Self-Efficacy When Multiple Comorbid Conditions Challenge Heart Failure Self-Care

Transcription

1 Self-Efficacy When Multiple Comorbid Conditions Challenge Heart Failure Self-Care Victoria Vaughan Dickson, PhD, CRNP New York University, College of Nursing Harleah G. Buck, PhD, CHNP The Pennsylvania State University, School of Nursing Barbara Riegel, DNSc, RN, FAAN University of Pennsylvania, School of Nursing

2 Presenter Disclosure Information Victoria Vaughan Dickson, PhD, CRNP Self-Efficacy When Multiple Comorbid Conditions Challenge Heart Failure Self-Care DISCLOSURE INFORMATION: The following relationships exist related to this presentation: NONE

3 The Heart Failure Epidemic Heart Failure Patients (mm) American Heart Association Heart and Stroke Statistical Update. Croft JB et al. J Am Geriatr Soc. 1997;45: million patients; estimated 10 million in 2037 Incidence: about 660,000 new cases each year 6.6% 9.8% aged > 65 years have heart failure

4 The problem of comorbidity 86% of patients with heart failure have 2 or more noncardiac comorbidities 25% have 6 or more other conditions Diabetes, chronic obstructive pulmonary disease, hypertension, and anemia are reported in 20-30% of the older adult HF population Stroke, rheumatoid arthritis, and renal disease are more common in HF patients than in the general population symptom burden (> 9 symptoms) Mortality, Morbidity, Healthcare costs

5 Self-Care is a Process of Maintenance and Management 5

6 Self-Efficacy The confidence that an individual has in his/her ability to perform a specific action and to persist in performing that action or behavior despite barriers Low self-efficacy = avoid tasks High self-efficacy = engage in tasks

7 Specific Aim To examine the relationship of self-efficacy and HF self-care among adults with HF plus another condition.

8 Mixed Methods Quantitative Data Sociodemographics Self-Care Heart Failure Index (SCHFI) Charlson Comorbidity Index (CCI) Data analysis Students t-test Chi Square Regression analysis Integrated Results Qualitative Data Self-care Self-efficacy Qualitative Meta-Analysis

9 Qualitative Meta-Analysis Process: Creating Interpretations of Interpretations (Noblit and Hare, 1988; McCormick, Rodney and Varcoe, 2003) Reviewed individual study findings, themes, categories and codes Returned to original data to verify, extend and enrich interpretations of the data Synthesizing translations required within study, across studies analysis Express the synthesis of findings

10 Four Studies A motivational counseling approach to improving heart failure self-care: Mechanisms of effectiveness (Riegel, et al, 2006) N=15,, 60% female, 53% Caucasian Mean age 59.7(±13.3) years, 67% NYHA II Factors associated with the development of expertise in heart failure self-care (Riegel, et. al., 2006) N=29; 60% male, 60% Caucasian Mean age ( 13.12) years; 60% NYHA III A typology of heart failure self-care management in non-elders (Dickson, et. al. 2008) N= % male, 68.3% Caucasian Mean age ( 10.51) years; 58.5% NYHA III Symptom recognition among elders with heart failure (Riegel, et al., 2009) N=29; 72.4% Male, Mean age ( 14.40); 58.6% NYHA II

11 Sample n=114 Age in years, mean (SD) 59 (15) Sex male 62% HF Type Systolic Diastolic Mixed 86.6% 6% 7.5% Years with HF, mean (SD) 6.28 (4.55) NYHA Functional Class II III IV 41.2% 52.9% 5.9% Ejection Fraction, mean (SD) (16.08) African- American 25% Ethnicity Hispanic 2% Asian 2% Caucasian 71%

12 Comorbidity Comorbid Conditions Charlson Comorbidity Category 60% 50% 40% 30% 20% 10% Medium 34% High 20% Low 46% 0% Arthritis Cancer COPD CVA Diabetes MI Renal Other Number of conditions Mean 3.06 ±1.08

13 Results: Quantitative Data Self-Care Heart Failure Index Maintenance mean= 73.3, Management mean= 69.89, Confidence mean= 71.15, % Above Cut-Off Score (>= 70) 100% 75% 50% 25% 0% Maintenance Management Confidence

14 Self-Care and Comorbidity SCMain SCMgt SCConf Total _Com Self-Care Pearson Correlation **.289 * * Maintenance Sig. (2-tailed) Self-Care Pearson Correlation.359 ** ** Management Sig. (2-tailed) Self-Care Pearson Correlation.289 *.434 ** Confidence Sig. (2-tailed) # Comorbid Pearson Correlation * Conditions Sig. (2-tailed) ** significant at the 0.01 level; * significant at the 0.05 level Those with low CCI category (<2 conditions) reported better selfcare maintenance than those with more than 2 conditions (p=.03). Those with high CCI category (>4 conditions) reported poorer selfcare management (p=.04)

15 5 % C I o f β p - v a l u e R Regression of Comorbidity and Self-Care Confidence on Self-Care Maintenance β 9 2 Cohen s f 2 Model Controls Age (-.282 to.077).261 Gender/Female.533 ( to 6.087).850 } Study Group ( to.673) Comorbid Conditions CCI total ( to.345) Self-Care Confidence SCHFI.303 (.128 to.479) * * considered medium effect size

16 5 % C I o f β p - v a l u e R Regression of Comorbidity and Self-Care Confidence on Self-Care Management β 9 2 Cohen s f 2 Model Controls Age (-.741 to -.132).006 Gender/Female ( to ).214 } * Study Group.014 (-4581 to 4.608) Comorbid Conditions CCI total ( to.922) * + Self-Care Confidence SCHFI.425 (.135 to.714) ** * considered medium effect size ** considered large effect size

17 Results: Qualitative Data Self-Efficacy influenced self-care through Integration of multiple self-care maintenance instructions I know what I can eat and what I can t, I can do that <diabetes diet>; this salt thing it is hard Prioritization of one chronic illness over another I can tell my sugar is up I can fix that I don t even have to stick myself

18 Integrated Data Concordance 85-95% Comorbid conditions complicated self-care Self-efficacy influenced self-care maintenance behaviors Self-care management very difficult when multiple (>4) conditions Self-efficacy influenced response to symptoms I can tell when my sugar is too high or too low no problem and I know the bones; they don t work so well anymore I get tired easy is that the heart or what mostly I just wait to see if it passes or not.

19 Discussion The presence of multiple comorbid conditions complicates self-care and a lack of self-efficacy increases the vulnerability of older adults to inadequate self-care. Prioritization based upon self-efficacy Fragmented self-care instructions from multiple providers

20 Limitations Interpretation relied on interview data obtained from the primary studies Homogenous sample CCI may not capture all comorbid conditions that influence self-care

21 Implications & Conclusions Self-care education should integrate HF self-care with other chronic condition selfcare (e.g., diabetes). Research testing coaching interventions that foster selfefficacy and focus on developing skill in self-care across multiple chronic conditions is needed.

22 Acknowledgments Funding: Sigma Theta Tau Doris Bloch Research Award Penn Institute of Aging