choices (OR = 5.99; 95 % CI: 1.67–21.45) remained as determinants of low confidence levels regarding self-care behavior (Table 3).
      Table 3Multivariate logistic regression analysis of determinants of low confidence levels regarding self-care behavior.
      VariablesOR95 % CIp-Value
      <Model 1>
      Age (per each year increase)0.970.94–1.000.029
      Female1.020.47–2.200.955
      High school education or less2.741.31–5.730.008
      SHFM-estimated 1-year survival rate (per each % increase)0.940.89–1.000.066
      Low quality of information about treatment and treatment choices5.991.67–21.450.006
      <Model 2>
      Age (per each year increase)0.970.94–1.000.032
      Female1.010.48–2.140.978
      High school education or less2.911.42–5.960.003
      SHFM-estimated 1-year survival rate (per each % increase)0.950.89–1.010.078
      Low quality of information about prognosis1.300.56–3.020.537
      OR, odds ratio; CI, confidence interval; SHFM, Seattle Heart Failure Model.
      Data regarding patients' recognition of HF symptoms are presented in Fig. 2. Among the total number of patients, 56.8 % were confident in the perception of worsening HF (completely confident, 16.5 %; confident, 40.3 %). Moreover, 37.5 % of patients were confident in distinguishing worsening symptoms of HF from other diseases (completely confident, 9.7 %; confident, 27.8 %). Univariate regression analysis revealed that low QoI from physicians about treatment and treatment choices (OR = 9.63; 95 % CI: 1.24–75.11) and about prognosis (OR = 2.73; 95 % CI: 1.11–6.71) were both significantly associated with low confidence in distinguishing worsening symptoms of HF from other diseases (Online Table 3). Conversely, patients with diabetes mellitus (OR = 0.53; 95 % CI: 0.28–0.99) or stroke (OR = 0.34; 95 % CI: 0.14–0.81) had high confidence in distinguishing worsening symptoms. The prevalence of diabetes mellitus (p = 0.044) and stroke (p = 0.012) was significantly higher in patients with high confidence in distinguishing worsening symptoms of HF from other diseases than in those with low confidence levels (Fig. 3). After adjustment, lower QoI from physicians about treatment and treatment choices (OR, 9.89; 95 % CI, 1.24–79.11) or about prognosis (OR = 2.70; 95 % CI: 1.07–6.82) remained as determinants of low confidence in distinguishing worsening symptoms (Table 4).
      Fig. 2
      Fig. 2Patients' perception and recognition of HF symptoms.
      HF, heart failure.
      Fig. 3
      Fig. 3Prevalence of comorbidities among patients with HF with high and low confidence levels regarding the distinction of worsening symptoms of HF from other diseases.
      HF, heart failure; COPD, chronic obstructive pulmonary disease. *p < 0.05.
      Table 4Multivariate logistic regression analysis of determinants of low confidence levels regarding distinction of worsening symptoms of HF from other diseases.
      VariablesOR95 % CIp-Value
      <Model 1>
      Age (per each year increase)1.000.97–1.020.687
      Female2.010.95–4.280.069
      High school education or less0.620.31–1.220.165
      SHFM-estimated 1-year survival rate (per each % increase)1.030.97–1.100.291
      Low quality of information about treatment and treatment choices9.891.24–79.110.031
      <Model 2>
      Age (per each year increase)0.990.97–1.020.624
      Female1.800.84–3.830.130
      High school education or less0.620.32–1.230.170
      SHFM-estimated 1-year survival rate (per each % increase)1.030.97–1.100.291
      Low quality of information about prognosis2.701.07–6.820.036
      HF, heart failure; OR, odds ratio; CI, confidence interval; SHFM, Seattle Heart Failure Model.

      Discussion

      This study examined patient perspectives on self-care after HF hospitalization. The key findings of the present study are as follows: 1) while patients' overall confidence levels for self-care behavior were satisfactory, patients had relatively low confidence regarding low-salt diet, regular exercise, and flu vaccination; 2) low confidence in self-care behavior was associated with younger age, lower education status, and low quality of patient-physician communication; and 3) approximately 60 % of patients were not confident in distinguishing between worsening symptoms of HF and other diseases, for which the quality of patient-physician communication was a determinant.
      There is a paucity of studies examining the extent to which patients have confidence in achieving each component of self-care. We comprehensively investigated patients' confidence levels in 12 self-care behaviors (eight lifestyle behavior items and four counseling behavior items) derived from the EHFScBS [
      • Jaarsma T.
      • Strömberg A.
      • Mårtensson J.
      • Dracup K.
      Development and testing of the european heart failure self-care behaviour scale.
      ]. In accordance with previous studies [
      • van der Wal M.H.
      • van Veldhuisen D.J.
      • Veeger N.J.
      • Rutten F.H.
      • Jaarsma T.
      Compliance with non-pharmacological recommendations and outcome in heart failure patients.
      ,
      • Szilagyi P.G.
      • Albertin C.
      • Casillas A.
      • Valderrama R.
      • Duru O.K.
      • Ong M.K.
      • et al.
      Effect of patient portal reminders sent by a health care system on influenza vaccination rates: a randomized clinical trial.
      ,
      • Sedlar N.
      • Lainscak M.
      • Farkas J.
      Self-care perception and behaviour in patients with heart failure: a qualitative and quantitative study.
      ,
      • Basuray A.
      • Dolansky M.
      • Josephson R.
      • Sattar A.
      • Grady E.M.
      • Vehovec A.
      • et al.
      Dietary sodium adherence is poor in chronic heart failure patients.
      ], our analysis revealed that patients' confidence regarding regular exercising, eating a low-salt diet, and flu vaccination were insufficient. This highlights the need for patient education programs with an emphasis on these components; the optimal transition of education and care from hospital to home may reduce the rates of avoidable rehospitalization [
      • Albert N.M.
      • Barnason S.
      • Deswal A.
      • Hernandez A.
      • Kociol R.
      • Lee E.
      • et al.
      Transitions of care in heart failure: a scientific statement from the American Heart Association.
      ]. Moreover, in the outpatient setting, questioning patients about physical activity and salt restriction as part of routine clinical examinations may be warranted. Furthermore, potential barriers for each item need to be addressed proactively. For exercise promotion, a detailed exercise program (e.g. home-based telerehabilitation) could be adopted, because patients' uncertainty regarding appropriate exercise modalities, intensities, and training protocols may be a barrier to routine exercise [
      • Jaarsma T.
      • Hill L.
      • Bayes-Genis A.
      • La Rocca H.B.
      • Castiello T.
      • Čelutkienė J.
      • et al.
      Self-care of heart failure patients: practical management recommendations from the heart failure Association of the European Society of cardiology.
      ,
      • Piotrowicz E.
      • Zieliński T.
      • Bodalski R.
      • Rywik T.
      • Dobraszkiewicz-Wasilewska B.
      • Sobieszczańska-Małek M.
      • et al.
      Home-based telemonitored nordic walking training is well accepted, safe, effective and has high adherence among heart failure patients, including those with cardiovascular implantable electronic devices: a randomised controlled study.
      ]. With regard to vaccinations, open discussions about the importance of vaccinations and any concerns that patients and families may be essential. Because of the suboptimal adherence to salt restriction after acute exacerbation of HF, dietitian-administered counseling needs to be considered in the outpatient setting [
      • Arcand J.A.
      • Brazel S.
      • Joliffe C.
      • Choleva M.
      • Berkoff F.
      • Allard J.P.
      • et al.
      Education by a dietitian in patients with heart failure results in improved adherence with a sodium-restricted diet: a randomized trial.
      ].
      Our results indicated that a higher quality of physician-provided information was associated with greater confidence in self-care behavior and management, which is concordant with previous studies in similar settings [
      • Bukstein D.A.
      Patient adherence and effective communication.
      ,
      • Chang T.J.
      • Bridges J.F.P.
      • Bynum M.
      • Jackson J.W.
      • Joseph J.J.
      • Fischer M.A.
      • et al.
      Association between patient-clinician relationships and adherence to antihypertensive medications among Black adults: an observational study design.
      ,
      • Bundesmann R.
      • Kaplowitz S.A.
      Provider communication and patient participation in diabetes self-care.
      ]. Although patient-physician communication may be a key therapeutic target to improve self-care, our findings did not identify the details of the information that physicians need to provide. Although the risk of worsening HF may be a major impetus to promoting adequate engagement in self-care [
      • Riegel B.
      • Moser D.K.
      • Buck H.G.
      • Dickson V.V.
      • Dunbar S.B.
      • Lee C.S.
      • et al.
      Self-care for the prevention and management of cardiovascular disease and stroke: a scientific statement for healthcare professionals from the American Heart Association.
      ], patients' understanding of the HF trajectory was not associated with their confidence in self-care in our study. Patients' understanding of the importance of self-care, which was not evaluated in this study, might affect their confidence level. Previous meta-analyses of randomized trials of self-management interventions in patients with HF demonstrated that interventions using face-to-face communication were more effective at influencing readmission compared with interventions without these strategies [
      • Sochalski J.
      • Jaarsma T.
      • Krumholz H.M.
      • Laramee A.
      • McMurray J.J.
      • Naylor M.D.
      • et al.
      What works in chronic care management: the case of heart failure.
      ]. Future studies should focus on the implementation of these interventions by cardiologists to enhance patient-physician communication in real-world settings (i.e. with limited human resources).
      In our hospitalized HF cohort, low confidence in self-care behavior was associated with younger age and lower education status, which is consistent with previous studies [
      • Riegel B.
      • Moser D.K.
      • Anker S.D.
      • Appel L.J.
      • Dunbar S.B.
      • Grady K.L.
      • et al.
      State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association.
      ,
      • Smith B.
      • Forkner E.
      • Krasuski R.A.
      • Galbreath A.D.
      • Freeman G.L.
      Educational attainment has a limited impact on disease management outcomes in heart failure.
      ,
      • Koirala B.
      • Himmelfarb C.D.
      • Budhathoki C.
      • Tankumpuan T.
      • Asano R.
      • Davidson P.M.
      Factors affecting heart failure self-care: an integrative review.
      ]. Although depression is a common factor that impedes self-care in other settings [
      • Jaarsma T.
      • Cameron J.
      • Riegel B.
      • Stromberg A.
      Factors related to self-care in heart failure patients according to the middle-range theory of self-care of chronic illness: a literature update.
      ,
      • Koirala B.
      • Himmelfarb C.D.
      • Budhathoki C.
      • Tankumpuan T.
      • Asano R.
      • Davidson P.M.
      Factors affecting heart failure self-care: an integrative review.
      ], PHQ-2 score was not associated with patients' confidence in self-care in our cohort. These findings clarify the subpopulations that should be targeted for implementing interventions to encourage adherence to self-care. Recent technological innovations (e.g. wearable activity monitors, smartphones, and other mobile applications) provide promising approaches for improving monitoring and patient engagement [
      • Writing C.
      • Maddox T.M.
      • Januzzi Jr., J.L.
      • Allen L.A.
      • Breathett K.
      • Butler J.
      • et al.
      2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution set Oversight Committee.
      ], especially in younger patients. “Low-tech” approaches (e.g. easy to use, low-literacy educational materials) or user-friendly devices may also be required for patients with limited education. Indeed, one pilot study demonstrated that a language-free tool successfully improved self-care behavior in ethnically diverse patients with low literacy [
      • Dickson V.V.
      • Chyun D.
      • Caridi C.
      • Gregory J.K.
      • Katz S.
      Low literacy self-care management patient education for a multi-lingual heart failure population: results of a pilot study.
      ]. Considering that patients' background in HF is heterogeneous, individualized approaches using these technologies should be considered rather than conventional uniform approaches.
      Although self-care is essential for complex patients with multiple comorbidities, monitoring symptoms and differentiating the cause of a particular symptom are the most challenging issues when more than one chronic illness is present [
      • Riegel B.
      • Moser D.K.
      • Buck H.G.
      • Dickson V.V.
      • Dunbar S.B.
      • Lee C.S.
      • et al.
      Self-care for the prevention and management of cardiovascular disease and stroke: a scientific statement for healthcare professionals from the American Heart Association.
      ,
      • Riegel B.
      • Moser D.K.
      • Anker S.D.
      • Appel L.J.
      • Dunbar S.B.
      • Grady K.L.
      • et al.
      State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association.
      ]. Notably, in this study, low confidence in distinguishing worsening symptoms of HF from other diseases was associated with a lower prevalence of diabetes and stroke. Although the precise reason for this relationship is unclear, multidisciplinary education about both HF and other diseases may contribute to higher confidence in self-monitoring. Because of the increased prevalence of multiple comorbidities in an aging society, a deeper understanding of appropriate multidisciplinary programs for patients with HF with multiple comorbidities in conjunction with programs for other comorbidities is necessary.
      There are several limitations to the present study that should be considered when interpreting the results. First, this was a small-scale study conducted in a single center; consequently, statistical power may have been insufficient to detect reliable outcomes. Second, confidence levels were based on patients' evaluations, which might be subjective rather than objective. However, recently, the need for patient-focused research to determine best practice interventions that meet patient needs for knowledge and self-care related to their condition has been emphasized [
      • Albert N.M.
      Universal definition and classification of heart failure: new clarity brings new clinical implications for health care professionals and the need for new research.
      ]. We believe that our study will enable medical providers to address patient needs through the understanding of patients' perspectives. Third, the cross-sectional design of this study limits our ability to clarify the impact of patients' confidence on actual self-care behavior. Therefore, post-discharge assessment of actual self-care behavior will add value to our study. In addition to self-reported validated questionnaires (e.g. EHFScBS), further exploration with objective and precise measurements of actual self-care behavior (e.g. physical activity using wearable devices, sodium intake by urine sodium measurement) [
      • Abshire M.
      • Xu J.
      • Baptiste D.
      • Almansa J.R.
      • Xu J.
      • Cummings A.
      • et al.
      Nutritional interventions in heart failure: a systematic review of the literature.
      ,
      • Shcherbina A.
      • Hershman S.G.
      • Lazzeroni L.
      • King A.C.
      • O'Sullivan J.W.
      • Hekler E.
      • et al.
      The effect of digital physical activity interventions on daily step count: a randomised controlled crossover substudy of the MyHeart counts cardiovascular health study.
      ] is warranted. Furthermore, the present study was also not able to disclose the relationship between patients' self-care behavior and long-term outcomes of HF. To investigate the prognostic association between patients' confidence and actual performance of self-care behavior, further large-scale longitudinal studies are warranted. Fourth, the cause-effect relationship (e.g. the association between patients' confidence in self-care behavior and the quality of patient-physician communication) cannot be assumed from our results. Notably, a previous meta-analysis has demonstrated that training physicians in communication skills results in substantial and significant improvement in patient adherence [
      • Zolnierek K.B.
      • Dimatteo M.R.
      Physician communication and patient adherence to treatment: a meta-analysis.
      ]. Although the quality of patient-physician communication was not significantly different among attending physicians (data not shown), the development of an educational program for physicians to improve their communication with patients could be an important future direction of this field. Finally, our findings may not be generalizable to other countries. Since HF is a global health issue, further studies with international collaborations should be conducted. Despite these limitations, our study provides insight into the perspectives of patients with HF regarding self-care behavior and its associations with patients' characteristics and the quality of patient-physician communication.
      In conclusion, there were substantial disparities in confidence levels regarding self-care in patients hospitalized with HF. Patients had relatively low confidence regarding eating a low-salt diet, performing regular exercise, and getting a flu vaccination. Low confidence levels in self-care were associated with younger age, lower education level, and low quality of patient-physician communication. Our findings underscore the need to provide intensive education programs to improve patients' knowledge and confidence regarding self-care behavior. Further, interventions that aim to enhance patient-physician communication concerning self-care behavior warrant further investigation.
      The following are the supplementary data related to this article.

      Declaration of competing interest

      Dr. Kohsaka reports investigator-initiated grant funding from Bayer and Daiichi Sankyo.
      Dr. Shiraishi is affiliated with an endowed department by Nippon Shinyaku Co., Ltd. and received a research grant from the SECOM Science and Technology Foundation and an honorarium from Otsuka Pharmaceutical Co., Ltd.

      Acknowledgment

      None.

      Sources of funding

      This study was supported by a Grant-in-Aid for Young Scientists ( JPSS KAKENHI , 18K15860 [Author; YS]), Grant in Aid for Scientific Research ( 17K09526 [Author; TK], 20K08408 [Author; TK]), Health Labor Sciences Research Grant ( 14528506 [Author; SK]), and Grant from the Japan Agency for Medical Research and Development ( 201439013C [Author; SK]).

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