Factors Associated With Patient Delay in Seeking Care After Worsening Symptoms in Heart Failure Patients

doi:10.1016/j.cardfail.2011.04.004

Journal of Cardiac Failure

Volume 17, Issue 8, August 2011, Pages 657-663

https://doi.org/10.1016/j.cardfail.2011.04.004 Get rights and content

Abstract

Background

To receive optimal treatment and care, it is essential that heart failure (HF) patients react adequately to worsening symptoms and contact a health care provider early. This specific “patient delay” is an important part of the total delay time. The purpose of this study was to assess patient delay and its associated variables in HF patients.

Methods and Results

In this cross-sectional study, data of 911 hospitalized HF patients from 17 Dutch hospitals (mean age 71 ± 12 years; 62% male; left ventricular ejection fraction 34 ± 15%) were analyzed. During the index hospitalization, patient delay and HF symptoms were assessed by interview. Patients completed questionnaires on depressive symptoms, knowledge and compliance. Clinical and demographic data were collected from medical charts and interviews by an independent data collector. Logistic regression analysis was performed to examine independent associations with patient delay. Median patient delay was 48 hours; 296 patients reported short delay (<12 h) and 341 long delay (≥168 h). A history of myocardial infarction (MI) (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.34-0.71) or stroke (OR 0.43, 95% CI 0.24-0.76) was independently associated with short patient delay. Male gender, more HF knowledge, and more HF symptoms were associated with long patient delay. No differences were found between patients with and without a history of HF.

Conclusions

Patients with a history of a life-threatening event (MI or stroke) had a shorter delay than patients without such an event. Patients without a life-threatening event might need to be educated on the recognition and need for appropriate action in a different way then those with an acute threatening previous experience.

Section snippets

Methods

This descriptive cross-sectional study on patient delay is a secondary analysis of COACH (Coordinating study evaluating Outcomes of Advising and Counseling in Heart failure). COACH was a randomized, multicenter, controlled study in which 1,023 hospitalized HF patients were included between November 2002 and February 2005 (registered at trialregister.nl, no. NTC98675639).18, 19 Patients were included in the study during an admission for HF (New York Heart Association [NYHA] functional class

Characteristics of the Study Population

A total of 1,023 patients participated in COACH. Of these patients, 112 had a patient delay time of 0 hours and, at the same time, were in NYHA functional class IV at admission and were therefore excluded from analyses. Those patients did not significantly differ in age, gender, and left ventricular ejection fraction (LVEF) from the 911 patients included in this substudy. The mean age of the study population (n = 911) was 71 ± 12 years, and 62% were male. The mean length of HF symptoms was 32 ±

Discussion

Although delay in HF patients was assessed in earlier studies, those studies assessed the time from worsening symptoms to arrival at the hospital. The scope of the present study was on patient delay, reflecting the time from worsening symptoms to actually contacting a health care provider. The most important findings of this study were that a history of MI or stroke was independently associated with short patient delay. We also found that male gender, more HF knowledge, and the presence of

Conclusion and Implications

Patients with a history of a serious, life-threatening event, such as MI or stroke, contacted a health care provider earlier in case of worsening HF symptoms, compared with those without such events. More HF knowledge, male gender, and more HF symptoms were also independently associated with long patient delay in all patients and those with a history of HF. Although these results might suggest a profile of HF patients vulnerable to long delay in seeking care after worsening symptoms, further

Disclosures

None.

References (32)

G.D. Schiff et al.
Decompensated heart failure: symptoms, patterns of onset, and contributing factors
Am J Med
(2003)
L.S. Evangelista et al.
Treatment-seeking delays in heart failure patients
J Heart Lung Transplant
(2000)
M.M. Friedman
Older adults’ symptoms and their duration before hospitalization for heart failure
Heart Lung
(1997)
R.J. Goldberg et al.
Delays in seeking medical care in hospitalized patients with decompensated heart failure
Am J Med
(2008)
F.M. Khraim et al.
Predictors of pre-hospital delay among patients with acute myocardial infarction
Patient Educ Couns
(2009)
L.S. Evangelista et al.
Relationship between psychosocial variables and compliance in patients with heart failure
Heart Lung
(2001)
C.R. Horowitz et al.
A story of maladies, misconceptions and mishaps: effective management of heart failure
Soc Sci Med
(2004)
T. Jaarsma et al.
Depression and the usefulness of a disease management program in heart failure: insights from the COACH (Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure) study
J Am Coll Cardiol
(2010)
K. Dickstein et al.
ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM)
Eur J Heart Fail
(2008)
T. Jaarsma et al.
Development and testing of the European Heart Failure Self-Care Behavior Scale
Eur J Heart Fail
(2003)

G. de Luca et al.

Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts

Circulation

(2004)

D.K. Moser et al.

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on cardiovascular nursing and stroke council

Circulation

(2006)

M.M. Friedman et al.

Heart failure patients” time, symptoms, and actions before a hospital admission

J Cardiovasc Nurs

(2008)

C.Y. Jurgens et al.

Why do elders delay responding to heart failure symptoms?

Nurs Res

(2009)

C.H. Rasmussen et al.

Patient delay from onset of chest pain suggesting acute coronary syndrome to hospital admission

Scand Cardiovasc J

(2003)

S.E. Sheifer et al.

Time to presentation with acute myocardial infarction in the elderly: associations with race, sex, and socioeconomic characteristics

Circulation

(2000)

Cited by (31)

Actual status of pre-discharge knowledge of hospitalised patients with heart failure and measurement tools to assess said knowledge: A scoping review
2024, Heart and Lung
Heart failure (HF) patients have high readmission rates and require continuous adherence to HF self-care. Lack of knowledge about HF has been identified as a factor that contributes to poor adherence.
To clarify and organise existing data about measurement tools used to assess pre-discharge knowledge of hospitalised HF patients, the content and level of pre-discharge knowledge, factors associated with the level of knowledge, and the effect of knowledge levels on patients’ outcomes.
Four electronic databases were searched for articles that described the content and level of knowledge of pre-discharge HF patients.
Thirty-three studies were included in this review. Twenty-two measurement tools were identified used for pre-discharge knowledge assessment. ‘Heart failure pathophysiology and treatment’ and ‘salt and fluid management’ were the most common knowledge content measured. The level of knowledge of ‘the nature, definition, and causes of symptoms of heart failure’ and ‘fluid and medication management’ tended to be low. High levels of knowledge were found for ‘higher educational background’, ‘previous heart failure hospitalisation’, and ‘previous heart failure education’, while low levels were found for: ‘high number of medications’ and ‘first heart failure hospitalisation’. The level of HF knowledge implies an impact on compliance and self-care.
HF patients have low level of knowledge of the nature and causes of HF and fluid management prior to hospital discharge. Some of the variables that influenced the level of patient knowledge were educational background, number of medications taken, and disease duration.
The development of a patient reported outcome measure for fatigue and breathlessness for patients with chronic heart failure (OxFAB)
2023, Heart and Lung
Fatigue and breathlessness are the two most common and distressing symptoms for patients with chronic heart failure. They affect a patient's quality of life and ability to undertake activities of daily living. Currently there are no symptom specific measures for fatigue and breathlessness available or developed and validated for use with this patient group and no questionnaire that incorporates both symptoms into one measure.
To develop a patient-reported outcome measure for patients with chronic heart failure for their fatigue and breathlessness symptoms.
A three-staged, approach was used. In stage One in-depth qualitative patient-interviews on factors of fatigue and breathlessness in chronic heart failure were undertaken to provide question themes. Items from these interviews were generated and pilot questionnaires developed and tested. In Stage Two, exploratory factor analysis with item reduction and final testing of the questionnaire was performed. Stage Three involved validation testing.
In Stage One, issues raised in interviews (n = 25) were used to generate items. Pilot questionnaires were developed and tested. Items were refined in the context of cognitive debrief interviews (n = 7) for possible inclusion in the final measure. Final testing of questionnaire properties with item reduction was carried out in Stage Two (n = 112). Validity and reliability were assessed in Stage Three (n = 96). Psychometric testing showed positive results, in internal consistency (Cronbach's alpha ranging from 0.8 to 0.94) and test-retest (no difference in means), content validity and relevance to patients.
This questionnaire could be useful in the assessment of fatigue and breathlessness in patients living with chronic heart failure.
Symptom Status Questionnaire – Heart Failure – Brazilian Version: cross-cultural adaptation and content validation
2021, Heart and Lung
Citation Excerpt :
Brazil has similar numbers of HF-related hospitalizations and deaths, with over 880,000 hospitalizations and 98,000 deaths from the disease since 2016.2 In patients with HF, persistent symptoms even after therapeutic optimization are prevalent,3–6 indicate poor prognosis,7 and are common causes for hospitalization.7–10 In addition, HF symptoms are associated with impaired functional capacity and limited performance of activities of daily living11 and are the most important predictors of quality of life,7,12 which is considerably poorer than that of age- and gender-matched elders.13
In Brazil, there are no instruments available to measure the presence, frequency, severity and distress related to heart failure (HF) symptoms.
To adapt the Symptom Status Questionnaire - HF (SSQ-HF) into Brazilian Portuguese and to examine the content validity of the adapted version.
The instrument was translated, back-translated and evaluated by an expert committee for semantic, idiomatic, cultural, and conceptual equivalences. An agreement ≥80% was considered adequate. The adapted version was evaluated by both an expert committee (n = 9) for clarity, theoretical relevance and practical relevance (acceptable content validity coefficient (CVC): ≥0.70), and by a patient committee regarding understanding (n = 40).
The adapted version obtained 100% agreement regarding the equivalences. The total instrument CVC was 0.99. All patients understood the items.
The SSQ-HF-Brazilian version has satisfactory evidence of equivalence and content validity. Additional psychometric tests are deemed to confirm that the instrument can be used in Brazil.
Computerized auditory cognitive training to improve cognition and functional outcomes in patients with heart failure: Results of a pilot study
2015, Heart and Lung
Citation Excerpt :
Such cognitively impaired patients with HF are 30% more likely to have poor self-care,8–10 medication adherence,11,12 and quality of life.13–15 Additionally, such patients delay seeking medical care for HF symptoms,16–18 and have higher mortality rates.19 Although multiple cognitive intervention studies in older adults have demonstrated improvements in cognition,20,21 there is scant research on interventions to improve cognitive function among patients with HF,22 which could potentially improve self-care.
Feasibility and efficacy of computerized auditory cognitive training (ACT) was examined among patients with heart failure (HF).
Individuals with HF have four times increased risk of cognitive impairment, yet cognitive intervention studies are sparse.
A pilot randomized controlled design was used.
The ACT group (n = 9) and control group (n = 8) had similar baseline characteristics. Seven participants (78%) completed ≥18 hours of ACT. Medium effect sizes were observed for improved cognition as indicated by auditory processing speed (d = 0.78), speech processing (d = 0.88), and working memory (d = 0.44–0.50). Small effect sizes were found for improved functional outcomes including HF selfcare (d = 0.34), Timed Instrumental Activities of Daily Living (d = 0.32), Six-Minute Walk Test (d = 0.38) and Short-Form-36 (d = 0.22) relative to controls.
Results indicated ACT is feasible among persons with HF. Despite a small sample size, ACT showed potential for improved speed of processing and working memory and improved functional outcomes, and warrants further exploration.
Prolonged impact of home versus clinic-based management of chronic heart failure: Extended follow-up of a pragmatic, multicentre randomized trial cohort
2014, International Journal of Cardiology
Citation Excerpt :
Significantly, as in our previous trials [3,16], group survival curves deviate at the point of application of the pivotal home visit at 7–14 days post-discharge. This phenomenon suggests immediate benefits in terms of detecting and managing residual/de novo clinical instability in a patient population in whom delay to treatment is common [24]. As suggested by the survival data presented in Fig. 1 and Appendix IV, whatever difference home-based management makes initially, it is probably reinforced with further home visits in survivors and persists over the longer-term.
We compared the longer-term impact of the two most commonly applied forms of post-discharge management designed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure (CHF).
We followed a multi-center randomized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368 ± 216 days. Blinded endpoints included event-free survival from all-cause emergency hospitalization or death, all-cause mortality and rate of all-cause hospitalization and stay.
280 patients (73% male, aged 71 ± 14 years and 73% left ventricular systolic dysfunction) were initially randomized to home-based (n = 143) or clinic-based (n = 137) intervention. During extended follow-up (complete for 274 patients), 1139 all-cause hospitalizations (7477 days of hospital stay) and 121 (43.2%) deaths occurred. There was no difference in the primary endpoint; 20 (14.0%) home-based versus 13 (7.4%) clinic-based patients remained event-free (adjusted HR 0.89, 95% CI 0.70 to 1.15; p = 0.378). Significantly fewer home-based (51/143, 35.7%) than clinic-based intervention (71/137, 51.8%) patients died (adjusted HR 0.62, 95% CI 0.42 to 0.90: p = 0.012). Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations (p = 0.087) associated with 3067 (median 4.0, IQR 2.0 to 6.8) versus 4410 (6.0, IQR 3.0 to 12.0) days of hospital stay (p < 0.01 for rate and duration of hospital stay).
Relative to clinic-based intervention, home-based intervention was not associated with prolonged event-free survival. Home-based intervention was, however, associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term.
Australian New Zealand Clinical Trials Registry number 12607000069459 (http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=81803)
Temporal trends and volume-outcome associations in periampullary cancer patients: A propensity score-adjusted nationwide population-based study
2014, American Journal of Surgery
The purpose of this study was to evaluate temporal trends in the incidence of pancreaticoduodenectomy (PD) with periampullary cancers and the impact of hospital volume and surgeon volume on patient outcomes and to explore predictors of these outcomes.
This population-based cohort study retrospectively analyzed 4,039 PD procedures performed from 1998 to 2009. The odds ratio and 95% confidence interval were calculated to assess the relative change rate. Hierarchical regression models were used to predict these outcomes.
The incidence of PDs per 10⁵ persons increased from .97 to 1.89, whereas the length of stay and hospital treatment cost declined. Current treatment in a low-volume hospital and current treatment by a low-volume surgeon showed significant positive associations with these outcomes (P < .001).
The data indicate that analysis and emulation of the treatment strategies used by high-volume hospitals and high-volume surgeons may reduce overall hospital resource use. Because high-volume hospitals and surgeons consistently achieve superior outcomes of PD, their treatment strategies should be carefully analyzed and emulated.

View all citing articles on Scopus

: Supported by the Netherlands Heart Foundation (grant 2000Z003).

: See page 662 for disclosure information.

View full text

Clinical InvestigationFactors Associated With Patient Delay in Seeking Care After Worsening Symptoms in Heart Failure Patients

Abstract

Background

Methods and Results

Conclusions

Section snippets

Methods

Characteristics of the Study Population

Discussion

Conclusion and Implications

Disclosures

Am J Med

J Heart Lung Transplant

Heart Lung

Am J Med

Patient Educ Couns

Heart Lung

Soc Sci Med

J Am Coll Cardiol

Eur J Heart Fail

Development and testing of the European Heart Failure Self-Care Behavior Scale

Eur J Heart Fail

Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts

Circulation

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on cardiovascular nursing and stroke council

Circulation

Heart failure patients” time, symptoms, and actions before a hospital admission

J Cardiovasc Nurs

Why do elders delay responding to heart failure symptoms?

Nurs Res

Patient delay from onset of chest pain suggesting acute coronary syndrome to hospital admission

Scand Cardiovasc J

Time to presentation with acute myocardial infarction in the elderly: associations with race, sex, and socioeconomic characteristics

Circulation

Clinical Investigation
Factors Associated With Patient Delay in Seeking Care After Worsening Symptoms in Heart Failure Patients