Since 2008, residents’ preference for their future practice location has shifted from smaller cities and rural areas to large population centers, according to findings reported by physician recruitment firm Merritt Hawkins.

In a survey of residents who completed their training in 2014, 24% said that they wanted to practice in a community with a population of more than 1 million, compared with 6% in 2008, while 23% of residents chose the next-highest level of population – 500,001 to 1 million – compared with 15% in 2008, according to Merritt Hawkins.

 

As for the smaller communities, residents who wanted to practice in a area of 50,000 or fewer dropped from 17% in 2008 to 7% in 2014. Support for communities of 50,001-100,000 fell from 19% in 2008 to 10% in 2014, the company said. Only 1% of residents wanted to practice in a community of 10,000 people or fewer in 2014.

Residents’ reservations about practicing in rural areas more often are related to their “concerns about being on a clinical ‘island’ without specialty support, information technology, and other resources than they may be about the amenities of rural communities,” Merritt Hawkins said in its analysis of the 1,208 survey responses.

rfranki@frontlinemedcom.com

Since 2008, residents’ preference for their future practice location has shifted from smaller cities and rural areas to large population centers, according to findings reported by physician recruitment firm Merritt Hawkins.

In a survey of residents who completed their training in 2014, 24% said that they wanted to practice in a community with a population of more than 1 million, compared with 6% in 2008, while 23% of residents chose the next-highest level of population – 500,001 to 1 million – compared with 15% in 2008, according to Merritt Hawkins.

 

As for the smaller communities, residents who wanted to practice in a area of 50,000 or fewer dropped from 17% in 2008 to 7% in 2014. Support for communities of 50,001-100,000 fell from 19% in 2008 to 10% in 2014, the company said. Only 1% of residents wanted to practice in a community of 10,000 people or fewer in 2014.

Residents’ reservations about practicing in rural areas more often are related to their “concerns about being on a clinical ‘island’ without specialty support, information technology, and other resources than they may be about the amenities of rural communities,” Merritt Hawkins said in its analysis of the 1,208 survey responses.

rfranki@frontlinemedcom.com

Since 2008, residents’ preference for their future practice location has shifted from smaller cities and rural areas to large population centers, according to findings reported by physician recruitment firm Merritt Hawkins.

In a survey of residents who completed their training in 2014, 24% said that they wanted to practice in a community with a population of more than 1 million, compared with 6% in 2008, while 23% of residents chose the next-highest level of population – 500,001 to 1 million – compared with 15% in 2008, according to Merritt Hawkins.

 

As for the smaller communities, residents who wanted to practice in a area of 50,000 or fewer dropped from 17% in 2008 to 7% in 2014. Support for communities of 50,001-100,000 fell from 19% in 2008 to 10% in 2014, the company said. Only 1% of residents wanted to practice in a community of 10,000 people or fewer in 2014.

Residents’ reservations about practicing in rural areas more often are related to their “concerns about being on a clinical ‘island’ without specialty support, information technology, and other resources than they may be about the amenities of rural communities,” Merritt Hawkins said in its analysis of the 1,208 survey responses.

rfranki@frontlinemedcom.com

From the Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA.

 

Abstract

• Objective: To review some of the proposed pathways that increase frailty risk in older persons with heart failure and to discuss tools that may be used to assess for changes in physical and cognitive functioning in this population in order to assist with appropriate and timely intervention.
• Methods: Review of the literature.
• Results: Heart failure is the only cardiovascular disease that is increasing by epidemic proportions, largely due to an aging society and therapeutic advances in disease management. Because heart failure is largely a cardiogeriatric syndrome, age-related syndromes such as frailty and cognitive impairment are common in heart failure patients. Compared with age-matched counterparts, older adults with heart failure 4 to 6 times more likely to be frail or cognitively impaired. The reason for the high prevalence of frailty and cognitive impairment in this population is not well known but may likely reflect the synergistic effects of heart failure and aging, which may heighten vulnerability to stressors and accelerate loss of physiologic reserve. Despite the high prevalence of frailty and cognitive impairment in the heart failure population, these conditions are not routinely screened for in clinical practice settings and guidelines on optimal assessment strategies are lacking.
• Conclusion: Persons with heart failure are at an increased risk for frailty, which may worsen symptoms, impair self-management, and lead to worse heart failure outcomes. Early detection of frailty and cognitive impairment may be an opportunity for intervention and a key strategy for improving clinical outcomes in older adults with heart failure.

 

Approximately 5.7 million persons in the United States are diagnosed with heart failure, and the number of reported new cases is expected to increase to over 700,000 cases annually by the year 2040 [1]. This rising incidence is fueled by an aging population; by the year 2030, 1 in 5 Americans will be over 65 years of age [2]. Heart failure is prevalent among those 65 years of age and older and is the most common reason for hospitalization in this age-group. High readmission rates, approaching 50% over 6 months, are a major contributor to the the escalating economic burden associated with heart failure [3].

Persons with heart failure are more likely to be frail and experience cognitive impairment than their age-matched counterparts without heart failure. The reasons for this are not well known but may be related to hemodynamic, vascular, and inflammatory changes occurring as heart failure progresses. In this paper, we review the link between frailty and cognitive impairment in heart failure, instruments that may be useful for early detection, and interventions such as exercise that may be beneficial for attenuating both conditions.

Frailty in Heart Failure

Epidemiology

Frailty is a heightened vulnerability to stressors in the presence of low physiological reserve [4]. When exposed to stressors, persons who are frail have a much higher probability for disproportionate decompensation, negative events, functional decline, disability, and mortality [5]. Among persons with heart failure, frailty may predispose them to decompensate at a lower threshold, requiring more frequent hospitalizations. Persons with heart failure are more likely to be frail than their age-matched counterparts without heart failure [6,7].

Frailty is a powerful predictor of poor clinical outcomes and mortality in cardiovascular disease [8,9]. Compared with the non-frail, frail persons with heart failure have increased rates of mortality (16.9% vs 4.8%) and increased rates of heart failure hospitalization (20.5% vs 13.3%) [10]. Frailty has also been shown to predict falls, disability, and hospitalization in heart failure patients [6,9,11] and was found to have a negative linear relationship with health-related quality of life [12]. Frail heart failure patients are also more likely to have comorbidities such diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, depression, anemia, and chronic kidney disease [9,13].

Pathophysiology

There is significant overlap in the underlying pathological mechanisms of heart failure and frailty. Symptoms of heart failure, such as dyspnea, fatigue, and muscle loss, mirror components that occur with frailty. Further, cardiac cachexia, a metabolic syndrome in advanced heart failure characterized by a loss of muscle mass, is very similar to the sarcopenia that occurs in frailty.

Frailty, characterized by an increased physiologic vulnerability to stressors, may predispose frail persons with heart failure to exacerbation and worsening of heart failure due to greater susceptibility to the harmful pathophysiologic processes in heart failure, such as inflammation and autonomic dysfunction. Proposed pathophysiologic pathways in frailty include free radicals and oxidative stress, cumulative DNA damage, decreased telomere length, and nuclear fragmentation [14,15]. Frailty has been associated with low-grade chronic inflammation and increased inflammatory cytokines, such as C-reactive protein, tumor necrosis factor–alpha (TNFα), interleukin-6 (IL-6)and fibrinogen [16–18]. Heart failure also is associated with a low-grade and chronic cardiac inflammatory response that is correlated with disease progression [19].

Inflammation. IL-6 is detectable in a higher proportion of persons who are frail compared to non-frail [16] and is the most highly correlated biomarker with frailty. In addition, among those with detectable IL-6 levels, those categorized as frail have higher IL-6 levels compared to those who are non-frail [16,20]. Individuals categorized as frail were found to have significantly higher levels of TNFα than those who were non-frail [16,20]. Increased IL-6 levels are associated with decreased muscle strength, while increased TNFα levels are associated with decreased skeletal muscle protein synthesis [21,22], thus contributing to frailty.

Oxidative stress. Protein carbonyls result from protein oxidation promoted by reactive oxygen species and are markers of oxidative stress. Protein carbonylation is implicated in the pathogenesis of the loss of skeletal muscle mass; high serum protein carbonyls are associated with poor grip strength [23]. 8-OHdG is an oxidized nucleoside indicative of oxidative damage to DNA and a measure of oxidative stress. Accumulation of 8-OHdG in skeletal muscle leads to loss of muscle mass and is associated with decreased hand grip strength in the elderly [24]. Higher serum levels of 8-OHdG are present in older adults who are frail as compared to those who are non-frail [25].

Measurement of Frailty in the Clinical Setting

Frailty has been conceptualized in a number of studies using different models and measures; however, there continues to be a lack of consensus on the definition and operationalization of frailty. Prior research has led to the development of several validated models of frailty that have demonstrated good prediction of adverse outcomes in older adults. Some models, such as the Fried phenotype [6], focus solely on the physical dimension, while other models take a multidimensional approach.Single-item measures (eg, gait speed, 6-minute walk test, handgrip strength) are also commonly used to screen for frailty, but a frailty measure that incorporates more than 1 physical dimension may be more sensitive and reliable. In our opinion, the ideal measure of frailty would consist of a brief assessment that can be serially performed in most clinical practice settings that can identify change in function over time. The incorporation of sensitive physical function measures that can detect frailty early has the potential to slow physical function decline by preserving physiological thresholds.

Cognitive Impairment in Heart Failure

Epidemiology

Cognitive impairment occurs frequently in patients with heart failure, and the presence of cognitive impairment in persons with heart failure has been shown to heighten risk for adverse clinical outcomes, disability, poor quality of life, and mortality [26,27]. Heart failure negatively influences cognitive functioning in most domains [28–32]. The most common domains adversely affected by heart failure and aging are memory and executive function. Deficits in these domains can substantially diminish patient ability to carry out essential self-care behaviors [30,32].

The most common form of cognitive impairment seen in patients with heart failure is mild cognitive impairment (MCI), which is a measurable deficit with memory or another core cognitive domain. Up to 60% of persons with heart failure have been reported to have MCI. Patients with MCI have cognitive deficits that are more pronounced than those seen in normal aging, but lack other symptoms of dementia, such as impaired judgment or reasoning. MCI often will not impede patients’ ability to carry out the activities of daily living (ADLs) independently, but patients may have difficulty in performing some instrumental activities of daily living (IADLs), such as remembering medications, scheduling provider appointments. Dementia, a decline in cognitive ability severe enough to hinder an individual’s ability to perform ADLs or IADLs or engage in social activities or occupational responsibilities, occurs in approximately 25% of persons with heart failure [33].

Persons with heart failure have a fourfold greater likelihood of developing CI than persons without heart failure. Several cohort studies have shown that persons with heart failure had lower performance on cognitive tests than individuals without heart failure [34,35] and were 50% more likely to progress to dementia.

Assessment Tools

Although a comprehensive neurocognitive battery would aid in detecting cognitive impairment in heart failure, few clinical practice settings have the resources to perform such a detailed and time-consuming measurement. Most studies in heart failure have relied on global screening questionnaires such as the Mini-Mental State Examination (MMSE) [36] to assess cognitive functioning in persons with heart failure and in other cardiovascular disorders. Global cognitive measures, however, often lack sensitivity for detecting subtle cognitive deficits such as seen in MCI [28–30]. Screening that measures executive function may be the most beneficial for busy clinical settings, since declines in this domain are well established as contributing to poor outcomes in persons with heart failure.

 

The Montreal Cognitive Assessment (MoCA) is a rapid screening test designed to detect MCI. It assesses different cognitive domains, including attention, memory, language, and executive function [37]. The MoCA lends itself to use in clinical setting because it is brief, requires little training to administer, and is easy to score. This instrument has been used successfully to assess MCI in persons with heart failure and may be more sensitive than the MMSE in identifying clinically relevant cognitive dysfunction. In 2013 study, Cameron et al [38] administered the MMSE and MoCA to 93 hospitalized heart failure patients and found that the MoCA classified 41% of patients as cognitively impaired that were not classified using the MMSE. For persons with a vascular cognitive deficit, the MMSE has been portrayed as an inadequate screening test due to lack of sensitivity for visuospatial and executive function deficits. Because the MoCA was designed to be more sensitive to such deficits, it may be a superior screening method for persons with heart failure. Although previous studies support the use of the MoCA in persons with heart failure, more research is needed in larger, more diverse heart failure samples with a wide range of cognitive deficits.

A Reasonable Clinical Assessment Approach

Considering the link between heart failure, frailty, and MCI, incorporating simple physical performance measures with cognitive screening may be an effective strategy to identify persons at risk for frailty. Two clinically relevant physical performance-based measures of frailty are proposed: the Fried phenotype (mentioned earlier) and the Short Physical Performance Battery (SBBP). In addition, cognitive screening using the MoCA is recommended as part of the routine examination for determining possible MCI or more severe cognitive deficits. The predictive validity of measuring physical frailty is enhanced when cognitive impairment is included in the assessment [36,39].

The performance-based measures included in this review have previously demonstrated excellent psychometric properties as well as sensitivity for change that is clinically meaningful. Minimal detectable change (MDC), a threshold score that refers to the minimal amount of change outside of error that reflects true change by a patient between 2 time points (rather than variation in measurement), is important for interpreting level of risk for frailty and is included for each instrument [40,41]. If a more brief frailty examination is needed, cut-points for gait speed and handgrip have been used effectively in a number of studies as a threshold for determining frailty, including in older patients with cardiovascular disease and in heart failure [8,42,43].

Fried Frailty Phenotype

The Fried phenotype is an appropriate method of measuring frailty in a clinical setting due to its wide application across diverse populations and consistent identification of adverse outcomes [44]. This model is derived from a frailty model proposed by Fried et al [6] in which a phenotypic cycle exists that includes disease, sarcopenia, decreased walking speed, chronic undernutrition, decreased total energy expenditure, senescent musculoskeletal changes, decreased resting metabolic rate, weight loss and decreased maximal oxygen consumption. Frailty exists when a critical mass of these cycle components are identified in an individual [6].

To validate the model, Fried et al used data from the Cardiovascular Health Study and used the model to show association with a 3-year and 7-year incidence of mobility and ADL disability among 4317 community-dwelling men and women aged 65 years and older, independent of comorbidities. Several studies have directly tested the frailty phenotype model alone and in comparison to other models of frailty in large prospective studies across different populations, such as the Survey of Health, Aging and Retirement in Europe (SHARE) [45], the European Male Aging Study [46], and the Canadian Health Study of Aging [47]. While these studies found the prevalence of frailty to vary across the populations, they all validated the Fried model and found no significant differences in the predictive ability of the Fried model and other models of frailty. The Frailty Consensus conference evaluated the different models of frailty and determined that the Fried model is a validated construct of frailty and is acceptable for use in the identification of individuals who are frail or likely to become frail [48]. Thus, the Fried et al frailty phenotype model is considered to be a standard measure of frailty in older individuals.

The Fried phenotype assesses 5 criteria: shrinking, weakness, exhaustion, gait speed and physical activity (Table 1) [6]. A score of 0 or 1 is assigned to each of the 5 criteria and summed to get a total frailty score. Scores of 3 or greater are assigned as frail, while scores of less than 3 are considered non-frail. Scores of 1 or 2 can also be assigned as intermediate or at-risk for frailty (pre-frail). The focus of the Fried phenotype on physical domains makes it a particular appropriate measure to consider in the heart failure population since physical function declines occur as disease severity worsens.

Short Physical Performance Battery

The SPPB has been used to evaluate frailty risk in older adults with heart failure [49,50]. The SPPB assesses lower extremity physical performance by testing balance, walking, and muscle strength (Table 2). Scores on the SPPB are easy to interpret for clinicians, with a change of 5 clinically meaningful. Three studies have evaluated outcomes using the SPPB as a risk assessment of frailty in older adults with heart failure. Di Bari et al compared SPPB scores and the 6-minute walk test distance (6MWD) in older adults with and without heart failure [51]. SPPB scores and 6MWD were lower and predicted poor clinical outcomes in patients with heart failure compared with those without heart failure. The SPPB was used by Chiarantini et al to assess whether the SPPB predicted the long-term survival of 157 older adults (mean age, 80 yr) discharged following a heart failure exacerbation [52]. The mean SPPB score was 4.5 but varied considerably by NYHA class (class I: 7.4 ± 1.1; class II: 5.0 ± 0.5; class III: 4.8 ± 0.5; class IV: 2.3 ± 0.7; P < 0.001). Poorer SPPB scores were associated with higher mortality rates; compared with a SPPB score of 9 to 12, scores of 0, 1 to 4, and 5 to 8 were associated with mortality risks of 6.06, 4.78, and 1.95, respectively. Importantly, of approximately 30% (n = 47) of participants who scored 0 on the SPPB, 47% were NYHA class IV and 74% were unable to perform any of the 3 tests on the SPPB. An average of 10 to 15 minutes were required to administer the SPPB in these frail, elderly hospitalized heart failure patients and no adverse events were reported.

In other chronic illness populations, the SPPB has also been used as a predictor of outcomes before, during, or after hospitalization. Valpato et al [53], for example, used the SPPB to assess older adults (mean age, 78 yr) admitted to the hospital with a diagnosis of heart failure (64%), pneumonia (13%), chronic obstructive pulmonary disease (16%), or minor stroke (6.6%) at admission (baseline) and discharge. Patients with the lowest SPPB quartile scores at hospital discharge had a fivefold greater risk of rehospitalization or mortality compared to the highest quartile. In addition, those who had an early decline in SPPB scores 1 month after hospital discharge had greater limitations in performing activities of daily living and a significantly greater probability of being re-hospitalized or death during the 1-year follow-up period. These studies suggest that the SPPB at the first follow-up outpatient visit following hospital discharge may be beneficial for identifying need for further intervention or the need for more frequent follow-up care. Although the SPPB is not part of the Fried et al phenotype, it may provide additional information concerning risk for falls and lower extremity strength that may be beneficial in the evaluation of some persons with heart failure [54]. The SPPB along with instructions and normative data are available for clinical use at no charge at www.grc.nia.nih.gov/branches/ledb/sppb/index.htm.

Interventions for Frailty in Heart Failure

Interventions to address frailty have included exercise training, comprehensive geriatric assessment and management services, social support systems, nutrition, and drugs; however, few intervention studies have examined frailty in heart failure [8]. Restoration of physical function through aerobic exercise and resistance training has shown benefit in frail older adults [55–57] and in persons with heart failure [58]. Maintaining and/or restoring physical function through aerobic and resistance exercise training may be the key to preventing further decline or potentially reversing frailty in older adults with heart failure.

Aerobic exercise has been shown to be beneficial for both frail older adults and frail persons with heart failure [18]. In a study of community-dwelling frail older adults aged 65 and older, a combined aerobic and resistance exercise intervention, performed over 16 weeks, demonstrated significant improvement in frailty scores during the 1-year follow-up in contrast to worsening frailty measures in the control group [57].

Older adults with heart failure experience a much lower exercise tolerance largely due to a 50% to 75% decrease in aerobic capacity in addition to the well-known alterations in peripheral musculoskeletal performance that contribute to fatigue and greater symptom severity. Aerobic exercise has been shown to be beneficial for most heart failure patients by altering the peripheral and central mechanisms, such as inflammatory cytokines, that contribute to heart failure exacerbations, worsened symptom severity, and poor clinical outcomes [59–62].Lower rates of hospitalization, improved physical function, and enhanced health-related quality of life are reported in heart failure patients who routinely exercise [59]. Resistance training has been shown to improve physical function in frail older adults [55]. Further, the use of TheraBand exercise bands in resistance training demonstrated improvement in physical function among frail older adults [56].

Exercise also appears to exert a positive effect on cognition, particularly executive functioning, and may also have a protective effect against cognitive decline with aging and among those with heart failure. The underlying mechanism for improvement in cognition remains poorly understood but is likely related to improved cardiac function, cerebral perfusion, and oxygenation, although this has not been clearly established. Larson et al (2006) evaluated the frequency of participation in a variety of physical activities (eg, walking, bicycling and swimming) over 6 years in 1740 older adults [63]. Older adults who exercised more than 3 times per week during initial assessment were 34% less likely to be diagnosed with dementia than those who exercised fewer than 3 times per week. Several meta-analyses in recent years have shown a consistent and positive relationship between aerobic exercise and cognition [64,65]. Importantly, findings from meta-analyses have shown a moderate effect size (> 0.5) from aerobic training, which was similar for normal and cognitively impaired adults [64].

 

Implications for Clinical Care

A systematic assessment performed periodically using physical and cognitive measures that may identify prefrailty may be the best strategy for preventing further functional loss, limitations, and disability in persons with heart failure. Persons with heart failure ideally should be evaluated annually for physical function, since a decline has been consistently shown to be a strong predictor of adverse health outcomes, disability, and death [6,66]. Cognitive function should also be assessed routinely in persons with heart failure, particularly when first diagnosed, when changes in treatment regimen occur, and with worsening disease severity, since these events have been shown to occur before changes in cognition [31]. Incorporating geriatric performance-based measures in heart failure management would allow for more treatment strategies aimed at improving physical function, cognitive outcomes, and quality of life. Further, identifying frailty in heart failure is an important component of clinical decision-making when determining if a patient can tolerate therapies such as implantable defibrillators, cardiac resynchronization therapy, or left ventricular assist device placement.

In older adults, performance measures are well established and commonly used as part of geriatric assessment to evaluate physical and cognitive functioning. Performance-based measures may be particularly beneficial in older adults with heart failure to monitor serial changes in physical function. Performance measures in clinical settings require staff time but little training, space, equipment, or risk. As performance measures become more common in practice settings, MDC thresholds may need to be re-evaluated based on the characteristics of the population [67].

For persons with heart failure whose screening outcomes suggest MCI, more comprehensive neuropsychological testing should be available as well as provision of resources to optimize functional independence. Early identification of impaired cognition may lower risk of poor self-management through simplification of medication regimens or providing resources to help manage other regimens essential for optimal heart failure care. It is also important to recognize that depressive symptoms are common in persons with heart failure and are highly correlated with cognitive impairment in this population. Screening for depressive symptoms therefore, may also enhance identification of persons with heart failure at risk for frailty [4,28].

Conclusion

Effective appraisal and development of effective interventions are essential in older adults with heart failure who are at high risk for frailty and cognitive impairment. This will become increasingly important as the population ages and the incidence of heart failure rises proportionately. Although curative treatments for frailty and cognitive impairment are not available, interdisciplinary interventions such as exercise and comprehensive geriatric assessment may improve outcomes in older persons with heart failure [68]. Information gained from objective, simple, inexpensive physical performance measures, when used in combination with cognitive screening, may enhance the ability to evaluate change that signal onset of frailty or cognitive impairment [54,69,70]. The high morbidity and mortality associated with frailty and cognitive impairment indicate that it should be a priority for future research as a strategy to improve clinical outcomes, enhance quality of life, and lower health care costs in this growing population.

 

Corresponding author: Rebecca Gary, PhD, RN, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, ragary@emory.edu.

Funding/support: B. Butts was partially funded for this work through National Institutes of Health/National
Institute of Nursing Research Grant #T32NR012715.

From the Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA.

 

Abstract

• Objective: To review some of the proposed pathways that increase frailty risk in older persons with heart failure and to discuss tools that may be used to assess for changes in physical and cognitive functioning in this population in order to assist with appropriate and timely intervention.
• Methods: Review of the literature.
• Results: Heart failure is the only cardiovascular disease that is increasing by epidemic proportions, largely due to an aging society and therapeutic advances in disease management. Because heart failure is largely a cardiogeriatric syndrome, age-related syndromes such as frailty and cognitive impairment are common in heart failure patients. Compared with age-matched counterparts, older adults with heart failure 4 to 6 times more likely to be frail or cognitively impaired. The reason for the high prevalence of frailty and cognitive impairment in this population is not well known but may likely reflect the synergistic effects of heart failure and aging, which may heighten vulnerability to stressors and accelerate loss of physiologic reserve. Despite the high prevalence of frailty and cognitive impairment in the heart failure population, these conditions are not routinely screened for in clinical practice settings and guidelines on optimal assessment strategies are lacking.
• Conclusion: Persons with heart failure are at an increased risk for frailty, which may worsen symptoms, impair self-management, and lead to worse heart failure outcomes. Early detection of frailty and cognitive impairment may be an opportunity for intervention and a key strategy for improving clinical outcomes in older adults with heart failure.

 

Approximately 5.7 million persons in the United States are diagnosed with heart failure, and the number of reported new cases is expected to increase to over 700,000 cases annually by the year 2040 [1]. This rising incidence is fueled by an aging population; by the year 2030, 1 in 5 Americans will be over 65 years of age [2]. Heart failure is prevalent among those 65 years of age and older and is the most common reason for hospitalization in this age-group. High readmission rates, approaching 50% over 6 months, are a major contributor to the the escalating economic burden associated with heart failure [3].

Persons with heart failure are more likely to be frail and experience cognitive impairment than their age-matched counterparts without heart failure. The reasons for this are not well known but may be related to hemodynamic, vascular, and inflammatory changes occurring as heart failure progresses. In this paper, we review the link between frailty and cognitive impairment in heart failure, instruments that may be useful for early detection, and interventions such as exercise that may be beneficial for attenuating both conditions.

Frailty in Heart Failure

Epidemiology

Frailty is a heightened vulnerability to stressors in the presence of low physiological reserve [4]. When exposed to stressors, persons who are frail have a much higher probability for disproportionate decompensation, negative events, functional decline, disability, and mortality [5]. Among persons with heart failure, frailty may predispose them to decompensate at a lower threshold, requiring more frequent hospitalizations. Persons with heart failure are more likely to be frail than their age-matched counterparts without heart failure [6,7].

Frailty is a powerful predictor of poor clinical outcomes and mortality in cardiovascular disease [8,9]. Compared with the non-frail, frail persons with heart failure have increased rates of mortality (16.9% vs 4.8%) and increased rates of heart failure hospitalization (20.5% vs 13.3%) [10]. Frailty has also been shown to predict falls, disability, and hospitalization in heart failure patients [6,9,11] and was found to have a negative linear relationship with health-related quality of life [12]. Frail heart failure patients are also more likely to have comorbidities such diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, depression, anemia, and chronic kidney disease [9,13].

Pathophysiology

There is significant overlap in the underlying pathological mechanisms of heart failure and frailty. Symptoms of heart failure, such as dyspnea, fatigue, and muscle loss, mirror components that occur with frailty. Further, cardiac cachexia, a metabolic syndrome in advanced heart failure characterized by a loss of muscle mass, is very similar to the sarcopenia that occurs in frailty.

Frailty, characterized by an increased physiologic vulnerability to stressors, may predispose frail persons with heart failure to exacerbation and worsening of heart failure due to greater susceptibility to the harmful pathophysiologic processes in heart failure, such as inflammation and autonomic dysfunction. Proposed pathophysiologic pathways in frailty include free radicals and oxidative stress, cumulative DNA damage, decreased telomere length, and nuclear fragmentation [14,15]. Frailty has been associated with low-grade chronic inflammation and increased inflammatory cytokines, such as C-reactive protein, tumor necrosis factor–alpha (TNFα), interleukin-6 (IL-6)and fibrinogen [16–18]. Heart failure also is associated with a low-grade and chronic cardiac inflammatory response that is correlated with disease progression [19].

Inflammation. IL-6 is detectable in a higher proportion of persons who are frail compared to non-frail [16] and is the most highly correlated biomarker with frailty. In addition, among those with detectable IL-6 levels, those categorized as frail have higher IL-6 levels compared to those who are non-frail [16,20]. Individuals categorized as frail were found to have significantly higher levels of TNFα than those who were non-frail [16,20]. Increased IL-6 levels are associated with decreased muscle strength, while increased TNFα levels are associated with decreased skeletal muscle protein synthesis [21,22], thus contributing to frailty.

Oxidative stress. Protein carbonyls result from protein oxidation promoted by reactive oxygen species and are markers of oxidative stress. Protein carbonylation is implicated in the pathogenesis of the loss of skeletal muscle mass; high serum protein carbonyls are associated with poor grip strength [23]. 8-OHdG is an oxidized nucleoside indicative of oxidative damage to DNA and a measure of oxidative stress. Accumulation of 8-OHdG in skeletal muscle leads to loss of muscle mass and is associated with decreased hand grip strength in the elderly [24]. Higher serum levels of 8-OHdG are present in older adults who are frail as compared to those who are non-frail [25].

Measurement of Frailty in the Clinical Setting

Frailty has been conceptualized in a number of studies using different models and measures; however, there continues to be a lack of consensus on the definition and operationalization of frailty. Prior research has led to the development of several validated models of frailty that have demonstrated good prediction of adverse outcomes in older adults. Some models, such as the Fried phenotype [6], focus solely on the physical dimension, while other models take a multidimensional approach.Single-item measures (eg, gait speed, 6-minute walk test, handgrip strength) are also commonly used to screen for frailty, but a frailty measure that incorporates more than 1 physical dimension may be more sensitive and reliable. In our opinion, the ideal measure of frailty would consist of a brief assessment that can be serially performed in most clinical practice settings that can identify change in function over time. The incorporation of sensitive physical function measures that can detect frailty early has the potential to slow physical function decline by preserving physiological thresholds.

Cognitive Impairment in Heart Failure

Epidemiology

Cognitive impairment occurs frequently in patients with heart failure, and the presence of cognitive impairment in persons with heart failure has been shown to heighten risk for adverse clinical outcomes, disability, poor quality of life, and mortality [26,27]. Heart failure negatively influences cognitive functioning in most domains [28–32]. The most common domains adversely affected by heart failure and aging are memory and executive function. Deficits in these domains can substantially diminish patient ability to carry out essential self-care behaviors [30,32].

The most common form of cognitive impairment seen in patients with heart failure is mild cognitive impairment (MCI), which is a measurable deficit with memory or another core cognitive domain. Up to 60% of persons with heart failure have been reported to have MCI. Patients with MCI have cognitive deficits that are more pronounced than those seen in normal aging, but lack other symptoms of dementia, such as impaired judgment or reasoning. MCI often will not impede patients’ ability to carry out the activities of daily living (ADLs) independently, but patients may have difficulty in performing some instrumental activities of daily living (IADLs), such as remembering medications, scheduling provider appointments. Dementia, a decline in cognitive ability severe enough to hinder an individual’s ability to perform ADLs or IADLs or engage in social activities or occupational responsibilities, occurs in approximately 25% of persons with heart failure [33].

Persons with heart failure have a fourfold greater likelihood of developing CI than persons without heart failure. Several cohort studies have shown that persons with heart failure had lower performance on cognitive tests than individuals without heart failure [34,35] and were 50% more likely to progress to dementia.

Assessment Tools

Although a comprehensive neurocognitive battery would aid in detecting cognitive impairment in heart failure, few clinical practice settings have the resources to perform such a detailed and time-consuming measurement. Most studies in heart failure have relied on global screening questionnaires such as the Mini-Mental State Examination (MMSE) [36] to assess cognitive functioning in persons with heart failure and in other cardiovascular disorders. Global cognitive measures, however, often lack sensitivity for detecting subtle cognitive deficits such as seen in MCI [28–30]. Screening that measures executive function may be the most beneficial for busy clinical settings, since declines in this domain are well established as contributing to poor outcomes in persons with heart failure.

 

The Montreal Cognitive Assessment (MoCA) is a rapid screening test designed to detect MCI. It assesses different cognitive domains, including attention, memory, language, and executive function [37]. The MoCA lends itself to use in clinical setting because it is brief, requires little training to administer, and is easy to score. This instrument has been used successfully to assess MCI in persons with heart failure and may be more sensitive than the MMSE in identifying clinically relevant cognitive dysfunction. In 2013 study, Cameron et al [38] administered the MMSE and MoCA to 93 hospitalized heart failure patients and found that the MoCA classified 41% of patients as cognitively impaired that were not classified using the MMSE. For persons with a vascular cognitive deficit, the MMSE has been portrayed as an inadequate screening test due to lack of sensitivity for visuospatial and executive function deficits. Because the MoCA was designed to be more sensitive to such deficits, it may be a superior screening method for persons with heart failure. Although previous studies support the use of the MoCA in persons with heart failure, more research is needed in larger, more diverse heart failure samples with a wide range of cognitive deficits.

A Reasonable Clinical Assessment Approach

Considering the link between heart failure, frailty, and MCI, incorporating simple physical performance measures with cognitive screening may be an effective strategy to identify persons at risk for frailty. Two clinically relevant physical performance-based measures of frailty are proposed: the Fried phenotype (mentioned earlier) and the Short Physical Performance Battery (SBBP). In addition, cognitive screening using the MoCA is recommended as part of the routine examination for determining possible MCI or more severe cognitive deficits. The predictive validity of measuring physical frailty is enhanced when cognitive impairment is included in the assessment [36,39].

The performance-based measures included in this review have previously demonstrated excellent psychometric properties as well as sensitivity for change that is clinically meaningful. Minimal detectable change (MDC), a threshold score that refers to the minimal amount of change outside of error that reflects true change by a patient between 2 time points (rather than variation in measurement), is important for interpreting level of risk for frailty and is included for each instrument [40,41]. If a more brief frailty examination is needed, cut-points for gait speed and handgrip have been used effectively in a number of studies as a threshold for determining frailty, including in older patients with cardiovascular disease and in heart failure [8,42,43].

Fried Frailty Phenotype

The Fried phenotype is an appropriate method of measuring frailty in a clinical setting due to its wide application across diverse populations and consistent identification of adverse outcomes [44]. This model is derived from a frailty model proposed by Fried et al [6] in which a phenotypic cycle exists that includes disease, sarcopenia, decreased walking speed, chronic undernutrition, decreased total energy expenditure, senescent musculoskeletal changes, decreased resting metabolic rate, weight loss and decreased maximal oxygen consumption. Frailty exists when a critical mass of these cycle components are identified in an individual [6].

To validate the model, Fried et al used data from the Cardiovascular Health Study and used the model to show association with a 3-year and 7-year incidence of mobility and ADL disability among 4317 community-dwelling men and women aged 65 years and older, independent of comorbidities. Several studies have directly tested the frailty phenotype model alone and in comparison to other models of frailty in large prospective studies across different populations, such as the Survey of Health, Aging and Retirement in Europe (SHARE) [45], the European Male Aging Study [46], and the Canadian Health Study of Aging [47]. While these studies found the prevalence of frailty to vary across the populations, they all validated the Fried model and found no significant differences in the predictive ability of the Fried model and other models of frailty. The Frailty Consensus conference evaluated the different models of frailty and determined that the Fried model is a validated construct of frailty and is acceptable for use in the identification of individuals who are frail or likely to become frail [48]. Thus, the Fried et al frailty phenotype model is considered to be a standard measure of frailty in older individuals.

The Fried phenotype assesses 5 criteria: shrinking, weakness, exhaustion, gait speed and physical activity (Table 1) [6]. A score of 0 or 1 is assigned to each of the 5 criteria and summed to get a total frailty score. Scores of 3 or greater are assigned as frail, while scores of less than 3 are considered non-frail. Scores of 1 or 2 can also be assigned as intermediate or at-risk for frailty (pre-frail). The focus of the Fried phenotype on physical domains makes it a particular appropriate measure to consider in the heart failure population since physical function declines occur as disease severity worsens.

Short Physical Performance Battery

The SPPB has been used to evaluate frailty risk in older adults with heart failure [49,50]. The SPPB assesses lower extremity physical performance by testing balance, walking, and muscle strength (Table 2). Scores on the SPPB are easy to interpret for clinicians, with a change of 5 clinically meaningful. Three studies have evaluated outcomes using the SPPB as a risk assessment of frailty in older adults with heart failure. Di Bari et al compared SPPB scores and the 6-minute walk test distance (6MWD) in older adults with and without heart failure [51]. SPPB scores and 6MWD were lower and predicted poor clinical outcomes in patients with heart failure compared with those without heart failure. The SPPB was used by Chiarantini et al to assess whether the SPPB predicted the long-term survival of 157 older adults (mean age, 80 yr) discharged following a heart failure exacerbation [52]. The mean SPPB score was 4.5 but varied considerably by NYHA class (class I: 7.4 ± 1.1; class II: 5.0 ± 0.5; class III: 4.8 ± 0.5; class IV: 2.3 ± 0.7; P < 0.001). Poorer SPPB scores were associated with higher mortality rates; compared with a SPPB score of 9 to 12, scores of 0, 1 to 4, and 5 to 8 were associated with mortality risks of 6.06, 4.78, and 1.95, respectively. Importantly, of approximately 30% (n = 47) of participants who scored 0 on the SPPB, 47% were NYHA class IV and 74% were unable to perform any of the 3 tests on the SPPB. An average of 10 to 15 minutes were required to administer the SPPB in these frail, elderly hospitalized heart failure patients and no adverse events were reported.

In other chronic illness populations, the SPPB has also been used as a predictor of outcomes before, during, or after hospitalization. Valpato et al [53], for example, used the SPPB to assess older adults (mean age, 78 yr) admitted to the hospital with a diagnosis of heart failure (64%), pneumonia (13%), chronic obstructive pulmonary disease (16%), or minor stroke (6.6%) at admission (baseline) and discharge. Patients with the lowest SPPB quartile scores at hospital discharge had a fivefold greater risk of rehospitalization or mortality compared to the highest quartile. In addition, those who had an early decline in SPPB scores 1 month after hospital discharge had greater limitations in performing activities of daily living and a significantly greater probability of being re-hospitalized or death during the 1-year follow-up period. These studies suggest that the SPPB at the first follow-up outpatient visit following hospital discharge may be beneficial for identifying need for further intervention or the need for more frequent follow-up care. Although the SPPB is not part of the Fried et al phenotype, it may provide additional information concerning risk for falls and lower extremity strength that may be beneficial in the evaluation of some persons with heart failure [54]. The SPPB along with instructions and normative data are available for clinical use at no charge at www.grc.nia.nih.gov/branches/ledb/sppb/index.htm.

Interventions for Frailty in Heart Failure

Interventions to address frailty have included exercise training, comprehensive geriatric assessment and management services, social support systems, nutrition, and drugs; however, few intervention studies have examined frailty in heart failure [8]. Restoration of physical function through aerobic exercise and resistance training has shown benefit in frail older adults [55–57] and in persons with heart failure [58]. Maintaining and/or restoring physical function through aerobic and resistance exercise training may be the key to preventing further decline or potentially reversing frailty in older adults with heart failure.

Aerobic exercise has been shown to be beneficial for both frail older adults and frail persons with heart failure [18]. In a study of community-dwelling frail older adults aged 65 and older, a combined aerobic and resistance exercise intervention, performed over 16 weeks, demonstrated significant improvement in frailty scores during the 1-year follow-up in contrast to worsening frailty measures in the control group [57].

Older adults with heart failure experience a much lower exercise tolerance largely due to a 50% to 75% decrease in aerobic capacity in addition to the well-known alterations in peripheral musculoskeletal performance that contribute to fatigue and greater symptom severity. Aerobic exercise has been shown to be beneficial for most heart failure patients by altering the peripheral and central mechanisms, such as inflammatory cytokines, that contribute to heart failure exacerbations, worsened symptom severity, and poor clinical outcomes [59–62].Lower rates of hospitalization, improved physical function, and enhanced health-related quality of life are reported in heart failure patients who routinely exercise [59]. Resistance training has been shown to improve physical function in frail older adults [55]. Further, the use of TheraBand exercise bands in resistance training demonstrated improvement in physical function among frail older adults [56].

Exercise also appears to exert a positive effect on cognition, particularly executive functioning, and may also have a protective effect against cognitive decline with aging and among those with heart failure. The underlying mechanism for improvement in cognition remains poorly understood but is likely related to improved cardiac function, cerebral perfusion, and oxygenation, although this has not been clearly established. Larson et al (2006) evaluated the frequency of participation in a variety of physical activities (eg, walking, bicycling and swimming) over 6 years in 1740 older adults [63]. Older adults who exercised more than 3 times per week during initial assessment were 34% less likely to be diagnosed with dementia than those who exercised fewer than 3 times per week. Several meta-analyses in recent years have shown a consistent and positive relationship between aerobic exercise and cognition [64,65]. Importantly, findings from meta-analyses have shown a moderate effect size (> 0.5) from aerobic training, which was similar for normal and cognitively impaired adults [64].

 

Implications for Clinical Care

A systematic assessment performed periodically using physical and cognitive measures that may identify prefrailty may be the best strategy for preventing further functional loss, limitations, and disability in persons with heart failure. Persons with heart failure ideally should be evaluated annually for physical function, since a decline has been consistently shown to be a strong predictor of adverse health outcomes, disability, and death [6,66]. Cognitive function should also be assessed routinely in persons with heart failure, particularly when first diagnosed, when changes in treatment regimen occur, and with worsening disease severity, since these events have been shown to occur before changes in cognition [31]. Incorporating geriatric performance-based measures in heart failure management would allow for more treatment strategies aimed at improving physical function, cognitive outcomes, and quality of life. Further, identifying frailty in heart failure is an important component of clinical decision-making when determining if a patient can tolerate therapies such as implantable defibrillators, cardiac resynchronization therapy, or left ventricular assist device placement.

In older adults, performance measures are well established and commonly used as part of geriatric assessment to evaluate physical and cognitive functioning. Performance-based measures may be particularly beneficial in older adults with heart failure to monitor serial changes in physical function. Performance measures in clinical settings require staff time but little training, space, equipment, or risk. As performance measures become more common in practice settings, MDC thresholds may need to be re-evaluated based on the characteristics of the population [67].

For persons with heart failure whose screening outcomes suggest MCI, more comprehensive neuropsychological testing should be available as well as provision of resources to optimize functional independence. Early identification of impaired cognition may lower risk of poor self-management through simplification of medication regimens or providing resources to help manage other regimens essential for optimal heart failure care. It is also important to recognize that depressive symptoms are common in persons with heart failure and are highly correlated with cognitive impairment in this population. Screening for depressive symptoms therefore, may also enhance identification of persons with heart failure at risk for frailty [4,28].

Conclusion

Effective appraisal and development of effective interventions are essential in older adults with heart failure who are at high risk for frailty and cognitive impairment. This will become increasingly important as the population ages and the incidence of heart failure rises proportionately. Although curative treatments for frailty and cognitive impairment are not available, interdisciplinary interventions such as exercise and comprehensive geriatric assessment may improve outcomes in older persons with heart failure [68]. Information gained from objective, simple, inexpensive physical performance measures, when used in combination with cognitive screening, may enhance the ability to evaluate change that signal onset of frailty or cognitive impairment [54,69,70]. The high morbidity and mortality associated with frailty and cognitive impairment indicate that it should be a priority for future research as a strategy to improve clinical outcomes, enhance quality of life, and lower health care costs in this growing population.

 

Corresponding author: Rebecca Gary, PhD, RN, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, ragary@emory.edu.

Funding/support: B. Butts was partially funded for this work through National Institutes of Health/National
Institute of Nursing Research Grant #T32NR012715.

From the Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA.

 

Abstract

• Objective: To review some of the proposed pathways that increase frailty risk in older persons with heart failure and to discuss tools that may be used to assess for changes in physical and cognitive functioning in this population in order to assist with appropriate and timely intervention.
• Methods: Review of the literature.
• Results: Heart failure is the only cardiovascular disease that is increasing by epidemic proportions, largely due to an aging society and therapeutic advances in disease management. Because heart failure is largely a cardiogeriatric syndrome, age-related syndromes such as frailty and cognitive impairment are common in heart failure patients. Compared with age-matched counterparts, older adults with heart failure 4 to 6 times more likely to be frail or cognitively impaired. The reason for the high prevalence of frailty and cognitive impairment in this population is not well known but may likely reflect the synergistic effects of heart failure and aging, which may heighten vulnerability to stressors and accelerate loss of physiologic reserve. Despite the high prevalence of frailty and cognitive impairment in the heart failure population, these conditions are not routinely screened for in clinical practice settings and guidelines on optimal assessment strategies are lacking.
• Conclusion: Persons with heart failure are at an increased risk for frailty, which may worsen symptoms, impair self-management, and lead to worse heart failure outcomes. Early detection of frailty and cognitive impairment may be an opportunity for intervention and a key strategy for improving clinical outcomes in older adults with heart failure.

 

Approximately 5.7 million persons in the United States are diagnosed with heart failure, and the number of reported new cases is expected to increase to over 700,000 cases annually by the year 2040 [1]. This rising incidence is fueled by an aging population; by the year 2030, 1 in 5 Americans will be over 65 years of age [2]. Heart failure is prevalent among those 65 years of age and older and is the most common reason for hospitalization in this age-group. High readmission rates, approaching 50% over 6 months, are a major contributor to the the escalating economic burden associated with heart failure [3].

Persons with heart failure are more likely to be frail and experience cognitive impairment than their age-matched counterparts without heart failure. The reasons for this are not well known but may be related to hemodynamic, vascular, and inflammatory changes occurring as heart failure progresses. In this paper, we review the link between frailty and cognitive impairment in heart failure, instruments that may be useful for early detection, and interventions such as exercise that may be beneficial for attenuating both conditions.

Frailty in Heart Failure

Epidemiology

Frailty is a heightened vulnerability to stressors in the presence of low physiological reserve [4]. When exposed to stressors, persons who are frail have a much higher probability for disproportionate decompensation, negative events, functional decline, disability, and mortality [5]. Among persons with heart failure, frailty may predispose them to decompensate at a lower threshold, requiring more frequent hospitalizations. Persons with heart failure are more likely to be frail than their age-matched counterparts without heart failure [6,7].

Frailty is a powerful predictor of poor clinical outcomes and mortality in cardiovascular disease [8,9]. Compared with the non-frail, frail persons with heart failure have increased rates of mortality (16.9% vs 4.8%) and increased rates of heart failure hospitalization (20.5% vs 13.3%) [10]. Frailty has also been shown to predict falls, disability, and hospitalization in heart failure patients [6,9,11] and was found to have a negative linear relationship with health-related quality of life [12]. Frail heart failure patients are also more likely to have comorbidities such diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, depression, anemia, and chronic kidney disease [9,13].

Pathophysiology

There is significant overlap in the underlying pathological mechanisms of heart failure and frailty. Symptoms of heart failure, such as dyspnea, fatigue, and muscle loss, mirror components that occur with frailty. Further, cardiac cachexia, a metabolic syndrome in advanced heart failure characterized by a loss of muscle mass, is very similar to the sarcopenia that occurs in frailty.

Frailty, characterized by an increased physiologic vulnerability to stressors, may predispose frail persons with heart failure to exacerbation and worsening of heart failure due to greater susceptibility to the harmful pathophysiologic processes in heart failure, such as inflammation and autonomic dysfunction. Proposed pathophysiologic pathways in frailty include free radicals and oxidative stress, cumulative DNA damage, decreased telomere length, and nuclear fragmentation [14,15]. Frailty has been associated with low-grade chronic inflammation and increased inflammatory cytokines, such as C-reactive protein, tumor necrosis factor–alpha (TNFα), interleukin-6 (IL-6)and fibrinogen [16–18]. Heart failure also is associated with a low-grade and chronic cardiac inflammatory response that is correlated with disease progression [19].

Inflammation. IL-6 is detectable in a higher proportion of persons who are frail compared to non-frail [16] and is the most highly correlated biomarker with frailty. In addition, among those with detectable IL-6 levels, those categorized as frail have higher IL-6 levels compared to those who are non-frail [16,20]. Individuals categorized as frail were found to have significantly higher levels of TNFα than those who were non-frail [16,20]. Increased IL-6 levels are associated with decreased muscle strength, while increased TNFα levels are associated with decreased skeletal muscle protein synthesis [21,22], thus contributing to frailty.

Oxidative stress. Protein carbonyls result from protein oxidation promoted by reactive oxygen species and are markers of oxidative stress. Protein carbonylation is implicated in the pathogenesis of the loss of skeletal muscle mass; high serum protein carbonyls are associated with poor grip strength [23]. 8-OHdG is an oxidized nucleoside indicative of oxidative damage to DNA and a measure of oxidative stress. Accumulation of 8-OHdG in skeletal muscle leads to loss of muscle mass and is associated with decreased hand grip strength in the elderly [24]. Higher serum levels of 8-OHdG are present in older adults who are frail as compared to those who are non-frail [25].

Measurement of Frailty in the Clinical Setting

Frailty has been conceptualized in a number of studies using different models and measures; however, there continues to be a lack of consensus on the definition and operationalization of frailty. Prior research has led to the development of several validated models of frailty that have demonstrated good prediction of adverse outcomes in older adults. Some models, such as the Fried phenotype [6], focus solely on the physical dimension, while other models take a multidimensional approach.Single-item measures (eg, gait speed, 6-minute walk test, handgrip strength) are also commonly used to screen for frailty, but a frailty measure that incorporates more than 1 physical dimension may be more sensitive and reliable. In our opinion, the ideal measure of frailty would consist of a brief assessment that can be serially performed in most clinical practice settings that can identify change in function over time. The incorporation of sensitive physical function measures that can detect frailty early has the potential to slow physical function decline by preserving physiological thresholds.

Cognitive Impairment in Heart Failure

Epidemiology

Cognitive impairment occurs frequently in patients with heart failure, and the presence of cognitive impairment in persons with heart failure has been shown to heighten risk for adverse clinical outcomes, disability, poor quality of life, and mortality [26,27]. Heart failure negatively influences cognitive functioning in most domains [28–32]. The most common domains adversely affected by heart failure and aging are memory and executive function. Deficits in these domains can substantially diminish patient ability to carry out essential self-care behaviors [30,32].

The most common form of cognitive impairment seen in patients with heart failure is mild cognitive impairment (MCI), which is a measurable deficit with memory or another core cognitive domain. Up to 60% of persons with heart failure have been reported to have MCI. Patients with MCI have cognitive deficits that are more pronounced than those seen in normal aging, but lack other symptoms of dementia, such as impaired judgment or reasoning. MCI often will not impede patients’ ability to carry out the activities of daily living (ADLs) independently, but patients may have difficulty in performing some instrumental activities of daily living (IADLs), such as remembering medications, scheduling provider appointments. Dementia, a decline in cognitive ability severe enough to hinder an individual’s ability to perform ADLs or IADLs or engage in social activities or occupational responsibilities, occurs in approximately 25% of persons with heart failure [33].

Persons with heart failure have a fourfold greater likelihood of developing CI than persons without heart failure. Several cohort studies have shown that persons with heart failure had lower performance on cognitive tests than individuals without heart failure [34,35] and were 50% more likely to progress to dementia.

Assessment Tools

Although a comprehensive neurocognitive battery would aid in detecting cognitive impairment in heart failure, few clinical practice settings have the resources to perform such a detailed and time-consuming measurement. Most studies in heart failure have relied on global screening questionnaires such as the Mini-Mental State Examination (MMSE) [36] to assess cognitive functioning in persons with heart failure and in other cardiovascular disorders. Global cognitive measures, however, often lack sensitivity for detecting subtle cognitive deficits such as seen in MCI [28–30]. Screening that measures executive function may be the most beneficial for busy clinical settings, since declines in this domain are well established as contributing to poor outcomes in persons with heart failure.

 

The Montreal Cognitive Assessment (MoCA) is a rapid screening test designed to detect MCI. It assesses different cognitive domains, including attention, memory, language, and executive function [37]. The MoCA lends itself to use in clinical setting because it is brief, requires little training to administer, and is easy to score. This instrument has been used successfully to assess MCI in persons with heart failure and may be more sensitive than the MMSE in identifying clinically relevant cognitive dysfunction. In 2013 study, Cameron et al [38] administered the MMSE and MoCA to 93 hospitalized heart failure patients and found that the MoCA classified 41% of patients as cognitively impaired that were not classified using the MMSE. For persons with a vascular cognitive deficit, the MMSE has been portrayed as an inadequate screening test due to lack of sensitivity for visuospatial and executive function deficits. Because the MoCA was designed to be more sensitive to such deficits, it may be a superior screening method for persons with heart failure. Although previous studies support the use of the MoCA in persons with heart failure, more research is needed in larger, more diverse heart failure samples with a wide range of cognitive deficits.

A Reasonable Clinical Assessment Approach

Considering the link between heart failure, frailty, and MCI, incorporating simple physical performance measures with cognitive screening may be an effective strategy to identify persons at risk for frailty. Two clinically relevant physical performance-based measures of frailty are proposed: the Fried phenotype (mentioned earlier) and the Short Physical Performance Battery (SBBP). In addition, cognitive screening using the MoCA is recommended as part of the routine examination for determining possible MCI or more severe cognitive deficits. The predictive validity of measuring physical frailty is enhanced when cognitive impairment is included in the assessment [36,39].

The performance-based measures included in this review have previously demonstrated excellent psychometric properties as well as sensitivity for change that is clinically meaningful. Minimal detectable change (MDC), a threshold score that refers to the minimal amount of change outside of error that reflects true change by a patient between 2 time points (rather than variation in measurement), is important for interpreting level of risk for frailty and is included for each instrument [40,41]. If a more brief frailty examination is needed, cut-points for gait speed and handgrip have been used effectively in a number of studies as a threshold for determining frailty, including in older patients with cardiovascular disease and in heart failure [8,42,43].

Fried Frailty Phenotype

The Fried phenotype is an appropriate method of measuring frailty in a clinical setting due to its wide application across diverse populations and consistent identification of adverse outcomes [44]. This model is derived from a frailty model proposed by Fried et al [6] in which a phenotypic cycle exists that includes disease, sarcopenia, decreased walking speed, chronic undernutrition, decreased total energy expenditure, senescent musculoskeletal changes, decreased resting metabolic rate, weight loss and decreased maximal oxygen consumption. Frailty exists when a critical mass of these cycle components are identified in an individual [6].

To validate the model, Fried et al used data from the Cardiovascular Health Study and used the model to show association with a 3-year and 7-year incidence of mobility and ADL disability among 4317 community-dwelling men and women aged 65 years and older, independent of comorbidities. Several studies have directly tested the frailty phenotype model alone and in comparison to other models of frailty in large prospective studies across different populations, such as the Survey of Health, Aging and Retirement in Europe (SHARE) [45], the European Male Aging Study [46], and the Canadian Health Study of Aging [47]. While these studies found the prevalence of frailty to vary across the populations, they all validated the Fried model and found no significant differences in the predictive ability of the Fried model and other models of frailty. The Frailty Consensus conference evaluated the different models of frailty and determined that the Fried model is a validated construct of frailty and is acceptable for use in the identification of individuals who are frail or likely to become frail [48]. Thus, the Fried et al frailty phenotype model is considered to be a standard measure of frailty in older individuals.

The Fried phenotype assesses 5 criteria: shrinking, weakness, exhaustion, gait speed and physical activity (Table 1) [6]. A score of 0 or 1 is assigned to each of the 5 criteria and summed to get a total frailty score. Scores of 3 or greater are assigned as frail, while scores of less than 3 are considered non-frail. Scores of 1 or 2 can also be assigned as intermediate or at-risk for frailty (pre-frail). The focus of the Fried phenotype on physical domains makes it a particular appropriate measure to consider in the heart failure population since physical function declines occur as disease severity worsens.

Short Physical Performance Battery

The SPPB has been used to evaluate frailty risk in older adults with heart failure [49,50]. The SPPB assesses lower extremity physical performance by testing balance, walking, and muscle strength (Table 2). Scores on the SPPB are easy to interpret for clinicians, with a change of 5 clinically meaningful. Three studies have evaluated outcomes using the SPPB as a risk assessment of frailty in older adults with heart failure. Di Bari et al compared SPPB scores and the 6-minute walk test distance (6MWD) in older adults with and without heart failure [51]. SPPB scores and 6MWD were lower and predicted poor clinical outcomes in patients with heart failure compared with those without heart failure. The SPPB was used by Chiarantini et al to assess whether the SPPB predicted the long-term survival of 157 older adults (mean age, 80 yr) discharged following a heart failure exacerbation [52]. The mean SPPB score was 4.5 but varied considerably by NYHA class (class I: 7.4 ± 1.1; class II: 5.0 ± 0.5; class III: 4.8 ± 0.5; class IV: 2.3 ± 0.7; P < 0.001). Poorer SPPB scores were associated with higher mortality rates; compared with a SPPB score of 9 to 12, scores of 0, 1 to 4, and 5 to 8 were associated with mortality risks of 6.06, 4.78, and 1.95, respectively. Importantly, of approximately 30% (n = 47) of participants who scored 0 on the SPPB, 47% were NYHA class IV and 74% were unable to perform any of the 3 tests on the SPPB. An average of 10 to 15 minutes were required to administer the SPPB in these frail, elderly hospitalized heart failure patients and no adverse events were reported.

In other chronic illness populations, the SPPB has also been used as a predictor of outcomes before, during, or after hospitalization. Valpato et al [53], for example, used the SPPB to assess older adults (mean age, 78 yr) admitted to the hospital with a diagnosis of heart failure (64%), pneumonia (13%), chronic obstructive pulmonary disease (16%), or minor stroke (6.6%) at admission (baseline) and discharge. Patients with the lowest SPPB quartile scores at hospital discharge had a fivefold greater risk of rehospitalization or mortality compared to the highest quartile. In addition, those who had an early decline in SPPB scores 1 month after hospital discharge had greater limitations in performing activities of daily living and a significantly greater probability of being re-hospitalized or death during the 1-year follow-up period. These studies suggest that the SPPB at the first follow-up outpatient visit following hospital discharge may be beneficial for identifying need for further intervention or the need for more frequent follow-up care. Although the SPPB is not part of the Fried et al phenotype, it may provide additional information concerning risk for falls and lower extremity strength that may be beneficial in the evaluation of some persons with heart failure [54]. The SPPB along with instructions and normative data are available for clinical use at no charge at www.grc.nia.nih.gov/branches/ledb/sppb/index.htm.

Interventions for Frailty in Heart Failure

Interventions to address frailty have included exercise training, comprehensive geriatric assessment and management services, social support systems, nutrition, and drugs; however, few intervention studies have examined frailty in heart failure [8]. Restoration of physical function through aerobic exercise and resistance training has shown benefit in frail older adults [55–57] and in persons with heart failure [58]. Maintaining and/or restoring physical function through aerobic and resistance exercise training may be the key to preventing further decline or potentially reversing frailty in older adults with heart failure.

Aerobic exercise has been shown to be beneficial for both frail older adults and frail persons with heart failure [18]. In a study of community-dwelling frail older adults aged 65 and older, a combined aerobic and resistance exercise intervention, performed over 16 weeks, demonstrated significant improvement in frailty scores during the 1-year follow-up in contrast to worsening frailty measures in the control group [57].

Older adults with heart failure experience a much lower exercise tolerance largely due to a 50% to 75% decrease in aerobic capacity in addition to the well-known alterations in peripheral musculoskeletal performance that contribute to fatigue and greater symptom severity. Aerobic exercise has been shown to be beneficial for most heart failure patients by altering the peripheral and central mechanisms, such as inflammatory cytokines, that contribute to heart failure exacerbations, worsened symptom severity, and poor clinical outcomes [59–62].Lower rates of hospitalization, improved physical function, and enhanced health-related quality of life are reported in heart failure patients who routinely exercise [59]. Resistance training has been shown to improve physical function in frail older adults [55]. Further, the use of TheraBand exercise bands in resistance training demonstrated improvement in physical function among frail older adults [56].

Exercise also appears to exert a positive effect on cognition, particularly executive functioning, and may also have a protective effect against cognitive decline with aging and among those with heart failure. The underlying mechanism for improvement in cognition remains poorly understood but is likely related to improved cardiac function, cerebral perfusion, and oxygenation, although this has not been clearly established. Larson et al (2006) evaluated the frequency of participation in a variety of physical activities (eg, walking, bicycling and swimming) over 6 years in 1740 older adults [63]. Older adults who exercised more than 3 times per week during initial assessment were 34% less likely to be diagnosed with dementia than those who exercised fewer than 3 times per week. Several meta-analyses in recent years have shown a consistent and positive relationship between aerobic exercise and cognition [64,65]. Importantly, findings from meta-analyses have shown a moderate effect size (> 0.5) from aerobic training, which was similar for normal and cognitively impaired adults [64].

 

Implications for Clinical Care

A systematic assessment performed periodically using physical and cognitive measures that may identify prefrailty may be the best strategy for preventing further functional loss, limitations, and disability in persons with heart failure. Persons with heart failure ideally should be evaluated annually for physical function, since a decline has been consistently shown to be a strong predictor of adverse health outcomes, disability, and death [6,66]. Cognitive function should also be assessed routinely in persons with heart failure, particularly when first diagnosed, when changes in treatment regimen occur, and with worsening disease severity, since these events have been shown to occur before changes in cognition [31]. Incorporating geriatric performance-based measures in heart failure management would allow for more treatment strategies aimed at improving physical function, cognitive outcomes, and quality of life. Further, identifying frailty in heart failure is an important component of clinical decision-making when determining if a patient can tolerate therapies such as implantable defibrillators, cardiac resynchronization therapy, or left ventricular assist device placement.

In older adults, performance measures are well established and commonly used as part of geriatric assessment to evaluate physical and cognitive functioning. Performance-based measures may be particularly beneficial in older adults with heart failure to monitor serial changes in physical function. Performance measures in clinical settings require staff time but little training, space, equipment, or risk. As performance measures become more common in practice settings, MDC thresholds may need to be re-evaluated based on the characteristics of the population [67].

For persons with heart failure whose screening outcomes suggest MCI, more comprehensive neuropsychological testing should be available as well as provision of resources to optimize functional independence. Early identification of impaired cognition may lower risk of poor self-management through simplification of medication regimens or providing resources to help manage other regimens essential for optimal heart failure care. It is also important to recognize that depressive symptoms are common in persons with heart failure and are highly correlated with cognitive impairment in this population. Screening for depressive symptoms therefore, may also enhance identification of persons with heart failure at risk for frailty [4,28].

Conclusion

Effective appraisal and development of effective interventions are essential in older adults with heart failure who are at high risk for frailty and cognitive impairment. This will become increasingly important as the population ages and the incidence of heart failure rises proportionately. Although curative treatments for frailty and cognitive impairment are not available, interdisciplinary interventions such as exercise and comprehensive geriatric assessment may improve outcomes in older persons with heart failure [68]. Information gained from objective, simple, inexpensive physical performance measures, when used in combination with cognitive screening, may enhance the ability to evaluate change that signal onset of frailty or cognitive impairment [54,69,70]. The high morbidity and mortality associated with frailty and cognitive impairment indicate that it should be a priority for future research as a strategy to improve clinical outcomes, enhance quality of life, and lower health care costs in this growing population.

 

Corresponding author: Rebecca Gary, PhD, RN, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, ragary@emory.edu.

Funding/support: B. Butts was partially funded for this work through National Institutes of Health/National
Institute of Nursing Research Grant #T32NR012715.

From the Institute for Patient- and Family-Centered Care, Bethesda, MD (Ms. Dokken, Ms. Kaufman, and Ms. Johnson), Anne Arundel Medical Center, Annapolis, MD (Dr. Perkins), Contra Costa Regional Medical Center & Health Centers, Martinez, CA (Ms. Benepal, Ms. Roth, and Vidant Health, Greenville, NC (Ms. Dutton and Ms. Jones).

 

Abstract

• Objective: To describe a campaign to eliminate restrictive hospital visiting policies and to put in place policies that recognize families as partners in care.
• Methods: Descriptive report.
• Results: Many hospitals still have “visiting” hours that limit family presence, often counter to patient preferences. To change the concept of families as visitors and eliminate restrictive hospital visiting policies, the Institute for Patient- and Family-Centered Care (IPFCC) launched the campaign Better Together: Partnering with Families, calling on all hospitals to welcome families 24 hours a day and transform their policies and approaches to care so that patients’ families and loved ones are included in care and decision making, according to patient preferences. As part of the campaign, IPFCC recognized 12 hospitals that exemplify success in eliminating restrictive visiting policies and have changed the concept of families from  “visitors” to partners. Leaders at these hospitals attest to the benefits of the changes through improved experience of care and other outcomes. Three exemplar hospitals are highlighted in this article and share their processes of change as well as key learnings and outcomes.
• Conclusion: Hospital policies and practices that encourage and support families as partners in care are essential to patients’ health, well-being, and safety.

 

Many families are restricted from the bedsides of loved ones because of hospital visiting policies [1–3]. Restrictive policies are often based on long-held beliefs that the presence and participation of families interferes with care, exhausts patients, is a burden to families, spreads infection, or violates HIPAA. However, there is no evidence to support those beliefs. In fact, isolating patients at their most vulnerable time from the people who know them best places them at risk for medical error, emotional harm, inconsistencies in care, and lack of preparedness for transitions in care [4,5]. Jackie Gruzenski’s story “Behind a Locked Door” (printed below) affectingly describes the impact of restrictive policies on a couple's last days.

Fortunately, a growing number of hospitals are lifting these restrictions. But opening the door is not enough. Hospitals need to change the concept of families as “visitors” to families as partners in care. Changing policies is a foundational step in creating a patient- and family-centered culture where families are recognized as essential to patients’ health and well-being and where they are respected as allies for quality and safety.

In response to this critical need for change, in June 2014 the Institute for Patient- and Family-Centered Care (IPFCC) launched the campaign Better Together: Partnering with Families. IPFCC, founded in 1992, is a nonprofit organization that provides essential leadership to advance the understanding and practice of patient- and family-centered care [6]. Emphasizing the importance of family presence and participation to quality and safety, the campaign seeks to eliminate restrictive “visiting” policies and calls upon hospitals to include families as members of the care team and to welcome them 24 hours a day, 7 days a week, according to patient preference [7]. The goal of the campaign is to change visiting policies in 1000 hospitals by 2017. Partnering with IPFCC in this initiative are the American Society for Healthcare Risk Management, American Association of Critical Care Nurses, National Partnership for Women & Families, New Yorkers for Patient and Family Empowerment, Health In Aging Foundation, and the Canadian Foundation for Healthcare Improvement.

The Better Together campaign currently recognizes 12 hospitals in the United States and Canada that exemplify success in changing their “visiting” policies. The hospitals vary in size, structure, and geographic location, as well as in the processes they used to change. These “exemplar” hospitals are helping IPFCC disseminate information about the campaign and will serve as mentors to other hospitals beginning the process through an online learning community. In this article, 3 exemplar hospitals describe their processes, discussing the impetus for change, the process itself, including involvement of key groups, as well as outcomes to date and “lessons learned” to share with other hospitals. An example visiting policy is also presented (Appendix).

Anne Arundel Medical Center

A regional not-for-profit hospital founded in 1902, Anne Arundel Medical Center in Annapolis, MD, provides acute inpatient and outpatient care to residents of 4 counties in Maryland. A 380-bed facility, Anne Arundel has a cancer institute, heart and vascular institute, joint center, spine center, and a women’s and children’s center. In April 2011, the hospital completed a $424 million expansion project, which included a pediatric emergency room, an expanded general emergency room, 50 new patient beds, and 8 new operating rooms.

In 2010, based on a desire to concretely implement the principles of patient- and family-centered care, leaders at Anne Arundel began working with patient and family advisors and initiated a process to change the hospital’s restrictive visiting policy. Now, there are no restrictions on family presence anywhere in the hospital, from ICUs to medical/surgical units to other clinical areas. Patients have the power to choose who they want to stay with them—24 hours a day, 7 days a week. According to Anne Arundel’s policy, each patient determines who is defined as “family.” A “Revisiting Visiting” task force, comprising support staff, providers, and patient and family advisors, worked for 9 months to develop the new family presence policy and support its implementation.

With Anne Arundel leadership encouragement and support, patient and family advisors  participated in all phases of the development and implementation of the new family presence policy and in other ways to advance the practice of patient- and family-centered care. The advisors also participated in the process to change the way nurse change of shift report was conducted, and they made recommendations for changes in the directional signs throughout the hospital. New signs, featuring a pineapple (a symbol of hospitality) and the words “Welcome Families” replaced old ones displaying the former restrictive visiting policy.

Supporting patient and family involvement in transitions in care is an integral aspect of implementing family presence policies and practices. Through an “Always Events” grant from the Picker Institute (for information about the Always Events program, see www.ihi.org/Engage/Initiatives/PatientFamilyCenteredCare/Pages/AlwaysEvents.aspx), patient and family advisors, staff, and providers at Anne Arundel developed the SMART discharge protocol, which includes a simple 5-item checklist that is reviewed and discussed with the patient and family prior to discharge. SMART is an acronym for Signs, Medications, Appointments, Results, and Talk. In its work, the SMART team built on current evidence, created urgency and expectation for use with patients, families, and caregivers, disseminated findings, and promoted the protocol as a national standard. The tool is available at www.ihi.org/resources/Pages/Tools/SMARTDischargeProtocol.aspx.

 

According to Anne Arundel’s COO and CNO, Sherry Perkins, a critical part of the change process was to first understand staff’s fears and then learn what the evidence says. For example, with regard to the impact of additional family presence on infection control, they learned that family presence did not pose additional infection control concerns.

In 2009, there were no patient and family advisors volunteering at Anne Arundel. In 2014, there are approximately 80 advisors. Since 2009, the overall HCAHPS rating of the hospital has gone from 75.4% to 82% (the national average is 70%). While patient satisfaction scores have previously been in the top deciles at Anne Arundel, they have consistently risen since expanding family presence and implementing additional patient- and family-centered strategies.

Contra Costa Regional Medical Center and Health Centers

Contra Costa Health Services in Martinez, CA, includes Contra Costa Regional Medical Center and 10 health centers as part of a comprehensive county health system. Its 164-bed public hospital is dedicated to offering services that are welcoming, accessible, safe and respectful for everyone.

Like many hospitals in the country, for years Contra Costa Regional Medical Center restricted the hours when family members and loved ones could visit patients. However, the hospital’s medical staff often felt uncomfortable that they had to usher family and care partners away from patients when visiting hours were over. Anna Roth, Contra Costa’s CEO, recalls an incident that caused great anguish and contributed to the hospital’s decision to eliminate its restrictive visiting policy. A young boy whose grandfather was in the ICU was denied visitation. The grandfather, who had raised him, passed away, with the two having had no chance to say goodbye. Roth said that the incident hit home for her and the entire staff, and they knew they could do better. “Our old policies treated family members like visitors, until we realized that we are the visitors in people’s lives, not the other way around,” she noted.

In 2012, the hospital established an interdisciplinary team to transform its existing visiting policy into a “welcoming policy.” The team comprised the director of inpatient nursing, the chief of nursing, the chief of security, a public health program specialist, the facilities manager, and a patient partner. The new policy would support family presence 24/7 as well as change the concept of families as “visitors.”

Over the course of a year, the team designed the framework for a 3-day pilot and developed a check-in process to help loved ones gain access to patients after regular hospital hours. Working closely with nursing leadership, front-line staff, patient partners, and security, the team made necessary adjustments to the policy throughout the pilot period. The pilot was well-received and the policy was implemented soon after.

In the policy’s first year, more than 7000 family members and care partners were able to be with their loved ones between 8 pm and 6 am, the time period formerly restricted. The feedback from staff, patients and loved ones has been overwhelmingly positive. Front-line nurses are currently strengthening their skills and confidence in conducting change of shift report at bedside with patients and families. Other “welcoming” measures have also been implemented, including making signage more user-friendly, providing comfortable chairs to sleep in, and installing new vending machines with healthy snacks and drinks.

Vidant Health

Vidant Health serves 1.4 million people in a 29-county region of eastern North Carolina and comprises over 70 primary and specialty physician office practices, a 900-bed academic medical center, 7 community hospitals, an ambulatory surgery center, and home health and hospice services. Vidant Health’s efforts to advance a culture of patient- and family-centered care began in the late 1990s in the James and Connie Maynard Children’s Hospital and the regional rehabilitation center, but this culture did not spread consistently throughout Vidant Health, leading to differing experiences of care for patients and families.

The Vidant Health executive team and senior leaders heard about these inconsistencies firsthand in the spring of 2007 when an employee shared her family’s experiences during her brother’s ICU stay. Christie Odom described how the visitation policy restricted her family’s access to her brother to 15-minute increments, 6 times a day, which led to heightened fear and anxiety for her brother, family, and friends and impeded patient and family engagement in care and decision-making. Odom’s brother died alone with no family by his side. A physical therapist, Odom observed that in the regional rehabilitation center, families were partners in care, yet in the adult ICU, they were visitors.

After hearing Christie’s story, the system’s executive team, board of directors, and physician leaders made a commitment to eliminate these restrictive visitation guidelines. Leaders understood that this would require the organization’s culture to change from viewing patients and families as passive recipients of care to recognizing them as partners. Subsequently, the commitment to patient-family partnerships was imbedded in key documents including the corporation’s strategic and 5-year quality plans. An Office of Patient-Family Experience was established at Vidant Medical Center in 2008 and, a year later, a corporate office was established to guide system transformation. Emphasis was placed on building a solid team of patient-family advisors and staff champions. An initial focus was to replace the restrictive visitation policy with family presence guidelines. A key tenet of these guidelines is that patients define who their family members are and how they should be included in care and decision-making.

This policy and practice change provided the impetus for ongoing evolution of patient-family partnerships. Patient-family advisors are now integrated across the health care system. They serve on performance improvement teams, make safety rounds, serve as faculty in education programs, interview applicants for key positions, and develop and edit patient education materials. The outcomes achieved by this system transformation are evidenced in exceptional HCAHPS performance, significant reductions in serious safety events and hospital acquired infections and national recognition for commitment to patient-family partnerships.

Conclusion

Changing the concept of families as visitors to families as partners in care, according to patient preference, is foundational to advancing the practice of patient- and family-centered care and to building a safe, high-quality, cost-effective system of care. In 2009, Lucian Leape and colleagues envisioned a transformed health care culture in which “the family is respected as part of the care team—never visitors—in every area of the hospital, including the emergency department and the intensive care unit” [8]. A 2014 report by the National Patient Safety Foundation’s Lucian Leape Institute affirmed,  “patients and families can play a critical role in preventing medical errors and reducing harm” [9].

Many hospitals still do not encourage family presence and participation and do not embrace the concept of families as true partners in care. But as demonstrated by the actions of the exemplar hospitals described here, it is possible to make this critical culture shift. The exemplar hospitals understand the importance of partnering with patients’ families instead of treating them as outsiders who are interfering in their loved one’s care. These hospitals are proving that giving patients the access they want to their loved ones actually helps themget better.

Through its campaign Better Together: Partnering with Families, IPFCC challenges hospitals across the United States and Canada to pledge to join this important initiative. Now is the time for all hospitals to embrace family presence and participation and to welcome families and other care partners 24 hours a day, 7 days a week.

Hospitals are invited to join this initiative. Steps to begin the change process may be found at www.ipfcc.org/advance/topics/better-together-pledge.html. Also available at IPFCC website is the Better Together toolkit, other materials and information that support the initiative, and a complete list of the exemplar hospitals and their processes and policies. The toolkit includes an organizational self-assessment, sample processes and policies, videos, and guides for families and staff to use in developing partnership. It is available at no charge at www.ipfcc.org/bettertogether/.

Corresponding author: Beverley H. Johnson, 6917 Arlington Rd., Ste. 309, Bethesda, MD 20814, bjohson@ipfcc.org.

 

Behind a Locked Door

This is our story as I remember it.

One day I came home from work, and my husband was confused. In all the years we’d been married, I’d never known him to be confused. He was sitting in the family room, and he looked frightened.

I said, “Bill, what’s going on?” He said, “Well, I was just going to get up and go look outside for Joey.” I said, “Bill, Joey’s not here.” He insisted, “Oh yes, we just came back from vacation. Joey just went outside, and I was going to check on him.”

I was alarmed and said, “Bill, I think you’re a little confused. I’m concerned because this morning you told me you had a headache. Maybe we should go to the hospital.” He resisted, but I simply told him, “Bill, if something was to happen to you, I might be held responsible because I didn’t do what was in your best interest. We can come home if everything is okay.”

And so we went to the emergency room, where we learned that my husband had a small bleed in his brain. We were told that we needed to go to another hospital that had a neurosurgeon on staff. My husband was transported by ambulance to a hospital about a mile away, and I followed him there in our car.

I want to stop here and tell you a bit about my husband and about myself. My name is Jackie Gruzenski, and I am a nurse involved in the field of psychiatric nursing. My husband’s name was Dr. William Gruzenski. He was a psychiatrist for forty years, and he was a chief medical officer for the last twelve years of his career.

Bill was a very good doctor and a very good husband. And toward the end of his life, he realized that all of his degrees, along with money and material possessions, didn’t matter. They were nothing. He just wanted to have me with him. We loved each other very deeply, and we wanted to share our last days and moments together, but I’m getting ahead of myself.

When we got to the second hospital, my husband was in the emergency room from about 7:00 p.m. until about 6:00 a.m. the next morning. At some point, he started to develop a hypertensive crisis, and the staff could not bring his blood pressure down. They started an IV medication, which required that he be monitored closely in the intensive care unit (ICU).

Of course, I went with him as he was transferred from emergency to ICU. When we got to the ICU door, I was told, “Now, just go into the waiting room. We’re going to settle your husband, and then we’ll come and get you.”

I was a nervous wreck while I waited. I knew my husband had been pretty sick while in emergency. What if he got more confused? What if he lost even this current level of functioning and wouldn’t
remember me? The longer I waited, the more my anxiety grew.

The waiting room was a small area, with chairs around the perimeter, except by the locked door. After an hour with no news, I saw a phone on the wall and called. I said to the voice on the other end, “My name is Mrs. Gruzenski. I was informed that my husband was going to be settled and that someone would come and get me.”

The next thing I knew a young, perky nurse came out, greeted me, and then directed me totally away from my husband, away from the door to the ICU, to a little room. She proceeded to give me the strict policies and procedures for the ICU, including that visitation was allowed only four times a day for thirty minutes each time.

Not believing what I was hearing, I said, “But my husband is going to be worried that I am not with him. We are the center of each other’s lives—we are only apart when we are at work!” Her response was, “Well, you can’t be with him. Those are the rules.”

I lived ten miles away. What was I supposed to do between these widely spaced thirty-minute visits? I felt I had to play by the rules. I was afraid that if I questioned too much or was abrupt with someone, they would treat my husband meanly. And because he was behind a locked door, I would never know.

I didn’t know what else to do and so, shortly before 8:00 a.m., I went home to get some rest. Ironically, just after I got home and started to settle after our long night in the ER, I got a flurry of calls from different residents who wanted information about my husband. They never said, “Come over and visit. He’s missing you.” They called because they needed the information I could give them, but they kept me locked out.

When I was able to have my first visit the next day, my husband asked where I had been. I explained that there were very limited visiting hours. This prompted my husband to speak to his nurse and say, “You know, she’s not a visitor. She’s my wife!” But he was informed that didn’t matter, that there were rules, and that I was a visitor and had to be treated as a visitor.

The rule trumped both of us and what we wanted. The rule meant he had to suffer alone. This was an accredited hospital, but in my view it was archaic. Staff hid behind the rules rather than using their heads and their hearts.

Over the next few days, I saw that my not being there with my husband was leading to more and more distress for him. As he became more ill, he would not allow the nurses to wash him, and he would not eat their food. He was doing everything he could do to get the staff’s attention to revisit the visiting restrictions. If I’d been allowed to stay, I’m sure I could have helped with feeding, with bathing, and with toileting. I’m certain I could have calmed him and helped lower his blood pressure.

I was treated as though I was an enemy, but all I wanted was to be with him, to share the last days of his life. I had always been his anchor. I was the person who navigated the everyday waters of his life. The hospital’s rules meant that he was adrift, and I was lost.

During his hospitalization, he was not afforded the respect he had given to all his patients and the nurses and doctors he had worked with each day. For example, the ICU staff never asked him how he would like to be addressed. They called him “Bill” when he should have been addressed as “Doctor Gruzenski.” He wouldn’t have thought of calling a resident by his first name, and there were only a few people in his life, his inner circle of family and friends, who called him “Bill.”

One day, I actually witnessed one doctor refer to my husband not even as “Bill” but as “Billy.”
I followed this doctor out of the ICU and challenged him saying “Would you think you were valued as a medical professional, and that your life had meant something if, in forty years’ time, someone called you ‘Billy’? ‘Billy’ is what you call some young boy you like, not someone who is sixty-eight years old and is a dignified gentleman and physician.”

My husband earned the title of “Doctor.” He attended four years of medical school, one year of internship, four years as a resident psychiatrist, and he was board certified in psychiatry. He had earned respect by exceeding all the societal standards for being addressed as “Doctor.” These achievements should not be washed away once you are hospitalized. In fact, I believe my husband might have felt a little safer if he had been addressed as “Doctor.”

My husband was in the ICU for eight of the last sixteen days of his life, and there were lots of missed opportunities for us. He wanted me there more than I was allowed. We missed time together we could have had. I feel it was a very cruel thing that was done to us.

We both knew the gravity of his condition, and my husband wanted quality of life, not quantity. I was a large part of the quality he wanted, but I was locked out for the greater part of his last days.

After my husband died, I felt I had to do something so that what happened to us wouldn’t happen to anyone else. I wrote letters to the chief executive officer of the hospital. I wrote to the chief of the medical staff. I wrote to the chief of nursing. And I wrote to the chaplain. The only person I ever heard from was the chaplain. No one apologized or said they would change the rules.

I believe more harm comes when family are not actively involved, and research is proving my belief is sound. And so I will continue to tell my story. I hope that if I tell it enough times, maybe people who write the rules in hospitals will realize that loved ones are advocates, not visitors.

I will never stop advocating for the elimination of visiting hours.

Reprinted from Crocker L, Johnson B. Privileged presence. Personal stories of connections in health care. 2nd ed. Boulder, CO: Bull Publishing; 2014.

From the Institute for Patient- and Family-Centered Care, Bethesda, MD (Ms. Dokken, Ms. Kaufman, and Ms. Johnson), Anne Arundel Medical Center, Annapolis, MD (Dr. Perkins), Contra Costa Regional Medical Center & Health Centers, Martinez, CA (Ms. Benepal, Ms. Roth, and Vidant Health, Greenville, NC (Ms. Dutton and Ms. Jones).

 

Abstract

• Objective: To describe a campaign to eliminate restrictive hospital visiting policies and to put in place policies that recognize families as partners in care.
• Methods: Descriptive report.
• Results: Many hospitals still have “visiting” hours that limit family presence, often counter to patient preferences. To change the concept of families as visitors and eliminate restrictive hospital visiting policies, the Institute for Patient- and Family-Centered Care (IPFCC) launched the campaign Better Together: Partnering with Families, calling on all hospitals to welcome families 24 hours a day and transform their policies and approaches to care so that patients’ families and loved ones are included in care and decision making, according to patient preferences. As part of the campaign, IPFCC recognized 12 hospitals that exemplify success in eliminating restrictive visiting policies and have changed the concept of families from  “visitors” to partners. Leaders at these hospitals attest to the benefits of the changes through improved experience of care and other outcomes. Three exemplar hospitals are highlighted in this article and share their processes of change as well as key learnings and outcomes.
• Conclusion: Hospital policies and practices that encourage and support families as partners in care are essential to patients’ health, well-being, and safety.

 

Many families are restricted from the bedsides of loved ones because of hospital visiting policies [1–3]. Restrictive policies are often based on long-held beliefs that the presence and participation of families interferes with care, exhausts patients, is a burden to families, spreads infection, or violates HIPAA. However, there is no evidence to support those beliefs. In fact, isolating patients at their most vulnerable time from the people who know them best places them at risk for medical error, emotional harm, inconsistencies in care, and lack of preparedness for transitions in care [4,5]. Jackie Gruzenski’s story “Behind a Locked Door” (printed below) affectingly describes the impact of restrictive policies on a couple's last days.

Fortunately, a growing number of hospitals are lifting these restrictions. But opening the door is not enough. Hospitals need to change the concept of families as “visitors” to families as partners in care. Changing policies is a foundational step in creating a patient- and family-centered culture where families are recognized as essential to patients’ health and well-being and where they are respected as allies for quality and safety.

In response to this critical need for change, in June 2014 the Institute for Patient- and Family-Centered Care (IPFCC) launched the campaign Better Together: Partnering with Families. IPFCC, founded in 1992, is a nonprofit organization that provides essential leadership to advance the understanding and practice of patient- and family-centered care [6]. Emphasizing the importance of family presence and participation to quality and safety, the campaign seeks to eliminate restrictive “visiting” policies and calls upon hospitals to include families as members of the care team and to welcome them 24 hours a day, 7 days a week, according to patient preference [7]. The goal of the campaign is to change visiting policies in 1000 hospitals by 2017. Partnering with IPFCC in this initiative are the American Society for Healthcare Risk Management, American Association of Critical Care Nurses, National Partnership for Women & Families, New Yorkers for Patient and Family Empowerment, Health In Aging Foundation, and the Canadian Foundation for Healthcare Improvement.

The Better Together campaign currently recognizes 12 hospitals in the United States and Canada that exemplify success in changing their “visiting” policies. The hospitals vary in size, structure, and geographic location, as well as in the processes they used to change. These “exemplar” hospitals are helping IPFCC disseminate information about the campaign and will serve as mentors to other hospitals beginning the process through an online learning community. In this article, 3 exemplar hospitals describe their processes, discussing the impetus for change, the process itself, including involvement of key groups, as well as outcomes to date and “lessons learned” to share with other hospitals. An example visiting policy is also presented (Appendix).

Anne Arundel Medical Center

A regional not-for-profit hospital founded in 1902, Anne Arundel Medical Center in Annapolis, MD, provides acute inpatient and outpatient care to residents of 4 counties in Maryland. A 380-bed facility, Anne Arundel has a cancer institute, heart and vascular institute, joint center, spine center, and a women’s and children’s center. In April 2011, the hospital completed a $424 million expansion project, which included a pediatric emergency room, an expanded general emergency room, 50 new patient beds, and 8 new operating rooms.

In 2010, based on a desire to concretely implement the principles of patient- and family-centered care, leaders at Anne Arundel began working with patient and family advisors and initiated a process to change the hospital’s restrictive visiting policy. Now, there are no restrictions on family presence anywhere in the hospital, from ICUs to medical/surgical units to other clinical areas. Patients have the power to choose who they want to stay with them—24 hours a day, 7 days a week. According to Anne Arundel’s policy, each patient determines who is defined as “family.” A “Revisiting Visiting” task force, comprising support staff, providers, and patient and family advisors, worked for 9 months to develop the new family presence policy and support its implementation.

With Anne Arundel leadership encouragement and support, patient and family advisors  participated in all phases of the development and implementation of the new family presence policy and in other ways to advance the practice of patient- and family-centered care. The advisors also participated in the process to change the way nurse change of shift report was conducted, and they made recommendations for changes in the directional signs throughout the hospital. New signs, featuring a pineapple (a symbol of hospitality) and the words “Welcome Families” replaced old ones displaying the former restrictive visiting policy.

Supporting patient and family involvement in transitions in care is an integral aspect of implementing family presence policies and practices. Through an “Always Events” grant from the Picker Institute (for information about the Always Events program, see www.ihi.org/Engage/Initiatives/PatientFamilyCenteredCare/Pages/AlwaysEvents.aspx), patient and family advisors, staff, and providers at Anne Arundel developed the SMART discharge protocol, which includes a simple 5-item checklist that is reviewed and discussed with the patient and family prior to discharge. SMART is an acronym for Signs, Medications, Appointments, Results, and Talk. In its work, the SMART team built on current evidence, created urgency and expectation for use with patients, families, and caregivers, disseminated findings, and promoted the protocol as a national standard. The tool is available at www.ihi.org/resources/Pages/Tools/SMARTDischargeProtocol.aspx.

 

According to Anne Arundel’s COO and CNO, Sherry Perkins, a critical part of the change process was to first understand staff’s fears and then learn what the evidence says. For example, with regard to the impact of additional family presence on infection control, they learned that family presence did not pose additional infection control concerns.

In 2009, there were no patient and family advisors volunteering at Anne Arundel. In 2014, there are approximately 80 advisors. Since 2009, the overall HCAHPS rating of the hospital has gone from 75.4% to 82% (the national average is 70%). While patient satisfaction scores have previously been in the top deciles at Anne Arundel, they have consistently risen since expanding family presence and implementing additional patient- and family-centered strategies.

Contra Costa Regional Medical Center and Health Centers

Contra Costa Health Services in Martinez, CA, includes Contra Costa Regional Medical Center and 10 health centers as part of a comprehensive county health system. Its 164-bed public hospital is dedicated to offering services that are welcoming, accessible, safe and respectful for everyone.

Like many hospitals in the country, for years Contra Costa Regional Medical Center restricted the hours when family members and loved ones could visit patients. However, the hospital’s medical staff often felt uncomfortable that they had to usher family and care partners away from patients when visiting hours were over. Anna Roth, Contra Costa’s CEO, recalls an incident that caused great anguish and contributed to the hospital’s decision to eliminate its restrictive visiting policy. A young boy whose grandfather was in the ICU was denied visitation. The grandfather, who had raised him, passed away, with the two having had no chance to say goodbye. Roth said that the incident hit home for her and the entire staff, and they knew they could do better. “Our old policies treated family members like visitors, until we realized that we are the visitors in people’s lives, not the other way around,” she noted.

In 2012, the hospital established an interdisciplinary team to transform its existing visiting policy into a “welcoming policy.” The team comprised the director of inpatient nursing, the chief of nursing, the chief of security, a public health program specialist, the facilities manager, and a patient partner. The new policy would support family presence 24/7 as well as change the concept of families as “visitors.”

Over the course of a year, the team designed the framework for a 3-day pilot and developed a check-in process to help loved ones gain access to patients after regular hospital hours. Working closely with nursing leadership, front-line staff, patient partners, and security, the team made necessary adjustments to the policy throughout the pilot period. The pilot was well-received and the policy was implemented soon after.

In the policy’s first year, more than 7000 family members and care partners were able to be with their loved ones between 8 pm and 6 am, the time period formerly restricted. The feedback from staff, patients and loved ones has been overwhelmingly positive. Front-line nurses are currently strengthening their skills and confidence in conducting change of shift report at bedside with patients and families. Other “welcoming” measures have also been implemented, including making signage more user-friendly, providing comfortable chairs to sleep in, and installing new vending machines with healthy snacks and drinks.

Vidant Health

Vidant Health serves 1.4 million people in a 29-county region of eastern North Carolina and comprises over 70 primary and specialty physician office practices, a 900-bed academic medical center, 7 community hospitals, an ambulatory surgery center, and home health and hospice services. Vidant Health’s efforts to advance a culture of patient- and family-centered care began in the late 1990s in the James and Connie Maynard Children’s Hospital and the regional rehabilitation center, but this culture did not spread consistently throughout Vidant Health, leading to differing experiences of care for patients and families.

The Vidant Health executive team and senior leaders heard about these inconsistencies firsthand in the spring of 2007 when an employee shared her family’s experiences during her brother’s ICU stay. Christie Odom described how the visitation policy restricted her family’s access to her brother to 15-minute increments, 6 times a day, which led to heightened fear and anxiety for her brother, family, and friends and impeded patient and family engagement in care and decision-making. Odom’s brother died alone with no family by his side. A physical therapist, Odom observed that in the regional rehabilitation center, families were partners in care, yet in the adult ICU, they were visitors.

After hearing Christie’s story, the system’s executive team, board of directors, and physician leaders made a commitment to eliminate these restrictive visitation guidelines. Leaders understood that this would require the organization’s culture to change from viewing patients and families as passive recipients of care to recognizing them as partners. Subsequently, the commitment to patient-family partnerships was imbedded in key documents including the corporation’s strategic and 5-year quality plans. An Office of Patient-Family Experience was established at Vidant Medical Center in 2008 and, a year later, a corporate office was established to guide system transformation. Emphasis was placed on building a solid team of patient-family advisors and staff champions. An initial focus was to replace the restrictive visitation policy with family presence guidelines. A key tenet of these guidelines is that patients define who their family members are and how they should be included in care and decision-making.

This policy and practice change provided the impetus for ongoing evolution of patient-family partnerships. Patient-family advisors are now integrated across the health care system. They serve on performance improvement teams, make safety rounds, serve as faculty in education programs, interview applicants for key positions, and develop and edit patient education materials. The outcomes achieved by this system transformation are evidenced in exceptional HCAHPS performance, significant reductions in serious safety events and hospital acquired infections and national recognition for commitment to patient-family partnerships.

Conclusion

Changing the concept of families as visitors to families as partners in care, according to patient preference, is foundational to advancing the practice of patient- and family-centered care and to building a safe, high-quality, cost-effective system of care. In 2009, Lucian Leape and colleagues envisioned a transformed health care culture in which “the family is respected as part of the care team—never visitors—in every area of the hospital, including the emergency department and the intensive care unit” [8]. A 2014 report by the National Patient Safety Foundation’s Lucian Leape Institute affirmed,  “patients and families can play a critical role in preventing medical errors and reducing harm” [9].

Many hospitals still do not encourage family presence and participation and do not embrace the concept of families as true partners in care. But as demonstrated by the actions of the exemplar hospitals described here, it is possible to make this critical culture shift. The exemplar hospitals understand the importance of partnering with patients’ families instead of treating them as outsiders who are interfering in their loved one’s care. These hospitals are proving that giving patients the access they want to their loved ones actually helps themget better.

Through its campaign Better Together: Partnering with Families, IPFCC challenges hospitals across the United States and Canada to pledge to join this important initiative. Now is the time for all hospitals to embrace family presence and participation and to welcome families and other care partners 24 hours a day, 7 days a week.

Hospitals are invited to join this initiative. Steps to begin the change process may be found at www.ipfcc.org/advance/topics/better-together-pledge.html. Also available at IPFCC website is the Better Together toolkit, other materials and information that support the initiative, and a complete list of the exemplar hospitals and their processes and policies. The toolkit includes an organizational self-assessment, sample processes and policies, videos, and guides for families and staff to use in developing partnership. It is available at no charge at www.ipfcc.org/bettertogether/.

Corresponding author: Beverley H. Johnson, 6917 Arlington Rd., Ste. 309, Bethesda, MD 20814, bjohson@ipfcc.org.

 

Behind a Locked Door

This is our story as I remember it.

One day I came home from work, and my husband was confused. In all the years we’d been married, I’d never known him to be confused. He was sitting in the family room, and he looked frightened.

I said, “Bill, what’s going on?” He said, “Well, I was just going to get up and go look outside for Joey.” I said, “Bill, Joey’s not here.” He insisted, “Oh yes, we just came back from vacation. Joey just went outside, and I was going to check on him.”

I was alarmed and said, “Bill, I think you’re a little confused. I’m concerned because this morning you told me you had a headache. Maybe we should go to the hospital.” He resisted, but I simply told him, “Bill, if something was to happen to you, I might be held responsible because I didn’t do what was in your best interest. We can come home if everything is okay.”

And so we went to the emergency room, where we learned that my husband had a small bleed in his brain. We were told that we needed to go to another hospital that had a neurosurgeon on staff. My husband was transported by ambulance to a hospital about a mile away, and I followed him there in our car.

I want to stop here and tell you a bit about my husband and about myself. My name is Jackie Gruzenski, and I am a nurse involved in the field of psychiatric nursing. My husband’s name was Dr. William Gruzenski. He was a psychiatrist for forty years, and he was a chief medical officer for the last twelve years of his career.

Bill was a very good doctor and a very good husband. And toward the end of his life, he realized that all of his degrees, along with money and material possessions, didn’t matter. They were nothing. He just wanted to have me with him. We loved each other very deeply, and we wanted to share our last days and moments together, but I’m getting ahead of myself.

When we got to the second hospital, my husband was in the emergency room from about 7:00 p.m. until about 6:00 a.m. the next morning. At some point, he started to develop a hypertensive crisis, and the staff could not bring his blood pressure down. They started an IV medication, which required that he be monitored closely in the intensive care unit (ICU).

Of course, I went with him as he was transferred from emergency to ICU. When we got to the ICU door, I was told, “Now, just go into the waiting room. We’re going to settle your husband, and then we’ll come and get you.”

I was a nervous wreck while I waited. I knew my husband had been pretty sick while in emergency. What if he got more confused? What if he lost even this current level of functioning and wouldn’t
remember me? The longer I waited, the more my anxiety grew.

The waiting room was a small area, with chairs around the perimeter, except by the locked door. After an hour with no news, I saw a phone on the wall and called. I said to the voice on the other end, “My name is Mrs. Gruzenski. I was informed that my husband was going to be settled and that someone would come and get me.”

The next thing I knew a young, perky nurse came out, greeted me, and then directed me totally away from my husband, away from the door to the ICU, to a little room. She proceeded to give me the strict policies and procedures for the ICU, including that visitation was allowed only four times a day for thirty minutes each time.

Not believing what I was hearing, I said, “But my husband is going to be worried that I am not with him. We are the center of each other’s lives—we are only apart when we are at work!” Her response was, “Well, you can’t be with him. Those are the rules.”

I lived ten miles away. What was I supposed to do between these widely spaced thirty-minute visits? I felt I had to play by the rules. I was afraid that if I questioned too much or was abrupt with someone, they would treat my husband meanly. And because he was behind a locked door, I would never know.

I didn’t know what else to do and so, shortly before 8:00 a.m., I went home to get some rest. Ironically, just after I got home and started to settle after our long night in the ER, I got a flurry of calls from different residents who wanted information about my husband. They never said, “Come over and visit. He’s missing you.” They called because they needed the information I could give them, but they kept me locked out.

When I was able to have my first visit the next day, my husband asked where I had been. I explained that there were very limited visiting hours. This prompted my husband to speak to his nurse and say, “You know, she’s not a visitor. She’s my wife!” But he was informed that didn’t matter, that there were rules, and that I was a visitor and had to be treated as a visitor.

The rule trumped both of us and what we wanted. The rule meant he had to suffer alone. This was an accredited hospital, but in my view it was archaic. Staff hid behind the rules rather than using their heads and their hearts.

Over the next few days, I saw that my not being there with my husband was leading to more and more distress for him. As he became more ill, he would not allow the nurses to wash him, and he would not eat their food. He was doing everything he could do to get the staff’s attention to revisit the visiting restrictions. If I’d been allowed to stay, I’m sure I could have helped with feeding, with bathing, and with toileting. I’m certain I could have calmed him and helped lower his blood pressure.

I was treated as though I was an enemy, but all I wanted was to be with him, to share the last days of his life. I had always been his anchor. I was the person who navigated the everyday waters of his life. The hospital’s rules meant that he was adrift, and I was lost.

During his hospitalization, he was not afforded the respect he had given to all his patients and the nurses and doctors he had worked with each day. For example, the ICU staff never asked him how he would like to be addressed. They called him “Bill” when he should have been addressed as “Doctor Gruzenski.” He wouldn’t have thought of calling a resident by his first name, and there were only a few people in his life, his inner circle of family and friends, who called him “Bill.”

One day, I actually witnessed one doctor refer to my husband not even as “Bill” but as “Billy.”
I followed this doctor out of the ICU and challenged him saying “Would you think you were valued as a medical professional, and that your life had meant something if, in forty years’ time, someone called you ‘Billy’? ‘Billy’ is what you call some young boy you like, not someone who is sixty-eight years old and is a dignified gentleman and physician.”

My husband earned the title of “Doctor.” He attended four years of medical school, one year of internship, four years as a resident psychiatrist, and he was board certified in psychiatry. He had earned respect by exceeding all the societal standards for being addressed as “Doctor.” These achievements should not be washed away once you are hospitalized. In fact, I believe my husband might have felt a little safer if he had been addressed as “Doctor.”

My husband was in the ICU for eight of the last sixteen days of his life, and there were lots of missed opportunities for us. He wanted me there more than I was allowed. We missed time together we could have had. I feel it was a very cruel thing that was done to us.

We both knew the gravity of his condition, and my husband wanted quality of life, not quantity. I was a large part of the quality he wanted, but I was locked out for the greater part of his last days.

After my husband died, I felt I had to do something so that what happened to us wouldn’t happen to anyone else. I wrote letters to the chief executive officer of the hospital. I wrote to the chief of the medical staff. I wrote to the chief of nursing. And I wrote to the chaplain. The only person I ever heard from was the chaplain. No one apologized or said they would change the rules.

I believe more harm comes when family are not actively involved, and research is proving my belief is sound. And so I will continue to tell my story. I hope that if I tell it enough times, maybe people who write the rules in hospitals will realize that loved ones are advocates, not visitors.

I will never stop advocating for the elimination of visiting hours.

Reprinted from Crocker L, Johnson B. Privileged presence. Personal stories of connections in health care. 2nd ed. Boulder, CO: Bull Publishing; 2014.

From the Institute for Patient- and Family-Centered Care, Bethesda, MD (Ms. Dokken, Ms. Kaufman, and Ms. Johnson), Anne Arundel Medical Center, Annapolis, MD (Dr. Perkins), Contra Costa Regional Medical Center & Health Centers, Martinez, CA (Ms. Benepal, Ms. Roth, and Vidant Health, Greenville, NC (Ms. Dutton and Ms. Jones).

 

Abstract

• Objective: To describe a campaign to eliminate restrictive hospital visiting policies and to put in place policies that recognize families as partners in care.
• Methods: Descriptive report.
• Results: Many hospitals still have “visiting” hours that limit family presence, often counter to patient preferences. To change the concept of families as visitors and eliminate restrictive hospital visiting policies, the Institute for Patient- and Family-Centered Care (IPFCC) launched the campaign Better Together: Partnering with Families, calling on all hospitals to welcome families 24 hours a day and transform their policies and approaches to care so that patients’ families and loved ones are included in care and decision making, according to patient preferences. As part of the campaign, IPFCC recognized 12 hospitals that exemplify success in eliminating restrictive visiting policies and have changed the concept of families from  “visitors” to partners. Leaders at these hospitals attest to the benefits of the changes through improved experience of care and other outcomes. Three exemplar hospitals are highlighted in this article and share their processes of change as well as key learnings and outcomes.
• Conclusion: Hospital policies and practices that encourage and support families as partners in care are essential to patients’ health, well-being, and safety.

 

Many families are restricted from the bedsides of loved ones because of hospital visiting policies [1–3]. Restrictive policies are often based on long-held beliefs that the presence and participation of families interferes with care, exhausts patients, is a burden to families, spreads infection, or violates HIPAA. However, there is no evidence to support those beliefs. In fact, isolating patients at their most vulnerable time from the people who know them best places them at risk for medical error, emotional harm, inconsistencies in care, and lack of preparedness for transitions in care [4,5]. Jackie Gruzenski’s story “Behind a Locked Door” (printed below) affectingly describes the impact of restrictive policies on a couple's last days.

Fortunately, a growing number of hospitals are lifting these restrictions. But opening the door is not enough. Hospitals need to change the concept of families as “visitors” to families as partners in care. Changing policies is a foundational step in creating a patient- and family-centered culture where families are recognized as essential to patients’ health and well-being and where they are respected as allies for quality and safety.

In response to this critical need for change, in June 2014 the Institute for Patient- and Family-Centered Care (IPFCC) launched the campaign Better Together: Partnering with Families. IPFCC, founded in 1992, is a nonprofit organization that provides essential leadership to advance the understanding and practice of patient- and family-centered care [6]. Emphasizing the importance of family presence and participation to quality and safety, the campaign seeks to eliminate restrictive “visiting” policies and calls upon hospitals to include families as members of the care team and to welcome them 24 hours a day, 7 days a week, according to patient preference [7]. The goal of the campaign is to change visiting policies in 1000 hospitals by 2017. Partnering with IPFCC in this initiative are the American Society for Healthcare Risk Management, American Association of Critical Care Nurses, National Partnership for Women & Families, New Yorkers for Patient and Family Empowerment, Health In Aging Foundation, and the Canadian Foundation for Healthcare Improvement.

The Better Together campaign currently recognizes 12 hospitals in the United States and Canada that exemplify success in changing their “visiting” policies. The hospitals vary in size, structure, and geographic location, as well as in the processes they used to change. These “exemplar” hospitals are helping IPFCC disseminate information about the campaign and will serve as mentors to other hospitals beginning the process through an online learning community. In this article, 3 exemplar hospitals describe their processes, discussing the impetus for change, the process itself, including involvement of key groups, as well as outcomes to date and “lessons learned” to share with other hospitals. An example visiting policy is also presented (Appendix).

Anne Arundel Medical Center

A regional not-for-profit hospital founded in 1902, Anne Arundel Medical Center in Annapolis, MD, provides acute inpatient and outpatient care to residents of 4 counties in Maryland. A 380-bed facility, Anne Arundel has a cancer institute, heart and vascular institute, joint center, spine center, and a women’s and children’s center. In April 2011, the hospital completed a $424 million expansion project, which included a pediatric emergency room, an expanded general emergency room, 50 new patient beds, and 8 new operating rooms.

In 2010, based on a desire to concretely implement the principles of patient- and family-centered care, leaders at Anne Arundel began working with patient and family advisors and initiated a process to change the hospital’s restrictive visiting policy. Now, there are no restrictions on family presence anywhere in the hospital, from ICUs to medical/surgical units to other clinical areas. Patients have the power to choose who they want to stay with them—24 hours a day, 7 days a week. According to Anne Arundel’s policy, each patient determines who is defined as “family.” A “Revisiting Visiting” task force, comprising support staff, providers, and patient and family advisors, worked for 9 months to develop the new family presence policy and support its implementation.

With Anne Arundel leadership encouragement and support, patient and family advisors  participated in all phases of the development and implementation of the new family presence policy and in other ways to advance the practice of patient- and family-centered care. The advisors also participated in the process to change the way nurse change of shift report was conducted, and they made recommendations for changes in the directional signs throughout the hospital. New signs, featuring a pineapple (a symbol of hospitality) and the words “Welcome Families” replaced old ones displaying the former restrictive visiting policy.

Supporting patient and family involvement in transitions in care is an integral aspect of implementing family presence policies and practices. Through an “Always Events” grant from the Picker Institute (for information about the Always Events program, see www.ihi.org/Engage/Initiatives/PatientFamilyCenteredCare/Pages/AlwaysEvents.aspx), patient and family advisors, staff, and providers at Anne Arundel developed the SMART discharge protocol, which includes a simple 5-item checklist that is reviewed and discussed with the patient and family prior to discharge. SMART is an acronym for Signs, Medications, Appointments, Results, and Talk. In its work, the SMART team built on current evidence, created urgency and expectation for use with patients, families, and caregivers, disseminated findings, and promoted the protocol as a national standard. The tool is available at www.ihi.org/resources/Pages/Tools/SMARTDischargeProtocol.aspx.

 

According to Anne Arundel’s COO and CNO, Sherry Perkins, a critical part of the change process was to first understand staff’s fears and then learn what the evidence says. For example, with regard to the impact of additional family presence on infection control, they learned that family presence did not pose additional infection control concerns.

In 2009, there were no patient and family advisors volunteering at Anne Arundel. In 2014, there are approximately 80 advisors. Since 2009, the overall HCAHPS rating of the hospital has gone from 75.4% to 82% (the national average is 70%). While patient satisfaction scores have previously been in the top deciles at Anne Arundel, they have consistently risen since expanding family presence and implementing additional patient- and family-centered strategies.

Contra Costa Regional Medical Center and Health Centers

Contra Costa Health Services in Martinez, CA, includes Contra Costa Regional Medical Center and 10 health centers as part of a comprehensive county health system. Its 164-bed public hospital is dedicated to offering services that are welcoming, accessible, safe and respectful for everyone.

Like many hospitals in the country, for years Contra Costa Regional Medical Center restricted the hours when family members and loved ones could visit patients. However, the hospital’s medical staff often felt uncomfortable that they had to usher family and care partners away from patients when visiting hours were over. Anna Roth, Contra Costa’s CEO, recalls an incident that caused great anguish and contributed to the hospital’s decision to eliminate its restrictive visiting policy. A young boy whose grandfather was in the ICU was denied visitation. The grandfather, who had raised him, passed away, with the two having had no chance to say goodbye. Roth said that the incident hit home for her and the entire staff, and they knew they could do better. “Our old policies treated family members like visitors, until we realized that we are the visitors in people’s lives, not the other way around,” she noted.

In 2012, the hospital established an interdisciplinary team to transform its existing visiting policy into a “welcoming policy.” The team comprised the director of inpatient nursing, the chief of nursing, the chief of security, a public health program specialist, the facilities manager, and a patient partner. The new policy would support family presence 24/7 as well as change the concept of families as “visitors.”

Over the course of a year, the team designed the framework for a 3-day pilot and developed a check-in process to help loved ones gain access to patients after regular hospital hours. Working closely with nursing leadership, front-line staff, patient partners, and security, the team made necessary adjustments to the policy throughout the pilot period. The pilot was well-received and the policy was implemented soon after.

In the policy’s first year, more than 7000 family members and care partners were able to be with their loved ones between 8 pm and 6 am, the time period formerly restricted. The feedback from staff, patients and loved ones has been overwhelmingly positive. Front-line nurses are currently strengthening their skills and confidence in conducting change of shift report at bedside with patients and families. Other “welcoming” measures have also been implemented, including making signage more user-friendly, providing comfortable chairs to sleep in, and installing new vending machines with healthy snacks and drinks.

Vidant Health

Vidant Health serves 1.4 million people in a 29-county region of eastern North Carolina and comprises over 70 primary and specialty physician office practices, a 900-bed academic medical center, 7 community hospitals, an ambulatory surgery center, and home health and hospice services. Vidant Health’s efforts to advance a culture of patient- and family-centered care began in the late 1990s in the James and Connie Maynard Children’s Hospital and the regional rehabilitation center, but this culture did not spread consistently throughout Vidant Health, leading to differing experiences of care for patients and families.

The Vidant Health executive team and senior leaders heard about these inconsistencies firsthand in the spring of 2007 when an employee shared her family’s experiences during her brother’s ICU stay. Christie Odom described how the visitation policy restricted her family’s access to her brother to 15-minute increments, 6 times a day, which led to heightened fear and anxiety for her brother, family, and friends and impeded patient and family engagement in care and decision-making. Odom’s brother died alone with no family by his side. A physical therapist, Odom observed that in the regional rehabilitation center, families were partners in care, yet in the adult ICU, they were visitors.

After hearing Christie’s story, the system’s executive team, board of directors, and physician leaders made a commitment to eliminate these restrictive visitation guidelines. Leaders understood that this would require the organization’s culture to change from viewing patients and families as passive recipients of care to recognizing them as partners. Subsequently, the commitment to patient-family partnerships was imbedded in key documents including the corporation’s strategic and 5-year quality plans. An Office of Patient-Family Experience was established at Vidant Medical Center in 2008 and, a year later, a corporate office was established to guide system transformation. Emphasis was placed on building a solid team of patient-family advisors and staff champions. An initial focus was to replace the restrictive visitation policy with family presence guidelines. A key tenet of these guidelines is that patients define who their family members are and how they should be included in care and decision-making.

This policy and practice change provided the impetus for ongoing evolution of patient-family partnerships. Patient-family advisors are now integrated across the health care system. They serve on performance improvement teams, make safety rounds, serve as faculty in education programs, interview applicants for key positions, and develop and edit patient education materials. The outcomes achieved by this system transformation are evidenced in exceptional HCAHPS performance, significant reductions in serious safety events and hospital acquired infections and national recognition for commitment to patient-family partnerships.

Conclusion

Changing the concept of families as visitors to families as partners in care, according to patient preference, is foundational to advancing the practice of patient- and family-centered care and to building a safe, high-quality, cost-effective system of care. In 2009, Lucian Leape and colleagues envisioned a transformed health care culture in which “the family is respected as part of the care team—never visitors—in every area of the hospital, including the emergency department and the intensive care unit” [8]. A 2014 report by the National Patient Safety Foundation’s Lucian Leape Institute affirmed,  “patients and families can play a critical role in preventing medical errors and reducing harm” [9].

Many hospitals still do not encourage family presence and participation and do not embrace the concept of families as true partners in care. But as demonstrated by the actions of the exemplar hospitals described here, it is possible to make this critical culture shift. The exemplar hospitals understand the importance of partnering with patients’ families instead of treating them as outsiders who are interfering in their loved one’s care. These hospitals are proving that giving patients the access they want to their loved ones actually helps themget better.

Through its campaign Better Together: Partnering with Families, IPFCC challenges hospitals across the United States and Canada to pledge to join this important initiative. Now is the time for all hospitals to embrace family presence and participation and to welcome families and other care partners 24 hours a day, 7 days a week.

Hospitals are invited to join this initiative. Steps to begin the change process may be found at www.ipfcc.org/advance/topics/better-together-pledge.html. Also available at IPFCC website is the Better Together toolkit, other materials and information that support the initiative, and a complete list of the exemplar hospitals and their processes and policies. The toolkit includes an organizational self-assessment, sample processes and policies, videos, and guides for families and staff to use in developing partnership. It is available at no charge at www.ipfcc.org/bettertogether/.

Corresponding author: Beverley H. Johnson, 6917 Arlington Rd., Ste. 309, Bethesda, MD 20814, bjohson@ipfcc.org.

 

Behind a Locked Door

This is our story as I remember it.

One day I came home from work, and my husband was confused. In all the years we’d been married, I’d never known him to be confused. He was sitting in the family room, and he looked frightened.

I said, “Bill, what’s going on?” He said, “Well, I was just going to get up and go look outside for Joey.” I said, “Bill, Joey’s not here.” He insisted, “Oh yes, we just came back from vacation. Joey just went outside, and I was going to check on him.”

I was alarmed and said, “Bill, I think you’re a little confused. I’m concerned because this morning you told me you had a headache. Maybe we should go to the hospital.” He resisted, but I simply told him, “Bill, if something was to happen to you, I might be held responsible because I didn’t do what was in your best interest. We can come home if everything is okay.”

And so we went to the emergency room, where we learned that my husband had a small bleed in his brain. We were told that we needed to go to another hospital that had a neurosurgeon on staff. My husband was transported by ambulance to a hospital about a mile away, and I followed him there in our car.

I want to stop here and tell you a bit about my husband and about myself. My name is Jackie Gruzenski, and I am a nurse involved in the field of psychiatric nursing. My husband’s name was Dr. William Gruzenski. He was a psychiatrist for forty years, and he was a chief medical officer for the last twelve years of his career.

Bill was a very good doctor and a very good husband. And toward the end of his life, he realized that all of his degrees, along with money and material possessions, didn’t matter. They were nothing. He just wanted to have me with him. We loved each other very deeply, and we wanted to share our last days and moments together, but I’m getting ahead of myself.

When we got to the second hospital, my husband was in the emergency room from about 7:00 p.m. until about 6:00 a.m. the next morning. At some point, he started to develop a hypertensive crisis, and the staff could not bring his blood pressure down. They started an IV medication, which required that he be monitored closely in the intensive care unit (ICU).

Of course, I went with him as he was transferred from emergency to ICU. When we got to the ICU door, I was told, “Now, just go into the waiting room. We’re going to settle your husband, and then we’ll come and get you.”

I was a nervous wreck while I waited. I knew my husband had been pretty sick while in emergency. What if he got more confused? What if he lost even this current level of functioning and wouldn’t
remember me? The longer I waited, the more my anxiety grew.

The waiting room was a small area, with chairs around the perimeter, except by the locked door. After an hour with no news, I saw a phone on the wall and called. I said to the voice on the other end, “My name is Mrs. Gruzenski. I was informed that my husband was going to be settled and that someone would come and get me.”

The next thing I knew a young, perky nurse came out, greeted me, and then directed me totally away from my husband, away from the door to the ICU, to a little room. She proceeded to give me the strict policies and procedures for the ICU, including that visitation was allowed only four times a day for thirty minutes each time.

Not believing what I was hearing, I said, “But my husband is going to be worried that I am not with him. We are the center of each other’s lives—we are only apart when we are at work!” Her response was, “Well, you can’t be with him. Those are the rules.”

I lived ten miles away. What was I supposed to do between these widely spaced thirty-minute visits? I felt I had to play by the rules. I was afraid that if I questioned too much or was abrupt with someone, they would treat my husband meanly. And because he was behind a locked door, I would never know.

I didn’t know what else to do and so, shortly before 8:00 a.m., I went home to get some rest. Ironically, just after I got home and started to settle after our long night in the ER, I got a flurry of calls from different residents who wanted information about my husband. They never said, “Come over and visit. He’s missing you.” They called because they needed the information I could give them, but they kept me locked out.

When I was able to have my first visit the next day, my husband asked where I had been. I explained that there were very limited visiting hours. This prompted my husband to speak to his nurse and say, “You know, she’s not a visitor. She’s my wife!” But he was informed that didn’t matter, that there were rules, and that I was a visitor and had to be treated as a visitor.

The rule trumped both of us and what we wanted. The rule meant he had to suffer alone. This was an accredited hospital, but in my view it was archaic. Staff hid behind the rules rather than using their heads and their hearts.

Over the next few days, I saw that my not being there with my husband was leading to more and more distress for him. As he became more ill, he would not allow the nurses to wash him, and he would not eat their food. He was doing everything he could do to get the staff’s attention to revisit the visiting restrictions. If I’d been allowed to stay, I’m sure I could have helped with feeding, with bathing, and with toileting. I’m certain I could have calmed him and helped lower his blood pressure.

I was treated as though I was an enemy, but all I wanted was to be with him, to share the last days of his life. I had always been his anchor. I was the person who navigated the everyday waters of his life. The hospital’s rules meant that he was adrift, and I was lost.

During his hospitalization, he was not afforded the respect he had given to all his patients and the nurses and doctors he had worked with each day. For example, the ICU staff never asked him how he would like to be addressed. They called him “Bill” when he should have been addressed as “Doctor Gruzenski.” He wouldn’t have thought of calling a resident by his first name, and there were only a few people in his life, his inner circle of family and friends, who called him “Bill.”

One day, I actually witnessed one doctor refer to my husband not even as “Bill” but as “Billy.”
I followed this doctor out of the ICU and challenged him saying “Would you think you were valued as a medical professional, and that your life had meant something if, in forty years’ time, someone called you ‘Billy’? ‘Billy’ is what you call some young boy you like, not someone who is sixty-eight years old and is a dignified gentleman and physician.”

My husband earned the title of “Doctor.” He attended four years of medical school, one year of internship, four years as a resident psychiatrist, and he was board certified in psychiatry. He had earned respect by exceeding all the societal standards for being addressed as “Doctor.” These achievements should not be washed away once you are hospitalized. In fact, I believe my husband might have felt a little safer if he had been addressed as “Doctor.”

My husband was in the ICU for eight of the last sixteen days of his life, and there were lots of missed opportunities for us. He wanted me there more than I was allowed. We missed time together we could have had. I feel it was a very cruel thing that was done to us.

We both knew the gravity of his condition, and my husband wanted quality of life, not quantity. I was a large part of the quality he wanted, but I was locked out for the greater part of his last days.

After my husband died, I felt I had to do something so that what happened to us wouldn’t happen to anyone else. I wrote letters to the chief executive officer of the hospital. I wrote to the chief of the medical staff. I wrote to the chief of nursing. And I wrote to the chaplain. The only person I ever heard from was the chaplain. No one apologized or said they would change the rules.

I believe more harm comes when family are not actively involved, and research is proving my belief is sound. And so I will continue to tell my story. I hope that if I tell it enough times, maybe people who write the rules in hospitals will realize that loved ones are advocates, not visitors.

I will never stop advocating for the elimination of visiting hours.

Reprinted from Crocker L, Johnson B. Privileged presence. Personal stories of connections in health care. 2nd ed. Boulder, CO: Bull Publishing; 2014.

From the University of Virginia School of Medicine, Charlottesville, VA.

 

Abstract

• Objective: To describe the impact of culture on delivering bad news to patients and to describe a patient-centered approach physicians can use when delivering bad news.
• Methods: Descriptive report and discussion utilizing an illustrative case.
• Results: Physicians often find it challenging to deliver bad news in a culturally sensitive manner. Patients vary in their preferences for how they receive bad news, both within and across cultural groups. A strategy to address these preferences is presented that integrates the ethnographic Kleinman model and the SPIKES model.
• Conclusion: Delivering bad news is a challenging endeavor for many physicians. Strategies are available to guide clinicians through these conversations in a manner that is culturally sensitive and patient-centered.

 

A 52-year-old patient from Mexico is seeing his physician because he has been experiencing some fatigue and abdominal pain. The doctor asks the patient about his symptoms with the aid of an interpreter  (in all the dialogues, a Spanish interpreter is present).

Doctor: How can I help you today?

Patient: I think it’s probably nothing, but my wife is worried and wanted me to see you. I don’t quite feel myself, just a little more tired than usual.

Doctor: Do you have any other symptoms?

Patient: Well, I have been having some pain in my stomach, just a little crampy feeling down low. My wife says I have lost some weight and she wanted me to see a doctor. I haven’t been eating as much as I usually do. I just don’t have much of an appetite, especially when I get the pain.

The doctor goes on to ask some additional questions and conducts a physical examination. He discovers the patient lost 20 pounds since his last visit 8 months ago. He is worried that the patient may have something serious going on, possibly colon cancer. He recommends some testing to the patient.

Doctor: I would like to do some tests to see what is going on.

Patient: What kind of tests?

Doctor: A few blood tests and a colonoscopy. Do you know what that is?

Patient: Yes, my brother had one a few years ago.

Doctor: Ok, my nurse will set that up and explain what you will need to do. We’ll schedule another appointment for you to come back to discuss the results. You mentioned your wife. Would you like her or anyone else to be with you at that appointment?

Patient: Yes, my wife and son. My son knows a lot more about medical things than I do, and I know he would want to come.

 

 

The Need for Culturally Sensitive Care

The concept of one’s culture encompasses a host of components including how an individual identifies oneself as well as the language, customs, beliefs, and value system one utilizes. Culture, in turn, profoundly affects patients’ belief systems regarding health and wellness, disease and illness, and the delivery of health care services, including the use of healers and alternative providers [1].In order to provide culturally sensitive and high-quality care to diverse patient populations, it is important for providers to gain an understanding and sensitivity to the influences of culture on patients’ beliefs and behaviors [2].

The ability to provide care to people of different cultures is more important than ever before. In 2011, the number of legal and unauthorized immigrants in the United States rose to 40.4 million (13% of the population) and between 2007 and 2011 alone, this number rose by 2.4 million [3].According to a 2010 census bureau report, in the last 30 years the number of individuals over the age of 5 who spoke a language other than English in their home more than doubled, an increase that was 4 times greater than the rate of population growth [4].In addition, in 2009 the United States resettled more refugees than any other nation (60,000+) and this number reached almost 70,000 in 2013 [5,6].Patient populations in the United States are becoming increasingly diverse, and providers must have the skills to communicate effectively with these groups. A one-size-fits-all approach is not sufficient for our changing population.

The Challenges of Delivering Bad News and the Impact of Culture

Perhaps one of the most challenging communication scenarios faced by physicians is the need to deliver bad news to a patient. “Bad news” can be described as any information that adversely alters one’s expectations for the future [7].Clinicians from nearly all specialties are confronted with the task of giving bad news [8],and this is particularly true regarding cancer care. Among oncologists, 60% reported the need to break bad news to patients between 5 to 20 times per month, with 14% reporting greater than 20 times per month [9].The concept of giving bad news is often viewed as stressful by clinicians [10],  and clinicians must be able to balance a myriad of elements, including patients’ emotional responses, information needs, uncertainties of disease progression and treatments, patients’ preferred level of involvement in decision making, patient expectations, involvement of family members, and how to maintain hope, among others [9,11]. Indeed, it seems that clinicians find it difficult to take into account the full spectrum of patient needs [8]. While the descriptive literature indicates that patient satisfaction and psychological well-being is improved when a patient-centered approach is utilized that attends to the emotional needs of patients [12], clinicians often focus on biomedical information, with less focus on patients’ psychosocial needs and their level of understanding [13–15].

Further, the interaction of patient culture and context with the complexity of the “bad news” interaction can be daunting, and clinicians have noted their diminished level of comfort in adjusting to these cultural preferences [16].The ability of clinicians to “match” the patient’s preferred level of involvement in decision making is associated with higher patient satisfaction with decision making and lower depression after 3 months [11],yet clinicians often find it difficult to determine which patients want to be involved in the decision making to a greater or lesser extent [12].In addition, words have different meanings when used in medical settings or in lay contexts [8],not to mention the challenges of translation when dealing with non–English-speaking patients. Yet, the manner in which clinicians deliver bad news can affect patients’ understanding of their disease, treatment options, and patients’ adjustment to the diagnosis [8],as well as patients’ expected quality of life and intentions to adhere to recommendations [17].

Information Disclosure

One of the key areas impacted by culture relates to preferred disclosure of medical information. Walsh et al noted in their review that the majority of patients in English-speaking countries wanted relatively full disclosure regarding their illness in comparison to individuals from other countries [18].As a further distinction, Blackhall et al noted that African Americans and European Americans were more likely to believe that a patient should be told of a terminal diagnosis than Mexican and Korean Americans [19].In addition, Mexican and Korean Americans were more likely to believe that clinicians should not discuss death and dying with patients, as it could be harmful. Fujimori noted that Asians are less likely to prefer discussions of life expectancy in contrast to Westerners [20].In a survey of Albanian nationals, < 50% of patients wanted to know their true diagnosis; however, individuals who were male, urban, and educated demonstrated a significantly greater preference for disclosure [21].In the Middle East, the concept of disclosure is highly variable in terms of both provider and patient preferences [22].

Involvement of Family Members

A second important area relates to the involvement of family members. Fujimori noted high variability of patient preferences for having family members present when discussing bad news. Of Japanese patients, 78% preferred to be told with family members present, with the number decreasing for Portugal (61%), Australia (53%-57%), and Ireland (40%). Eighty-one percent of the US patients did not want anyone else present. However, almost all placed high value on physician expertise and honesty [20]. Blackhall noted that Mexican and Korean Americans were more likely to favor a family-centered approach to decision making [19]. In addition, Orona indicated that Mexican-American and Chinese-American families felt it was their duty to protect their relatives from a cancer diagnosis to keep the patient’s remaining time free of worry [23]. Haggerty found mixed evidence for patient preferences regarding disclosure of cancer prognosis to family members [24].

Given these variations and complexities, it is natural to try to develop a system for managing them, eg, a list of traits or attributes one can apply to certain groups. For example, patients of Asian origin prefer _______. However, there is an inherent danger in doing this, as it leads to stereotyping [25]. Cultural factors also may be given inappropriate meaning. Specifically, a well-meaning clinician might attribute certain characteristics to a patient when in fact it has little bearing on the patient’s perspective [25]. In addition, given the nature of communication, travel, and the fact that many individuals identify with more than one cultural group, it may be inappropriate to attribute a singular cultural identity to a group in contemporary society. As a result, Kleinman [25] proposed an ethnographic approach as opposed to a cultural approach. Specifically, this involves understanding a patient and his/her illness from an individual’s perspective as opposed to the cultural collective.

Communication Skills to Help Deliver Bad News

Two models can be particularly useful as communication guides when the need arises to deliver bad news. The Kleinman model, as previously mentioned, incorporates an ethnographic approach and focuses on understanding the individualized influence of a patient’s culture and context [25]. The “SPIKES” model was developed in reference to cancer patients and guides the clinician through a 6-step communication process with patients [9]. An integrated approach that incorporates both models can be found in the Table. When combined, these 2 approaches provide a framework to help the clinician communicate in a way that is patient-centered, humanistic, and culturally responsive. These approaches provide practical guidance and identify specific questions one can use to better understand the patient’s perspective of his diagnosis and treatment preferences. Additionally, the specific steps may be used over several sessions with the patient and are not necessarily meant to be done in a linear fashion.

 

Set Up the Interview

Before meeting with the patient, it is important to review the medical data and have a plan in mind for delivering the bad news. Schedule adequate time for discussion and avoid interruptions. Meet in a quiet, private room that is large enough to accommodate family members or friends whom the patient may have brought. In our case example, the patient has brought his wife and son to the appointment.

Doctor: Hello, Mr. Ruiz. (Turning to the patient’s wife and son) I am Dr. Simon.

Patient: Hello, Doctor. This is my wife, Maria, and son, Alejandro.

Doctor: Please have a seat. Are you comfortable?

Patient: Yes. We are anxious to hear the results of the tests.

Son: My father doesn’t always understand medical terms and I wanted to be here to help. I am very worried about him.

Doctor: I understand your concern and I will explain everything to you.

Assess the Patient’s Perception of the Problem

Before telling the patient the diagnosis, it is important to get an idea of the patient’s understanding of the problem, including what he calls it, what he thinks caused it, and how severe he thinks it is.

Doctor: Before I tell you the results, I would like to get a sense first of what you think is going on.

Patient: Well, I really don’t know for sure, but I know the pain is getting worse and I have been feeling weaker. The pain started right after my son’s wedding. There was a lot of food and I ate more than usual. Maybe it was something bad that I ate?

Doctor: (Turning to the wife and son) Do you have any thoughts about the illness?

Wife: I can see he is in pain a lot, even though he tries to hide it from me. I want to know what’s wrong. I am worried it could be something bad.

Obtain the Patient’s Invitation to Disclose the Information

It is important to know if the patient wants to be told the information about his or her diagnosis. Ideally, physicians should discuss this in general terms as part of routine care, before any bad news needs to be delivered. For example,

Doctor: There may come a time when I will need to tell you something bad about your health. Hopefully, that time will never come, but I want to know your preferences so I can honor them if the time does arise. Would you want to be told about this, or would you want someone else, perhaps someone in your family, to be told?

Patient: I appreciate your asking, Doctor. I haven’t really thought about it, but I get kind of nervous and upset when I hear bad news. I would rather you tell me when my wife and son can be there too.

Give Knowledge and Information to the Patient

It is important to provide information that is at a level that the patient can understand. Avoid the use of medical jargon. When speaking through an interpreter, the clinician may need to have a conversation with the interpreter before meeting the patient to explain the situation and the need to be sensitive. For example, if the clinician does not use the word “cancer” after determining from the patient or family the preference for an alternative word, be sure to inform the interpreter not to use the word “cancer.” Provide the information in small chunks and check in frequently to make sure the patient understands. Avoid language that takes away hope. If there is a family member who speaks English, there is a tendency to speak to that person rather than the patient directly. Avoid doing this unless the patient explicitly requests that the clinician speak directly to that individual. This is often the case with older patients. The following might take place at a subsequent appointment:

Doctor: Mr. Ruiz, you told me previously that you would like me to tell you the results of your tests, along with you wife and son. Unfortunately, I have some bad news to tell you. (Pause) The colonoscopy showed that you have a tumor in the colon, also called the large intestine. It is located in the part that we call the ascending colon (draws a picture to show them where this is). We will need to do some other scans to make sure that the tumor is just in the colon and has not spread. I am hopeful, though, that we have caught it fairly early and it has not spread. That would be the best situation. (Pause) Do you understand what I have told you so far?

Address the Patient’s and Family’s Emotions

Every patient will express their reactions to bad news differently, and their reactions may be different from what the physician might experience in a similar situation. Thus, the clinician should be self-aware and be prepared to respond to a variety of responses. It is important to express empathy and validate the patient’s and family reactions and emotions. If the patient does not express any emotion, the clinician should explore this carefully. It may require more than one visit for the patient to open up with his feelings.

Doctor: I am so sorry. I know that this must be a big shock for you.

Patient: I kind of figured it might be something bad, but it is still a shock. Even so, I am a religious man and I believe that I will get through this with the help of my wife and family.

Doctor: It sounds as if you have a great support system and get strength from your faith. You are lucky to have such a wonderful family and that will be a big help as we move forward.

 

Strategize and Summarize

Ask the patient if he or she is ready to have a discussion about treatment, including his or her goals of treatment. Continue to explore the patient’s knowledge, expectations and hopes. Always allow the patient to express his fears and concerns. Most importantly, let the patient know that you will share the responsibility of decision making with the patient and be there to support him.

Doctor: This is never easy and it’s a lot to take in. Would you like to discuss the next steps and possible treatments at this time or should we make another appointment after your CAT scan?

Patient: My wife is pretty upset and I think it might be better if we stop here for now. Is that ok?

Son: We want to come back as soon as we can after the CAT scan. In the meantime, can you provide me with some information or a good website to check out?

Doctor: Yes, of course. That sounds like a good plan.

Conclusion

The task of giving bad news is a necessity for physicians of most specialties and is often viewed as challenging and even stressful to some. However, the manner in which information is discussed with patients can impact patients’ satisfaction, understanding of their illness, adjustment to the diagnosis, expected quality of life, and intentions to adhere to recommendations [8,17]. Providing bad news in a culturally sensitive manner adds an additional level of complexity to an already challenging encounter. While an individual’s culture can strongly influence patient belief systems and utilization of care, there is an inherent danger when clinicians make assumptions about individuals’ culture and the role it plays in their lives. Instead of focusing on creating a mental list of cultural attributes, we recommend a patient-centered approach where few assumptions about the patient are made and instead, the clinician gains an understanding of each individual patient through queries and adjusts his/her approach and language according to each individual’s needs.

 

Corresponding author: Lisa K. Rollins, PhD, Dept. of Family Medicine, Univ.of Virginia, PO Box 800729, Charlottesville,VA 22908-0729, lkr2h@virginia.edu.

Financial disclosures: None.

From the University of Virginia School of Medicine, Charlottesville, VA.

 

Abstract

• Objective: To describe the impact of culture on delivering bad news to patients and to describe a patient-centered approach physicians can use when delivering bad news.
• Methods: Descriptive report and discussion utilizing an illustrative case.
• Results: Physicians often find it challenging to deliver bad news in a culturally sensitive manner. Patients vary in their preferences for how they receive bad news, both within and across cultural groups. A strategy to address these preferences is presented that integrates the ethnographic Kleinman model and the SPIKES model.
• Conclusion: Delivering bad news is a challenging endeavor for many physicians. Strategies are available to guide clinicians through these conversations in a manner that is culturally sensitive and patient-centered.

 

A 52-year-old patient from Mexico is seeing his physician because he has been experiencing some fatigue and abdominal pain. The doctor asks the patient about his symptoms with the aid of an interpreter  (in all the dialogues, a Spanish interpreter is present).

Doctor: How can I help you today?

Patient: I think it’s probably nothing, but my wife is worried and wanted me to see you. I don’t quite feel myself, just a little more tired than usual.

Doctor: Do you have any other symptoms?

Patient: Well, I have been having some pain in my stomach, just a little crampy feeling down low. My wife says I have lost some weight and she wanted me to see a doctor. I haven’t been eating as much as I usually do. I just don’t have much of an appetite, especially when I get the pain.

The doctor goes on to ask some additional questions and conducts a physical examination. He discovers the patient lost 20 pounds since his last visit 8 months ago. He is worried that the patient may have something serious going on, possibly colon cancer. He recommends some testing to the patient.

Doctor: I would like to do some tests to see what is going on.

Patient: What kind of tests?

Doctor: A few blood tests and a colonoscopy. Do you know what that is?

Patient: Yes, my brother had one a few years ago.

Doctor: Ok, my nurse will set that up and explain what you will need to do. We’ll schedule another appointment for you to come back to discuss the results. You mentioned your wife. Would you like her or anyone else to be with you at that appointment?

Patient: Yes, my wife and son. My son knows a lot more about medical things than I do, and I know he would want to come.

 

 

The Need for Culturally Sensitive Care

The concept of one’s culture encompasses a host of components including how an individual identifies oneself as well as the language, customs, beliefs, and value system one utilizes. Culture, in turn, profoundly affects patients’ belief systems regarding health and wellness, disease and illness, and the delivery of health care services, including the use of healers and alternative providers [1].In order to provide culturally sensitive and high-quality care to diverse patient populations, it is important for providers to gain an understanding and sensitivity to the influences of culture on patients’ beliefs and behaviors [2].

The ability to provide care to people of different cultures is more important than ever before. In 2011, the number of legal and unauthorized immigrants in the United States rose to 40.4 million (13% of the population) and between 2007 and 2011 alone, this number rose by 2.4 million [3].According to a 2010 census bureau report, in the last 30 years the number of individuals over the age of 5 who spoke a language other than English in their home more than doubled, an increase that was 4 times greater than the rate of population growth [4].In addition, in 2009 the United States resettled more refugees than any other nation (60,000+) and this number reached almost 70,000 in 2013 [5,6].Patient populations in the United States are becoming increasingly diverse, and providers must have the skills to communicate effectively with these groups. A one-size-fits-all approach is not sufficient for our changing population.

The Challenges of Delivering Bad News and the Impact of Culture

Perhaps one of the most challenging communication scenarios faced by physicians is the need to deliver bad news to a patient. “Bad news” can be described as any information that adversely alters one’s expectations for the future [7].Clinicians from nearly all specialties are confronted with the task of giving bad news [8],and this is particularly true regarding cancer care. Among oncologists, 60% reported the need to break bad news to patients between 5 to 20 times per month, with 14% reporting greater than 20 times per month [9].The concept of giving bad news is often viewed as stressful by clinicians [10],  and clinicians must be able to balance a myriad of elements, including patients’ emotional responses, information needs, uncertainties of disease progression and treatments, patients’ preferred level of involvement in decision making, patient expectations, involvement of family members, and how to maintain hope, among others [9,11]. Indeed, it seems that clinicians find it difficult to take into account the full spectrum of patient needs [8]. While the descriptive literature indicates that patient satisfaction and psychological well-being is improved when a patient-centered approach is utilized that attends to the emotional needs of patients [12], clinicians often focus on biomedical information, with less focus on patients’ psychosocial needs and their level of understanding [13–15].

Further, the interaction of patient culture and context with the complexity of the “bad news” interaction can be daunting, and clinicians have noted their diminished level of comfort in adjusting to these cultural preferences [16].The ability of clinicians to “match” the patient’s preferred level of involvement in decision making is associated with higher patient satisfaction with decision making and lower depression after 3 months [11],yet clinicians often find it difficult to determine which patients want to be involved in the decision making to a greater or lesser extent [12].In addition, words have different meanings when used in medical settings or in lay contexts [8],not to mention the challenges of translation when dealing with non–English-speaking patients. Yet, the manner in which clinicians deliver bad news can affect patients’ understanding of their disease, treatment options, and patients’ adjustment to the diagnosis [8],as well as patients’ expected quality of life and intentions to adhere to recommendations [17].

Information Disclosure

One of the key areas impacted by culture relates to preferred disclosure of medical information. Walsh et al noted in their review that the majority of patients in English-speaking countries wanted relatively full disclosure regarding their illness in comparison to individuals from other countries [18].As a further distinction, Blackhall et al noted that African Americans and European Americans were more likely to believe that a patient should be told of a terminal diagnosis than Mexican and Korean Americans [19].In addition, Mexican and Korean Americans were more likely to believe that clinicians should not discuss death and dying with patients, as it could be harmful. Fujimori noted that Asians are less likely to prefer discussions of life expectancy in contrast to Westerners [20].In a survey of Albanian nationals, < 50% of patients wanted to know their true diagnosis; however, individuals who were male, urban, and educated demonstrated a significantly greater preference for disclosure [21].In the Middle East, the concept of disclosure is highly variable in terms of both provider and patient preferences [22].

Involvement of Family Members

A second important area relates to the involvement of family members. Fujimori noted high variability of patient preferences for having family members present when discussing bad news. Of Japanese patients, 78% preferred to be told with family members present, with the number decreasing for Portugal (61%), Australia (53%-57%), and Ireland (40%). Eighty-one percent of the US patients did not want anyone else present. However, almost all placed high value on physician expertise and honesty [20]. Blackhall noted that Mexican and Korean Americans were more likely to favor a family-centered approach to decision making [19]. In addition, Orona indicated that Mexican-American and Chinese-American families felt it was their duty to protect their relatives from a cancer diagnosis to keep the patient’s remaining time free of worry [23]. Haggerty found mixed evidence for patient preferences regarding disclosure of cancer prognosis to family members [24].

Given these variations and complexities, it is natural to try to develop a system for managing them, eg, a list of traits or attributes one can apply to certain groups. For example, patients of Asian origin prefer _______. However, there is an inherent danger in doing this, as it leads to stereotyping [25]. Cultural factors also may be given inappropriate meaning. Specifically, a well-meaning clinician might attribute certain characteristics to a patient when in fact it has little bearing on the patient’s perspective [25]. In addition, given the nature of communication, travel, and the fact that many individuals identify with more than one cultural group, it may be inappropriate to attribute a singular cultural identity to a group in contemporary society. As a result, Kleinman [25] proposed an ethnographic approach as opposed to a cultural approach. Specifically, this involves understanding a patient and his/her illness from an individual’s perspective as opposed to the cultural collective.

Communication Skills to Help Deliver Bad News

Two models can be particularly useful as communication guides when the need arises to deliver bad news. The Kleinman model, as previously mentioned, incorporates an ethnographic approach and focuses on understanding the individualized influence of a patient’s culture and context [25]. The “SPIKES” model was developed in reference to cancer patients and guides the clinician through a 6-step communication process with patients [9]. An integrated approach that incorporates both models can be found in the Table. When combined, these 2 approaches provide a framework to help the clinician communicate in a way that is patient-centered, humanistic, and culturally responsive. These approaches provide practical guidance and identify specific questions one can use to better understand the patient’s perspective of his diagnosis and treatment preferences. Additionally, the specific steps may be used over several sessions with the patient and are not necessarily meant to be done in a linear fashion.

 

Set Up the Interview

Before meeting with the patient, it is important to review the medical data and have a plan in mind for delivering the bad news. Schedule adequate time for discussion and avoid interruptions. Meet in a quiet, private room that is large enough to accommodate family members or friends whom the patient may have brought. In our case example, the patient has brought his wife and son to the appointment.

Doctor: Hello, Mr. Ruiz. (Turning to the patient’s wife and son) I am Dr. Simon.

Patient: Hello, Doctor. This is my wife, Maria, and son, Alejandro.

Doctor: Please have a seat. Are you comfortable?

Patient: Yes. We are anxious to hear the results of the tests.

Son: My father doesn’t always understand medical terms and I wanted to be here to help. I am very worried about him.

Doctor: I understand your concern and I will explain everything to you.

Assess the Patient’s Perception of the Problem

Before telling the patient the diagnosis, it is important to get an idea of the patient’s understanding of the problem, including what he calls it, what he thinks caused it, and how severe he thinks it is.

Doctor: Before I tell you the results, I would like to get a sense first of what you think is going on.

Patient: Well, I really don’t know for sure, but I know the pain is getting worse and I have been feeling weaker. The pain started right after my son’s wedding. There was a lot of food and I ate more than usual. Maybe it was something bad that I ate?

Doctor: (Turning to the wife and son) Do you have any thoughts about the illness?

Wife: I can see he is in pain a lot, even though he tries to hide it from me. I want to know what’s wrong. I am worried it could be something bad.

Obtain the Patient’s Invitation to Disclose the Information

It is important to know if the patient wants to be told the information about his or her diagnosis. Ideally, physicians should discuss this in general terms as part of routine care, before any bad news needs to be delivered. For example,

Doctor: There may come a time when I will need to tell you something bad about your health. Hopefully, that time will never come, but I want to know your preferences so I can honor them if the time does arise. Would you want to be told about this, or would you want someone else, perhaps someone in your family, to be told?

Patient: I appreciate your asking, Doctor. I haven’t really thought about it, but I get kind of nervous and upset when I hear bad news. I would rather you tell me when my wife and son can be there too.

Give Knowledge and Information to the Patient

It is important to provide information that is at a level that the patient can understand. Avoid the use of medical jargon. When speaking through an interpreter, the clinician may need to have a conversation with the interpreter before meeting the patient to explain the situation and the need to be sensitive. For example, if the clinician does not use the word “cancer” after determining from the patient or family the preference for an alternative word, be sure to inform the interpreter not to use the word “cancer.” Provide the information in small chunks and check in frequently to make sure the patient understands. Avoid language that takes away hope. If there is a family member who speaks English, there is a tendency to speak to that person rather than the patient directly. Avoid doing this unless the patient explicitly requests that the clinician speak directly to that individual. This is often the case with older patients. The following might take place at a subsequent appointment:

Doctor: Mr. Ruiz, you told me previously that you would like me to tell you the results of your tests, along with you wife and son. Unfortunately, I have some bad news to tell you. (Pause) The colonoscopy showed that you have a tumor in the colon, also called the large intestine. It is located in the part that we call the ascending colon (draws a picture to show them where this is). We will need to do some other scans to make sure that the tumor is just in the colon and has not spread. I am hopeful, though, that we have caught it fairly early and it has not spread. That would be the best situation. (Pause) Do you understand what I have told you so far?

Address the Patient’s and Family’s Emotions

Every patient will express their reactions to bad news differently, and their reactions may be different from what the physician might experience in a similar situation. Thus, the clinician should be self-aware and be prepared to respond to a variety of responses. It is important to express empathy and validate the patient’s and family reactions and emotions. If the patient does not express any emotion, the clinician should explore this carefully. It may require more than one visit for the patient to open up with his feelings.

Doctor: I am so sorry. I know that this must be a big shock for you.

Patient: I kind of figured it might be something bad, but it is still a shock. Even so, I am a religious man and I believe that I will get through this with the help of my wife and family.

Doctor: It sounds as if you have a great support system and get strength from your faith. You are lucky to have such a wonderful family and that will be a big help as we move forward.

 

Strategize and Summarize

Ask the patient if he or she is ready to have a discussion about treatment, including his or her goals of treatment. Continue to explore the patient’s knowledge, expectations and hopes. Always allow the patient to express his fears and concerns. Most importantly, let the patient know that you will share the responsibility of decision making with the patient and be there to support him.

Doctor: This is never easy and it’s a lot to take in. Would you like to discuss the next steps and possible treatments at this time or should we make another appointment after your CAT scan?

Patient: My wife is pretty upset and I think it might be better if we stop here for now. Is that ok?

Son: We want to come back as soon as we can after the CAT scan. In the meantime, can you provide me with some information or a good website to check out?

Doctor: Yes, of course. That sounds like a good plan.

Conclusion

The task of giving bad news is a necessity for physicians of most specialties and is often viewed as challenging and even stressful to some. However, the manner in which information is discussed with patients can impact patients’ satisfaction, understanding of their illness, adjustment to the diagnosis, expected quality of life, and intentions to adhere to recommendations [8,17]. Providing bad news in a culturally sensitive manner adds an additional level of complexity to an already challenging encounter. While an individual’s culture can strongly influence patient belief systems and utilization of care, there is an inherent danger when clinicians make assumptions about individuals’ culture and the role it plays in their lives. Instead of focusing on creating a mental list of cultural attributes, we recommend a patient-centered approach where few assumptions about the patient are made and instead, the clinician gains an understanding of each individual patient through queries and adjusts his/her approach and language according to each individual’s needs.

 

Corresponding author: Lisa K. Rollins, PhD, Dept. of Family Medicine, Univ.of Virginia, PO Box 800729, Charlottesville,VA 22908-0729, lkr2h@virginia.edu.

Financial disclosures: None.

From the University of Virginia School of Medicine, Charlottesville, VA.

 

Abstract

• Objective: To describe the impact of culture on delivering bad news to patients and to describe a patient-centered approach physicians can use when delivering bad news.
• Methods: Descriptive report and discussion utilizing an illustrative case.
• Results: Physicians often find it challenging to deliver bad news in a culturally sensitive manner. Patients vary in their preferences for how they receive bad news, both within and across cultural groups. A strategy to address these preferences is presented that integrates the ethnographic Kleinman model and the SPIKES model.
• Conclusion: Delivering bad news is a challenging endeavor for many physicians. Strategies are available to guide clinicians through these conversations in a manner that is culturally sensitive and patient-centered.

 

A 52-year-old patient from Mexico is seeing his physician because he has been experiencing some fatigue and abdominal pain. The doctor asks the patient about his symptoms with the aid of an interpreter  (in all the dialogues, a Spanish interpreter is present).

Doctor: How can I help you today?

Patient: I think it’s probably nothing, but my wife is worried and wanted me to see you. I don’t quite feel myself, just a little more tired than usual.

Doctor: Do you have any other symptoms?

Patient: Well, I have been having some pain in my stomach, just a little crampy feeling down low. My wife says I have lost some weight and she wanted me to see a doctor. I haven’t been eating as much as I usually do. I just don’t have much of an appetite, especially when I get the pain.

The doctor goes on to ask some additional questions and conducts a physical examination. He discovers the patient lost 20 pounds since his last visit 8 months ago. He is worried that the patient may have something serious going on, possibly colon cancer. He recommends some testing to the patient.

Doctor: I would like to do some tests to see what is going on.

Patient: What kind of tests?

Doctor: A few blood tests and a colonoscopy. Do you know what that is?

Patient: Yes, my brother had one a few years ago.

Doctor: Ok, my nurse will set that up and explain what you will need to do. We’ll schedule another appointment for you to come back to discuss the results. You mentioned your wife. Would you like her or anyone else to be with you at that appointment?

Patient: Yes, my wife and son. My son knows a lot more about medical things than I do, and I know he would want to come.

 

 

The Need for Culturally Sensitive Care

The concept of one’s culture encompasses a host of components including how an individual identifies oneself as well as the language, customs, beliefs, and value system one utilizes. Culture, in turn, profoundly affects patients’ belief systems regarding health and wellness, disease and illness, and the delivery of health care services, including the use of healers and alternative providers [1].In order to provide culturally sensitive and high-quality care to diverse patient populations, it is important for providers to gain an understanding and sensitivity to the influences of culture on patients’ beliefs and behaviors [2].

The ability to provide care to people of different cultures is more important than ever before. In 2011, the number of legal and unauthorized immigrants in the United States rose to 40.4 million (13% of the population) and between 2007 and 2011 alone, this number rose by 2.4 million [3].According to a 2010 census bureau report, in the last 30 years the number of individuals over the age of 5 who spoke a language other than English in their home more than doubled, an increase that was 4 times greater than the rate of population growth [4].In addition, in 2009 the United States resettled more refugees than any other nation (60,000+) and this number reached almost 70,000 in 2013 [5,6].Patient populations in the United States are becoming increasingly diverse, and providers must have the skills to communicate effectively with these groups. A one-size-fits-all approach is not sufficient for our changing population.

The Challenges of Delivering Bad News and the Impact of Culture

Perhaps one of the most challenging communication scenarios faced by physicians is the need to deliver bad news to a patient. “Bad news” can be described as any information that adversely alters one’s expectations for the future [7].Clinicians from nearly all specialties are confronted with the task of giving bad news [8],and this is particularly true regarding cancer care. Among oncologists, 60% reported the need to break bad news to patients between 5 to 20 times per month, with 14% reporting greater than 20 times per month [9].The concept of giving bad news is often viewed as stressful by clinicians [10],  and clinicians must be able to balance a myriad of elements, including patients’ emotional responses, information needs, uncertainties of disease progression and treatments, patients’ preferred level of involvement in decision making, patient expectations, involvement of family members, and how to maintain hope, among others [9,11]. Indeed, it seems that clinicians find it difficult to take into account the full spectrum of patient needs [8]. While the descriptive literature indicates that patient satisfaction and psychological well-being is improved when a patient-centered approach is utilized that attends to the emotional needs of patients [12], clinicians often focus on biomedical information, with less focus on patients’ psychosocial needs and their level of understanding [13–15].

Further, the interaction of patient culture and context with the complexity of the “bad news” interaction can be daunting, and clinicians have noted their diminished level of comfort in adjusting to these cultural preferences [16].The ability of clinicians to “match” the patient’s preferred level of involvement in decision making is associated with higher patient satisfaction with decision making and lower depression after 3 months [11],yet clinicians often find it difficult to determine which patients want to be involved in the decision making to a greater or lesser extent [12].In addition, words have different meanings when used in medical settings or in lay contexts [8],not to mention the challenges of translation when dealing with non–English-speaking patients. Yet, the manner in which clinicians deliver bad news can affect patients’ understanding of their disease, treatment options, and patients’ adjustment to the diagnosis [8],as well as patients’ expected quality of life and intentions to adhere to recommendations [17].

Information Disclosure

One of the key areas impacted by culture relates to preferred disclosure of medical information. Walsh et al noted in their review that the majority of patients in English-speaking countries wanted relatively full disclosure regarding their illness in comparison to individuals from other countries [18].As a further distinction, Blackhall et al noted that African Americans and European Americans were more likely to believe that a patient should be told of a terminal diagnosis than Mexican and Korean Americans [19].In addition, Mexican and Korean Americans were more likely to believe that clinicians should not discuss death and dying with patients, as it could be harmful. Fujimori noted that Asians are less likely to prefer discussions of life expectancy in contrast to Westerners [20].In a survey of Albanian nationals, < 50% of patients wanted to know their true diagnosis; however, individuals who were male, urban, and educated demonstrated a significantly greater preference for disclosure [21].In the Middle East, the concept of disclosure is highly variable in terms of both provider and patient preferences [22].

Involvement of Family Members

A second important area relates to the involvement of family members. Fujimori noted high variability of patient preferences for having family members present when discussing bad news. Of Japanese patients, 78% preferred to be told with family members present, with the number decreasing for Portugal (61%), Australia (53%-57%), and Ireland (40%). Eighty-one percent of the US patients did not want anyone else present. However, almost all placed high value on physician expertise and honesty [20]. Blackhall noted that Mexican and Korean Americans were more likely to favor a family-centered approach to decision making [19]. In addition, Orona indicated that Mexican-American and Chinese-American families felt it was their duty to protect their relatives from a cancer diagnosis to keep the patient’s remaining time free of worry [23]. Haggerty found mixed evidence for patient preferences regarding disclosure of cancer prognosis to family members [24].

Given these variations and complexities, it is natural to try to develop a system for managing them, eg, a list of traits or attributes one can apply to certain groups. For example, patients of Asian origin prefer _______. However, there is an inherent danger in doing this, as it leads to stereotyping [25]. Cultural factors also may be given inappropriate meaning. Specifically, a well-meaning clinician might attribute certain characteristics to a patient when in fact it has little bearing on the patient’s perspective [25]. In addition, given the nature of communication, travel, and the fact that many individuals identify with more than one cultural group, it may be inappropriate to attribute a singular cultural identity to a group in contemporary society. As a result, Kleinman [25] proposed an ethnographic approach as opposed to a cultural approach. Specifically, this involves understanding a patient and his/her illness from an individual’s perspective as opposed to the cultural collective.

Communication Skills to Help Deliver Bad News

Two models can be particularly useful as communication guides when the need arises to deliver bad news. The Kleinman model, as previously mentioned, incorporates an ethnographic approach and focuses on understanding the individualized influence of a patient’s culture and context [25]. The “SPIKES” model was developed in reference to cancer patients and guides the clinician through a 6-step communication process with patients [9]. An integrated approach that incorporates both models can be found in the Table. When combined, these 2 approaches provide a framework to help the clinician communicate in a way that is patient-centered, humanistic, and culturally responsive. These approaches provide practical guidance and identify specific questions one can use to better understand the patient’s perspective of his diagnosis and treatment preferences. Additionally, the specific steps may be used over several sessions with the patient and are not necessarily meant to be done in a linear fashion.

 

Set Up the Interview

Before meeting with the patient, it is important to review the medical data and have a plan in mind for delivering the bad news. Schedule adequate time for discussion and avoid interruptions. Meet in a quiet, private room that is large enough to accommodate family members or friends whom the patient may have brought. In our case example, the patient has brought his wife and son to the appointment.

Doctor: Hello, Mr. Ruiz. (Turning to the patient’s wife and son) I am Dr. Simon.

Patient: Hello, Doctor. This is my wife, Maria, and son, Alejandro.

Doctor: Please have a seat. Are you comfortable?

Patient: Yes. We are anxious to hear the results of the tests.

Son: My father doesn’t always understand medical terms and I wanted to be here to help. I am very worried about him.

Doctor: I understand your concern and I will explain everything to you.

Assess the Patient’s Perception of the Problem

Before telling the patient the diagnosis, it is important to get an idea of the patient’s understanding of the problem, including what he calls it, what he thinks caused it, and how severe he thinks it is.

Doctor: Before I tell you the results, I would like to get a sense first of what you think is going on.

Patient: Well, I really don’t know for sure, but I know the pain is getting worse and I have been feeling weaker. The pain started right after my son’s wedding. There was a lot of food and I ate more than usual. Maybe it was something bad that I ate?

Doctor: (Turning to the wife and son) Do you have any thoughts about the illness?

Wife: I can see he is in pain a lot, even though he tries to hide it from me. I want to know what’s wrong. I am worried it could be something bad.

Obtain the Patient’s Invitation to Disclose the Information

It is important to know if the patient wants to be told the information about his or her diagnosis. Ideally, physicians should discuss this in general terms as part of routine care, before any bad news needs to be delivered. For example,

Doctor: There may come a time when I will need to tell you something bad about your health. Hopefully, that time will never come, but I want to know your preferences so I can honor them if the time does arise. Would you want to be told about this, or would you want someone else, perhaps someone in your family, to be told?

Patient: I appreciate your asking, Doctor. I haven’t really thought about it, but I get kind of nervous and upset when I hear bad news. I would rather you tell me when my wife and son can be there too.

Give Knowledge and Information to the Patient

It is important to provide information that is at a level that the patient can understand. Avoid the use of medical jargon. When speaking through an interpreter, the clinician may need to have a conversation with the interpreter before meeting the patient to explain the situation and the need to be sensitive. For example, if the clinician does not use the word “cancer” after determining from the patient or family the preference for an alternative word, be sure to inform the interpreter not to use the word “cancer.” Provide the information in small chunks and check in frequently to make sure the patient understands. Avoid language that takes away hope. If there is a family member who speaks English, there is a tendency to speak to that person rather than the patient directly. Avoid doing this unless the patient explicitly requests that the clinician speak directly to that individual. This is often the case with older patients. The following might take place at a subsequent appointment:

Doctor: Mr. Ruiz, you told me previously that you would like me to tell you the results of your tests, along with you wife and son. Unfortunately, I have some bad news to tell you. (Pause) The colonoscopy showed that you have a tumor in the colon, also called the large intestine. It is located in the part that we call the ascending colon (draws a picture to show them where this is). We will need to do some other scans to make sure that the tumor is just in the colon and has not spread. I am hopeful, though, that we have caught it fairly early and it has not spread. That would be the best situation. (Pause) Do you understand what I have told you so far?

Address the Patient’s and Family’s Emotions

Every patient will express their reactions to bad news differently, and their reactions may be different from what the physician might experience in a similar situation. Thus, the clinician should be self-aware and be prepared to respond to a variety of responses. It is important to express empathy and validate the patient’s and family reactions and emotions. If the patient does not express any emotion, the clinician should explore this carefully. It may require more than one visit for the patient to open up with his feelings.

Doctor: I am so sorry. I know that this must be a big shock for you.

Patient: I kind of figured it might be something bad, but it is still a shock. Even so, I am a religious man and I believe that I will get through this with the help of my wife and family.

Doctor: It sounds as if you have a great support system and get strength from your faith. You are lucky to have such a wonderful family and that will be a big help as we move forward.

 

Strategize and Summarize

Ask the patient if he or she is ready to have a discussion about treatment, including his or her goals of treatment. Continue to explore the patient’s knowledge, expectations and hopes. Always allow the patient to express his fears and concerns. Most importantly, let the patient know that you will share the responsibility of decision making with the patient and be there to support him.

Doctor: This is never easy and it’s a lot to take in. Would you like to discuss the next steps and possible treatments at this time or should we make another appointment after your CAT scan?

Patient: My wife is pretty upset and I think it might be better if we stop here for now. Is that ok?

Son: We want to come back as soon as we can after the CAT scan. In the meantime, can you provide me with some information or a good website to check out?

Doctor: Yes, of course. That sounds like a good plan.

Conclusion

The task of giving bad news is a necessity for physicians of most specialties and is often viewed as challenging and even stressful to some. However, the manner in which information is discussed with patients can impact patients’ satisfaction, understanding of their illness, adjustment to the diagnosis, expected quality of life, and intentions to adhere to recommendations [8,17]. Providing bad news in a culturally sensitive manner adds an additional level of complexity to an already challenging encounter. While an individual’s culture can strongly influence patient belief systems and utilization of care, there is an inherent danger when clinicians make assumptions about individuals’ culture and the role it plays in their lives. Instead of focusing on creating a mental list of cultural attributes, we recommend a patient-centered approach where few assumptions about the patient are made and instead, the clinician gains an understanding of each individual patient through queries and adjusts his/her approach and language according to each individual’s needs.

 

Corresponding author: Lisa K. Rollins, PhD, Dept. of Family Medicine, Univ.of Virginia, PO Box 800729, Charlottesville,VA 22908-0729, lkr2h@virginia.edu.

Financial disclosures: None.

From the UCSF Benioff Children’s Hospital Oakland, Oakland, CA

 

Abstract

• Objective: Emotional distress may adversely affect the course and complicate treatment for individuals with sickle cell disease (SCD). We evaluated variables associated with physical and mental components of health-related quality of life (HRQL) in SCD in the context of a biobehavioral model.
• Methods: We conducted a cross-sectional cohort study of 77 adults with SCD (18–69 years; 60% female; 73% Hgb SS) attending an urban, academic medical center.  We measured emotional distress (Patient Health Questionnaire–9, Generalized Anxiety Disorder 7-item scale), clinical complications and utilization, barriers to health care, sociodemo-graphics and HRQL (SF-36 Health Survey). We developed models predictive of physical and mental HRQL by conducting stepwise regression analyses.
• Results: Sample prevalence of moderate to severe depression and anxiety symptoms was 33% and 36%, respectively; prevalence of impaired physical and mental HRQL was 17% and 16%, respectively. Increased symptoms of depression, older age, and ≥ 3 emergency department visits in the previous 12 months were independently associated with lower ratings of physical HRQL, controlling for anxiety and sex.  Increased symptoms of depression were independently associated with lower ratings of mental HRQL, controlling for barriers to care, insurance status, lifetime complications of SCD, and sex.
• Conclusion: Emotional distress is an important contributor to both physical and mental HRQL for adults with SCD, although sociodemographic variables and barriers to care must also be considered. Innovative approaches that integrate mental health interventions with SCD clinical care are needed.

 

Emotional distress, including symptoms of depression and anxiety, may adversely affect the course and complicate the treatment of chronic physical conditions [1]. For patients with sickle cell disease (SCD), a group of inherited red blood cell conditions, symptoms of depression and anxiety are more prevalent compared with rates found in the general population [2–8]. The most common symptom of SCD is acute pain events, and other complications range from mild to life-threatening, including anemia, increased risk of infection, acute chest syndrome, stroke, skin ulcers, and pulmonary hypertension [9]. Depression in adults with SCD has been associated with increased sickle cell vaso-occlusive pain events, poor pain control, multiple blood transfusions, and prescription of the disease-modifying therapy hydroxyurea [4]. Adults with SCD and comorbid depression and anxiety had more daily pain and greater distress and interference from pain compared with those who did not have comorbid depression or anxiety [10]. Patients have linked emotional distress and episodes of illness [11], and research has found a relation between pain episodes and depression [12]. In a diary study, negative mood was significantly higher on pain days compared with non-pain days [13].

Studies examining the consequences of emotional distress on health-related quality of life (HRQL) for patients with SCD are emerging. Depressed adults with SCD rated their quality of life on the SF-36 Health Survey [14] as significantly poorer in all areas compared with non-depressed adults with SCD [15].  In regression models, depression was a stronger predictor of SF-36 scores than demographics, hemoglobin type, and pain measures. In a multi-site study [16], 1046 adults with SCD completed the SF-36. Increasing age was associated with significantly lower scores on all subscales except mental health, while female sex additionally contributed to diminished physical function and vitality scale scores in multivariate models [16]. The presence of a mood disorder was associated with bodily pain, and diminished vitality, social functioning, emotional role, and the mental component of HRQL. Medical complications other than pain were not associated with impaired HRQL. Anie and colleagues [17,18] have highlighted the contributions of sickle cell–related pain to diminished mood and HRQL, both in the acute hospital phase and 1 week post discharge.

A comprehensive literature review of patient-reported outcomes for adults with SCD revealed broad categories of the impact of SCD and its treatment on the lives of adults [19]. Categories included pain and pain management, emotional distress, poor social role functioning, diminished overall quality of life, and poor quality of care. Follow-up individual and group interviews with adults with SCD (n = 122) as well as individual interviews with their providers (n = 15) revealed findings consistent with the literature review on the major effects of pain on the lives of adults with SCD, interwoven with emotional distress, poor quality of care, and stigmatization [19].

In the present study, our goal was to describe variables associated with physical and mental HRQL in SCD within the context of the recently published comprehensive conceptual model of broad clinical and life effects associated with SCD [19]. The present analysis uses an existing clinical database and evaluates the effects of the relations between clinical complications of SCD, emotional distress, health care utilization, and HRQL. Our model includes barriers to health care that might prevent vulnerable patients from accessing needed health care services. Sociodemographic variables including ethnic and racial minority status and lower socioeconomic status and educational attainment may create barriers to health care for patients with SCD, as they do for individuals with other chronic conditions [20–23]. Over 60% of patients with SCD are on public insurance [24] and can have difficulties with accessing quality health care [25]. Negative provider attitudes and stigmatization when patients are seeking care for acute pain episodes have been highlighted by patients as major barriers to seeking health care [19,26–28]. In a qualitative study, 45 youth with SCD reported that competing school or peer-group activities, “feeling good,” poor patient-provider relationships, adverse clinic experiences, and forgetting were barriers to clinic attendance [29]. Limited research suggests that barriers to accessing health care are associated with poorer HRQL [30,31]; however no studies were identified that directly evaluated the relation between barriers to care and HRQL for populations with SCD.

We hypothesized that clinical complications of SCD, including pain, and barriers to accessing health care would be independently associated with the physical component of HRQL for adult patients with SCD, controlling for demographic variables. Further, we hypothesized that emotional distress, clinical complications of SCD, and barriers to accessing health care would be independently associated with the mental component of HRQL for adult patients with SCD, controlling for demographic variables.

 

Methods

Patient Recruitment

Participants were 18 years and older and were a subgroup selected from a larger prospective cohort enrolled in the Sickle Cell Disease Treatment Demonstration Program (SCDTDP) funded by the Health Resources and Services Administration (HRSA). As 1 of 7 SCDTDP grantees, our network collected common demographic, disease-related, and HRQL data as the other grantees to examine sickle cell health and health care [32]. Enrollment at our site was n = 115 from birth through adult, with data collection occurring at baseline in 2010 and annually through 2014. Participants were eligible for enrollment if they had any confirmed diagnosis of SCD and if they were seen at any facility treating SCD in the San Francisco Bay Area region. Interpreter services were available where English was a second language; however, no participant requested those services. The data collection site was an urban comprehensive sickle cell center. Participants were recruited through mailings, posted flyers, or were introduced to the project by their clinical providers. The institutional review boards of the sponsoring hospitals approved all procedures. This report describes analyses from the baseline data collected in 2010 and excludes pediatric patients under the age of 18 years, as we developed our conceptual model based on the adult SCD literature.

Procedures

Patients directly contacted the project coordinator or were introduced by their health care provider. The project coordinator explained the study in more detail, and if the patient agreed to participate, the project coordinator obtained thier informed consent. Participants completed the study materials in a private space in the clinic immediately after or were scheduled for a separate visit at a convenient time and location. Participants with known or observed difficulties with reading completed the questionnaires as an interview. We allowed participants who were unable to complete the forms in one visit to take them home or schedule a follow-up visit to complete them. We asked participants who took the questionnaires home to return them within 2 business days and provided them with a stamped addressed envelope. Participants were compensated with gift cards for their involvement.

Measures

Demographics and Clinical Characteristics

Participants completed an Individual Utilization Questionnaire created for the SCDTDP grantees [32], either as an interview or in paper and pencil format. Participants indicated their age, race and ethnicity, education level, type of insurance, and annual household income. They indicated the type of SCD, number of hospital days and emergency department (ED) visits in the previous 12 months, disease-modifying therapies including hydroxyurea or transfusions, and lifetime incidence of sickle cell–related complications. Complications included pain, acute chest syndrome, fever, severe infection, stroke, kidney damage, gallbladder attack, spleen problems and priapism. Medical data was verified by reviewing medical records when possible; the clinical databases in the hematology/oncology department at the sponsoring hospital are maintained using Microsoft SQL Server, a relational database management system designed for the enterprise environment. However, not all of the participating institutions were linked via this common clinical database or by an electronic health record at the time the study was conducted.

Barriers to Care

We modified a checklist of barriers to accessing health care for patients with a range of chronic conditions [33] to create a SCD-specific checklist [34]. The final checklist consists of 53 items organized into 8 categories including insurance, transportation, accommodations and accessibility, provider knowledge and attitudes, social support, individual barriers such as forgetting or difficulties understanding instructions, emotional barriers such as fear or anger, and barriers posed by SCD itself (eg, pain, fatigue). Participants check off any applicable barrier, yielding a total score ranging from 0 to 53. The checklist overall has demonstrated face validity and test-retest reliability (Pearson  r = 0.74, P < 0.05).

Depressive Symptoms

Adults with SCD completed the PHQ-9, the 9-item depression scale of the Patient Health Questionnaire [35]. The PHQ-9 is a tool for assisting primary care clinicians in assessing symptoms of depression, based on criteria from the Diagnostic and Statistical Manual 4th edition (DSM-IV [36]). The PHQ-9 asks about such symptoms as sleep disturbance and difficulty concentrating over the past 2 weeks with scores ranging from 0 (Not at all) to 3 (Every day). The total symptom count is based on the number of items in which the respondent answered as “more than half of days” or greater, and scores are categorized as reflecting no (< 10), mild (10–14), moderate (15–19) or severe (≥ 20) symptoms of depression. Respondents indicate how difficult the symptoms make it for them to engage in daily activities from 0 (Not difficult at all) to 3 (Extremely difficult). The sensitivity and diagnostic and criterion validity of the PHQ-9 have been established [37]. The internal consistency of the PHQ-9 is high, with α > 0.85 in several studies and 48-hour test-retest reliability of 0.84. The PHQ has been used widely, including with African-American and Hispanic populations, and with individuals with chronic conditions [38].

 

Symptoms of Anxiety

Participants completed the Generalized Anxiety Disorder 7-item (GAD-7) questionnaire for screening and measuring severity of generalized anxiety disorder [39]. The GAD-7 asks about such symptoms as feeling nervous, anxious, or on edge over the past two weeks. Scores from all 7 items are added to obtain a total score [40]. Cut-points of 5, 10, and 15 represent mild, moderate, and severe levels of anxiety symptoms. Respondents indicate how difficult the symptoms make it for them to engage in daily activities from 0 (Not difficult at all) to 3 (Extremely difficult). The internal consistency of the GAD-7 is excellent (α = 0.92). Test-retest reliability is also good (Pearson r = 0.83) as is procedural validity (intraclass correlation = 0.83). The GAD-7 has excellent sensitivity and specificity to identify generalized anxiety disorder [41].

Health-Related Quality of Life

Participants completed the SF-36, which asks about the patient’s health status in the past week [14]. Eight subscales include physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. Two summary measures, the Physical Component Summary and the Mental Component Summary, are calculated from 4 scales each. Use of the summary measures has been shown to increase the reliability of scores and improve the validity of scores in discriminating between physical and psychosocial outcomes [14]. Higher scores represent better HRQL, with a mean score of 50 (SD = 50) for the general population. Internal consistency estimates for the component summary scores are α > 0.89, item discriminant validity estimates are greater than 92.5% and 2-week test-retest reliability was excellent. Scores on the SF-36 have been divided into categories of HRQL functioning [42,43]. Participants in the impaired to very impaired category have scores ≤ mean – 1 SD while participants with average to above average functioning have scores > mean – 1 SD.

The SF-36 has been used extensively in observational and randomized studies for a range of illness conditions. In SCD, some aspects of HRQL as measured by the SF-36 improved for adult patients who responded to hydroxyurea [44]. Participants in the Pain in Sickle Cell Epidemiology Study scored lower than national norms on all SF-36 subscales except psychosocial functioning [45]. HRQL decreased significantly as daily pain intensity increased [45]. Further, women reported worse bodily pain compared with men [46].

Data Analyses

All biostatistical analyses were conducted using Stata 13 [47]. Continuous variables were examined for normality with measures of skewness and peakedness. All variables satisfied the assumptions of normality with the exception of barriers to health care and ED utilization. The variable barriers to health care was transformed using a square root transformation, resulting in a more normally distributed variable. ED utilization was dichotomized as 0–2 versus 3 or more ED visits in the previous 12 months, based on the distribution of utilization in the sample. The cutpoint of ≥ 3 annual ED visits is consistent with other literature on SCD clinical severity [48].

Descriptive statistics were computed to include means, standard deviations and frequencies. Sociodemographic variables (age, sex, insurance status [public or private] and income) were examined as potential covariates using Pearson correlations and t tests. Associations among emotional distress (anxiety and depression symptoms), clinical complications and ED utilization, barriers to health care, and the outcomes of the Physical and Mental Component Summary scores from the SF-36 were examined using Pearson correlations. We conducted stepwise regression with forward selection to determine models predictive of physical and mental HRQL. We tested the addition of each chosen variable (anxiety symptoms, depression symptoms, clinical complications, ED utilization, barriers to health care, age, sex, insurance status, and income), adding the variables (if any) that were most correlated with the outcome, and repeated the process until the model was not improved. A significance level of 0.05 was used for all statistical tests.

Results

Demographic and Clinical Characteristics

Table 1 shows the demographic characteristics of the 77 participating adults with SCD. Sixty percent were female. Patients ranged in age from 18 to 69 years, with a mean age of 31.6 (SD = 13.1) years. Consistent with the general SCD population, participants were predominantly black/African American. Over 66% of families reporting had a median household income of less than $30,000 annually, although the mean household size was 3 to 4 persons. The majority of the participants (57%) had some college and beyond, although 14% had not completed high school. Over 80% of participants were on public insurance.

The majority of patients (73%) were diagnosed with Hgb SS disease and the most common lifetime complication was pain, reported by almost all of participants (Table 1). The next most common complication was fever, followed by acute chest syndrome. Twenty-seven percent of participants were currently on the disease-modifying therapy hydroxyurea, while 61% had a lifetime history of transfusion therapy. These data were verified with information from the clinical database for 73 participants (95%).

The median number of ED visits in the previous year was 1 (range, 0–50), with 19 patients (25%) with zero visits. The median number of hospital days in the previous year was 13 (range, 0–81). Twenty-nine patients (38%) had no hospital days in the previous year. These data were verified with information from the clinical database for 53 participants (69%), since hospital and ED visits occurred at institutions not always linked with the clinical databases at the sponsoring hospitals.

Emotional Distress, Barriers to Care, and Health-Related Quality of Life

The mean score for the sample on the PHQ-9 was 7.2 (SD = 5.6, α = 0.86, Table 2). The prevalence of moderate to severe symptoms of depression (ie, scores ≥ 10) was 33% (n = 25). Twelve patients with moderate to severe symptoms (48%) reported that symptoms of depression created some difficulty in work, daily activities, or relationships, while 10 patients (40%) reported very much to extreme difficulty in work, daily activities, or relationships due to depression symptoms.

The mean score on the GAD-7 was 7.9 (SD = 6.0, α = 0.90, Table 2). The prevalence of moderate to severe symptoms of anxiety (scores ≥ 10) was 36.4% (n = 28). Fourteen patients with moderate to severe symptoms (50%) reported that anxiety symptoms created some difficulty in work, daily activities, or relationships. Twelve patients (43%) reported that symptoms created very much to extreme difficulty in work, daily activities, or relationships. Fifteen patients (29%) with moderate to severe symptoms of anxiety or depression exhibited comorbid anxiety and depression.

The mean Physical Component Summary score on the SF-36 was 53.6 (SD = 24.1, α = 0.94, Table 2). The prevalence of impaired to very impaired HRQL in the physical domain was 17% (n = 13). The mean Mental Component Summary score on the SF-36 for the sample was 50.1 (SD = 23.7, α = 0.93), with a prevalence of 16% (n = 12) in the impaired to very impaired range for HRQL in the mental domain.

The mean number of barriers from the barriers checklist was 9.2 (SD = 10.1) out of 53 possible. Sixty-five participants (86%) reported at least 1 barrier to accessing health care (Table 2). The most frequently cited barriers to care were provider knowledge and attitudes, followed by transportation, insurance, and access to services (eg, hours and location of services). Less frequently cited barriers to care were individual barriers, including memory, health literacy and motivation, as well as those related to SCD itself, ie, fatigue and pain.

Sociodemographic Variables, Emotional Distress, and Health-Related Quality of Life

Symptoms of anxiety and depression were highly correlated with one another, as would be expected (r = 0.75, P < 0.001). Physical and mental HRQL were significantly correlated with symptoms of depression (r = –0.67, P < 0.001 for physical HRQL component and r = –0.70 for mental HRQL component, P < 0.001), with impaired HRQL in both domains correlated with greater symptoms of depression. Physical and Mental Component Summary scores were significantly correlated with symptoms of anxiety (r = –0.58, P < 0.001 for the physical component and r = –0.62 for the mental component, P < 0.001), with impaired HRQL in both domains correlated with greater symptoms of anxiety. Ratings of difficulty with daily functioning from depressive symptoms were correlated with impaired HRQL in the physical (r = –0.46, P < 0.01) and mental domains (r = –0.52, P < 0.001). Ratings of difficulty with daily functioning from anxiety symptoms were also correlated with impaired HRQL in the physical (r = –0.58, P < 0.001) and mental domains (r = –0.63, P < 0.001). Reports of more barriers to health care were significantly correlated with reports of more depressive and anxiety symptoms (r = 0.53, P < 0.001 and r = 0.48, P < 0.001), with lower Mental Component Summary scores (r = –0.43, P < 0.05), and with more ED visits in the past year (r = 0.43, P < 0.05).

Relations Between Independent Variables and Outcomes

Results of regression analyses (Table 3) indicated that a model including depression symptoms, age, ED utilization, anxiety symptoms and sex predicted the physical component of HRQL (R² = 0.55, F(5, 66) = 15.8, P < 0.001). Increased symptoms of depression, older age and 3 or more ED visits in the previous 12 months were independently associated with lower ratings of physical HRQL, controlling for anxiety and sex. A model including depression symptoms, barriers to care, insurance status, lifetime complications of SCD and sex predicted the mental component of HRQL (R2 = 0.56, F(5, 66) = 16.7, P < 0.001). Increased symptoms of depression were independently associated with lower ratings of mental HRQL, controlling for barriers to care, insurance status, lifetime complications of SCD, and sex.

 

Discussion

Results of this study showed that as expected, symptoms of depression were independently associated with the mental component of HRQL, controlling for other variables. Symptoms of depression were also independently associated with the physical component of HRQL. The effect size for both models was moderate but comparable to effect sizes of other studies of predictive models of physical and mental HRQL in SCD [49]. Our findings were consistent with previous literature, with older age and increased ED utilization independently associated with lower ratings of physical HRQL, with sex and anxiety symptoms entering into the predictive model [15–18,44,45]. Contrary to our hypotheses, barriers to accessing health care were not independently associated with physical or mental HRQL but did contribute to the model for mental HRQL, as did clinical complications and private insurance status.

While our sample was similar to previous samples in mean age and percentage of women participants, our patients reported significantly higher physical HRQL scores, and a wider range of HRQL scores (eg, 53.6,
SD = 24.1 compared with 39.6, SD = 10.0 [16]). The mean Physical Component Summary score was in fact similar to the general population mean of 50. This may reflect improvements in quality of care and subsequent overall improved patient health and HRQL given that these data were collected in year 2 of the HRSA SCDTDP. As an SCDTDP grantee, we implemented goals to improve coordination of service delivery and to increase access to care. However, it should also be considered that there was a selection bias in our study, in favor of those with better HRQL. Nevertheless, as already noted, our findings are consistent with previous literature with regard to inter-relations between variables, ie, associations between lower physical HRQL ratings and symptoms of depression, older age, and increased ED utilization [15]. Future studies in SCD that directly evaluate reported access to a medical home in relation to HRQL are needed to assess the impact of access to care and care coordination on HRQL ratings.

Our use of a data collection tool that focused on lifetime rather than acute history of complications may have contributed to our failure to find a relation between clinical manifestations and physical HRQL. Further, we were not able to assess the effects of pain separately from other complications, since almost every participant reported a lifetime history of pain. However, our findings were consistent with those of researchers who have found psychosocial and sociodemographic factors, versus clinical manifestations, to be major influences on both physical and mental HRQL for individuals with SCD and other chronic and life-threatening conditions [15, 16, 50]. Our confidence is increased in this finding, given that we were able to verify self-reports of clinical manifestations with our clinical database. Our results contribute to the developing body of knowledge that emphasizes the importance of understanding the broad impact on the lives of adults of living with SCD, not just the physical symptomatology.

There has been limited research on barriers to accessing health care as associated with HRQL for SCD populations. Health care barriers have been identified for ethnic minorities, even within patient-centered medical homes, with minority status moderating the effect of barriers to care on HRQL [30]. Our findings that barriers to health care were correlated with depression and anxiety symptoms, mental HRQL, and greater ED utilization support the need to view SCD care within a biobehavioral framework. Health care provider negative attitudes and lack of knowledge were the most frequently cited barriers for adults in our study, particularly in the context of ED and inpatient care. These findings are similar to other studies that have highlighted the impact of these provider variables on quality of care [26,51]. We were not able to separate out effects of ethnic minority status, given that our patients were predominantly African American.

Contributors to poor HRQL that have been identified in SCD are poverty [42] and public insurance status [49]. While over half of our participants had family incomes of less than $30,000, despite a mean household size of 3 members, we did not find that income contributed to either of our models predicting physical or mental HRQL. Over half of our patients were well educated, which could have moderated the effect of their low incomes, but we did not measure other potential moderators such as active coping and supportive relationships [19]. These analyses were beyond the scope of our existing database, but future studies are needed on such resilience factors and processes. Our adults were predominantly on public insurance and we did find that private insurance status was positively associated with higher ratings of mental HRQL, consistent with other SCD research [49]. Taken together, our findings underscore the importance of considering the interplay between emotional distress, sociodemographic and clinical factors and quality of care in order to address risk factors for poor patient-reported outcomes [52,53].

 

There have not been previous reports of symptoms of emotional distress in SCD using the PHQ-9 and GAD-7, but both measures have been used widely for depression and anxiety screening, including with African-American populations. We selected these over other measures for their brevity, free availability, and psychometric properties. Our prevalence of moderate to severe depression and anxiety symptoms in the present study was similar to what has been found using other tools [2–8]. The PHQ-9 and GAD-7 also provide ratings of symptom interference on daily functioning, and we found that these ratings were associated with impaired physical and mental HRQL. Given that there generally are limited mental health resources in the communities where individuals with SCD reside and are treated, ratings of emotional distress and HRQL can be taken together to stratify those patients with the most immediate need for interventions. Further, screening can be used for early detection with the goal to intervene and prevent the progression of symptoms of emotional distress to long-term, disabling mental health disorders [54]. There is a need for innovative and cost-effective strategies for assessment and treatment of mental health symptoms and disorders for patients with SCD. One model for evidence-based practice in the management of emotional distress for patients with in SCD is the collaborative care model.

The collaborative care model integrates physical and mental health care in the patient-centered medical home and focuses on treating the whole person and family [55]. In this model, a care management staff (eg, nurse, social worker, psychologist) is integrated with the primary care team. The care management staff, in consultation with a psychiatrist, provides evidence-based care coordination, brief behavioral interventions, and support for other treatments, including medications. The effectiveness of collaborative care programs has been demonstrated for ethnic minority and safety net populations such as the SCD population, which is disproportionately low-income and on public insurance [56, 57]. Future research with SCD populations should investigate such interventions as the collaborative care model that addresses both emotional distress and barriers to care.

Limitations

Our results need to be interpreted with caution given the small sample size and the potential bias introduced by  non-random sampling. In addition, as our patients are from an urban setting, findings might not generalize to rural populations. This study was cross sectional so no inferences can be made with regard to causality and temporal relations between anxiety symptoms, barriers to care, and HRQL. Our strategy for measuring total clinical complications and barriers to care conserved power but it was not possible to evaluate if specific complications or barriers may have exerted a greater impact on HRQL compared with others. Similarly, other studies have examined specific domains of HRQL, while we limited our analysis to the Physical and Mental Component Summary scores. The utilization questionnaire was designed to assess only lifetime complications, not complications more proximal to the HRQL ratings.

Patient-reported outcomes, now widely accepted as outcome measures, elicit patients’ descriptions of the impact of their condition on their day-to-day lives [34, 58–60]. However, measures of mental health symptoms and HRQL may be subject to recall bias, measurement error, and confounding [61,62]. Nevertheless, a range of studies support the idea that mental health symptoms and  HRQL are distinct constructs, and that patients with physical and mental health symptoms are vulnerable to lower ratings of HRQL [63,64]. Disease-modifying therapies such as hydroxyurea can contribute to improved ratings of HRQL [44,65], but we were not able to evaluate the contribution of hydroxyurea to HRQL as it appears to have been underutilized in our sample.

Conclusion

We evaluated emotional distress and other variables in the context of a biobehavioral model of HRQL outcomes for adults with SCD. Integrating the patient's perspective of the impact of the disease and its treatment with assessment of clinical indications is critical to implementing and evaluating effective therapies [25]. However, there are conceptual challenges in determining what actually contributes to HRQL from the patient’s perspective in the context of genetic disorders such as SCD [50]. Our findings highlight the importance of incorporating comprehensive psychosocial screening in order to support optimal HRQL in SCD. Providers may be reluctant to include such screening if, as is often the case, mental health services are difficult to access. Models such as the collaborative care model, which include mental health interventions within the sickle cell center or primary care provider’s office, should be implented. Barriers to care and HRQL should also be routinely evaluated for patients with SCD. Use of disease-specific tools, such as the Adult Sickle Cell Quality of Life measurement system [66], may increase the specificity needed to detect differences within adults with SCD and improvements related to interventions, whether medical or psychosocial. Contributors to HRQL in SCD go beyond clinical manifestations to include psychological and social factors, as well as provider and health system variables. Research conducted within the framework of a comprehensive conceptual model of broad clinical and life effects associated with SCD can inform clinical applications that ultimately enhance HRQL for patients with SCD.

 

Acknowledgment: The authors wish to thank San Keller, PhD, for her helpful comments on a previous version of this manuscript.

Corresponding author: Marsha J. Treadwell, PhD, Hematology/Oncology Dept., UCSF Benioff Children’s Hospital Oakland, 747 52nd St., Oakland, CA 94609, mtreadwell@mail.cho.org.

Funding/support: This research was conducted as part of the National Initiative for Children’s Healthcare Quality (NICHQ) Working to Improve Sickle Cell Healthcare (WISCH) project. Further support came from a grant from the Health Resources and Services Administration (HRSA) Sickle Cell Disease Treatment Demonstration Project Grant No. U1EMC16492 and from the National Institutes of Health (NIH) Clinical and Translational Science Award UL1 RR024131. The views expressed in this publication do not necessarily reflect the views of WISCH, NICHQ, HRSA or NIH.

Financial disclosures: None.

Author contributions: conception and design, MJT; analysis and interpretation of data, MJT, GG; drafting of article, MJT, GG; critical revision of the article, MJT, KK, FB; statistical expertise, GG; obtaining of funding, MJT; administrative or technical support, KK, FB; collection and assembly of data, KK, FB.

From the UCSF Benioff Children’s Hospital Oakland, Oakland, CA

 

Abstract

• Objective: Emotional distress may adversely affect the course and complicate treatment for individuals with sickle cell disease (SCD). We evaluated variables associated with physical and mental components of health-related quality of life (HRQL) in SCD in the context of a biobehavioral model.
• Methods: We conducted a cross-sectional cohort study of 77 adults with SCD (18–69 years; 60% female; 73% Hgb SS) attending an urban, academic medical center.  We measured emotional distress (Patient Health Questionnaire–9, Generalized Anxiety Disorder 7-item scale), clinical complications and utilization, barriers to health care, sociodemo-graphics and HRQL (SF-36 Health Survey). We developed models predictive of physical and mental HRQL by conducting stepwise regression analyses.
• Results: Sample prevalence of moderate to severe depression and anxiety symptoms was 33% and 36%, respectively; prevalence of impaired physical and mental HRQL was 17% and 16%, respectively. Increased symptoms of depression, older age, and ≥ 3 emergency department visits in the previous 12 months were independently associated with lower ratings of physical HRQL, controlling for anxiety and sex.  Increased symptoms of depression were independently associated with lower ratings of mental HRQL, controlling for barriers to care, insurance status, lifetime complications of SCD, and sex.
• Conclusion: Emotional distress is an important contributor to both physical and mental HRQL for adults with SCD, although sociodemographic variables and barriers to care must also be considered. Innovative approaches that integrate mental health interventions with SCD clinical care are needed.

 

Emotional distress, including symptoms of depression and anxiety, may adversely affect the course and complicate the treatment of chronic physical conditions [1]. For patients with sickle cell disease (SCD), a group of inherited red blood cell conditions, symptoms of depression and anxiety are more prevalent compared with rates found in the general population [2–8]. The most common symptom of SCD is acute pain events, and other complications range from mild to life-threatening, including anemia, increased risk of infection, acute chest syndrome, stroke, skin ulcers, and pulmonary hypertension [9]. Depression in adults with SCD has been associated with increased sickle cell vaso-occlusive pain events, poor pain control, multiple blood transfusions, and prescription of the disease-modifying therapy hydroxyurea [4]. Adults with SCD and comorbid depression and anxiety had more daily pain and greater distress and interference from pain compared with those who did not have comorbid depression or anxiety [10]. Patients have linked emotional distress and episodes of illness [11], and research has found a relation between pain episodes and depression [12]. In a diary study, negative mood was significantly higher on pain days compared with non-pain days [13].

Studies examining the consequences of emotional distress on health-related quality of life (HRQL) for patients with SCD are emerging. Depressed adults with SCD rated their quality of life on the SF-36 Health Survey [14] as significantly poorer in all areas compared with non-depressed adults with SCD [15].  In regression models, depression was a stronger predictor of SF-36 scores than demographics, hemoglobin type, and pain measures. In a multi-site study [16], 1046 adults with SCD completed the SF-36. Increasing age was associated with significantly lower scores on all subscales except mental health, while female sex additionally contributed to diminished physical function and vitality scale scores in multivariate models [16]. The presence of a mood disorder was associated with bodily pain, and diminished vitality, social functioning, emotional role, and the mental component of HRQL. Medical complications other than pain were not associated with impaired HRQL. Anie and colleagues [17,18] have highlighted the contributions of sickle cell–related pain to diminished mood and HRQL, both in the acute hospital phase and 1 week post discharge.

A comprehensive literature review of patient-reported outcomes for adults with SCD revealed broad categories of the impact of SCD and its treatment on the lives of adults [19]. Categories included pain and pain management, emotional distress, poor social role functioning, diminished overall quality of life, and poor quality of care. Follow-up individual and group interviews with adults with SCD (n = 122) as well as individual interviews with their providers (n = 15) revealed findings consistent with the literature review on the major effects of pain on the lives of adults with SCD, interwoven with emotional distress, poor quality of care, and stigmatization [19].

In the present study, our goal was to describe variables associated with physical and mental HRQL in SCD within the context of the recently published comprehensive conceptual model of broad clinical and life effects associated with SCD [19]. The present analysis uses an existing clinical database and evaluates the effects of the relations between clinical complications of SCD, emotional distress, health care utilization, and HRQL. Our model includes barriers to health care that might prevent vulnerable patients from accessing needed health care services. Sociodemographic variables including ethnic and racial minority status and lower socioeconomic status and educational attainment may create barriers to health care for patients with SCD, as they do for individuals with other chronic conditions [20–23]. Over 60% of patients with SCD are on public insurance [24] and can have difficulties with accessing quality health care [25]. Negative provider attitudes and stigmatization when patients are seeking care for acute pain episodes have been highlighted by patients as major barriers to seeking health care [19,26–28]. In a qualitative study, 45 youth with SCD reported that competing school or peer-group activities, “feeling good,” poor patient-provider relationships, adverse clinic experiences, and forgetting were barriers to clinic attendance [29]. Limited research suggests that barriers to accessing health care are associated with poorer HRQL [30,31]; however no studies were identified that directly evaluated the relation between barriers to care and HRQL for populations with SCD.

We hypothesized that clinical complications of SCD, including pain, and barriers to accessing health care would be independently associated with the physical component of HRQL for adult patients with SCD, controlling for demographic variables. Further, we hypothesized that emotional distress, clinical complications of SCD, and barriers to accessing health care would be independently associated with the mental component of HRQL for adult patients with SCD, controlling for demographic variables.

 

Methods

Patient Recruitment

Participants were 18 years and older and were a subgroup selected from a larger prospective cohort enrolled in the Sickle Cell Disease Treatment Demonstration Program (SCDTDP) funded by the Health Resources and Services Administration (HRSA). As 1 of 7 SCDTDP grantees, our network collected common demographic, disease-related, and HRQL data as the other grantees to examine sickle cell health and health care [32]. Enrollment at our site was n = 115 from birth through adult, with data collection occurring at baseline in 2010 and annually through 2014. Participants were eligible for enrollment if they had any confirmed diagnosis of SCD and if they were seen at any facility treating SCD in the San Francisco Bay Area region. Interpreter services were available where English was a second language; however, no participant requested those services. The data collection site was an urban comprehensive sickle cell center. Participants were recruited through mailings, posted flyers, or were introduced to the project by their clinical providers. The institutional review boards of the sponsoring hospitals approved all procedures. This report describes analyses from the baseline data collected in 2010 and excludes pediatric patients under the age of 18 years, as we developed our conceptual model based on the adult SCD literature.

Procedures

Patients directly contacted the project coordinator or were introduced by their health care provider. The project coordinator explained the study in more detail, and if the patient agreed to participate, the project coordinator obtained thier informed consent. Participants completed the study materials in a private space in the clinic immediately after or were scheduled for a separate visit at a convenient time and location. Participants with known or observed difficulties with reading completed the questionnaires as an interview. We allowed participants who were unable to complete the forms in one visit to take them home or schedule a follow-up visit to complete them. We asked participants who took the questionnaires home to return them within 2 business days and provided them with a stamped addressed envelope. Participants were compensated with gift cards for their involvement.

Measures

Demographics and Clinical Characteristics

Participants completed an Individual Utilization Questionnaire created for the SCDTDP grantees [32], either as an interview or in paper and pencil format. Participants indicated their age, race and ethnicity, education level, type of insurance, and annual household income. They indicated the type of SCD, number of hospital days and emergency department (ED) visits in the previous 12 months, disease-modifying therapies including hydroxyurea or transfusions, and lifetime incidence of sickle cell–related complications. Complications included pain, acute chest syndrome, fever, severe infection, stroke, kidney damage, gallbladder attack, spleen problems and priapism. Medical data was verified by reviewing medical records when possible; the clinical databases in the hematology/oncology department at the sponsoring hospital are maintained using Microsoft SQL Server, a relational database management system designed for the enterprise environment. However, not all of the participating institutions were linked via this common clinical database or by an electronic health record at the time the study was conducted.

Barriers to Care

We modified a checklist of barriers to accessing health care for patients with a range of chronic conditions [33] to create a SCD-specific checklist [34]. The final checklist consists of 53 items organized into 8 categories including insurance, transportation, accommodations and accessibility, provider knowledge and attitudes, social support, individual barriers such as forgetting or difficulties understanding instructions, emotional barriers such as fear or anger, and barriers posed by SCD itself (eg, pain, fatigue). Participants check off any applicable barrier, yielding a total score ranging from 0 to 53. The checklist overall has demonstrated face validity and test-retest reliability (Pearson  r = 0.74, P < 0.05).

Depressive Symptoms

Adults with SCD completed the PHQ-9, the 9-item depression scale of the Patient Health Questionnaire [35]. The PHQ-9 is a tool for assisting primary care clinicians in assessing symptoms of depression, based on criteria from the Diagnostic and Statistical Manual 4th edition (DSM-IV [36]). The PHQ-9 asks about such symptoms as sleep disturbance and difficulty concentrating over the past 2 weeks with scores ranging from 0 (Not at all) to 3 (Every day). The total symptom count is based on the number of items in which the respondent answered as “more than half of days” or greater, and scores are categorized as reflecting no (< 10), mild (10–14), moderate (15–19) or severe (≥ 20) symptoms of depression. Respondents indicate how difficult the symptoms make it for them to engage in daily activities from 0 (Not difficult at all) to 3 (Extremely difficult). The sensitivity and diagnostic and criterion validity of the PHQ-9 have been established [37]. The internal consistency of the PHQ-9 is high, with α > 0.85 in several studies and 48-hour test-retest reliability of 0.84. The PHQ has been used widely, including with African-American and Hispanic populations, and with individuals with chronic conditions [38].

 

Symptoms of Anxiety

Participants completed the Generalized Anxiety Disorder 7-item (GAD-7) questionnaire for screening and measuring severity of generalized anxiety disorder [39]. The GAD-7 asks about such symptoms as feeling nervous, anxious, or on edge over the past two weeks. Scores from all 7 items are added to obtain a total score [40]. Cut-points of 5, 10, and 15 represent mild, moderate, and severe levels of anxiety symptoms. Respondents indicate how difficult the symptoms make it for them to engage in daily activities from 0 (Not difficult at all) to 3 (Extremely difficult). The internal consistency of the GAD-7 is excellent (α = 0.92). Test-retest reliability is also good (Pearson r = 0.83) as is procedural validity (intraclass correlation = 0.83). The GAD-7 has excellent sensitivity and specificity to identify generalized anxiety disorder [41].

Health-Related Quality of Life

Participants completed the SF-36, which asks about the patient’s health status in the past week [14]. Eight subscales include physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. Two summary measures, the Physical Component Summary and the Mental Component Summary, are calculated from 4 scales each. Use of the summary measures has been shown to increase the reliability of scores and improve the validity of scores in discriminating between physical and psychosocial outcomes [14]. Higher scores represent better HRQL, with a mean score of 50 (SD = 50) for the general population. Internal consistency estimates for the component summary scores are α > 0.89, item discriminant validity estimates are greater than 92.5% and 2-week test-retest reliability was excellent. Scores on the SF-36 have been divided into categories of HRQL functioning [42,43]. Participants in the impaired to very impaired category have scores ≤ mean – 1 SD while participants with average to above average functioning have scores > mean – 1 SD.

The SF-36 has been used extensively in observational and randomized studies for a range of illness conditions. In SCD, some aspects of HRQL as measured by the SF-36 improved for adult patients who responded to hydroxyurea [44]. Participants in the Pain in Sickle Cell Epidemiology Study scored lower than national norms on all SF-36 subscales except psychosocial functioning [45]. HRQL decreased significantly as daily pain intensity increased [45]. Further, women reported worse bodily pain compared with men [46].

Data Analyses

All biostatistical analyses were conducted using Stata 13 [47]. Continuous variables were examined for normality with measures of skewness and peakedness. All variables satisfied the assumptions of normality with the exception of barriers to health care and ED utilization. The variable barriers to health care was transformed using a square root transformation, resulting in a more normally distributed variable. ED utilization was dichotomized as 0–2 versus 3 or more ED visits in the previous 12 months, based on the distribution of utilization in the sample. The cutpoint of ≥ 3 annual ED visits is consistent with other literature on SCD clinical severity [48].

Descriptive statistics were computed to include means, standard deviations and frequencies. Sociodemographic variables (age, sex, insurance status [public or private] and income) were examined as potential covariates using Pearson correlations and t tests. Associations among emotional distress (anxiety and depression symptoms), clinical complications and ED utilization, barriers to health care, and the outcomes of the Physical and Mental Component Summary scores from the SF-36 were examined using Pearson correlations. We conducted stepwise regression with forward selection to determine models predictive of physical and mental HRQL. We tested the addition of each chosen variable (anxiety symptoms, depression symptoms, clinical complications, ED utilization, barriers to health care, age, sex, insurance status, and income), adding the variables (if any) that were most correlated with the outcome, and repeated the process until the model was not improved. A significance level of 0.05 was used for all statistical tests.

Results

Demographic and Clinical Characteristics

Table 1 shows the demographic characteristics of the 77 participating adults with SCD. Sixty percent were female. Patients ranged in age from 18 to 69 years, with a mean age of 31.6 (SD = 13.1) years. Consistent with the general SCD population, participants were predominantly black/African American. Over 66% of families reporting had a median household income of less than $30,000 annually, although the mean household size was 3 to 4 persons. The majority of the participants (57%) had some college and beyond, although 14% had not completed high school. Over 80% of participants were on public insurance.

The majority of patients (73%) were diagnosed with Hgb SS disease and the most common lifetime complication was pain, reported by almost all of participants (Table 1). The next most common complication was fever, followed by acute chest syndrome. Twenty-seven percent of participants were currently on the disease-modifying therapy hydroxyurea, while 61% had a lifetime history of transfusion therapy. These data were verified with information from the clinical database for 73 participants (95%).

The median number of ED visits in the previous year was 1 (range, 0–50), with 19 patients (25%) with zero visits. The median number of hospital days in the previous year was 13 (range, 0–81). Twenty-nine patients (38%) had no hospital days in the previous year. These data were verified with information from the clinical database for 53 participants (69%), since hospital and ED visits occurred at institutions not always linked with the clinical databases at the sponsoring hospitals.

Emotional Distress, Barriers to Care, and Health-Related Quality of Life

The mean score for the sample on the PHQ-9 was 7.2 (SD = 5.6, α = 0.86, Table 2). The prevalence of moderate to severe symptoms of depression (ie, scores ≥ 10) was 33% (n = 25). Twelve patients with moderate to severe symptoms (48%) reported that symptoms of depression created some difficulty in work, daily activities, or relationships, while 10 patients (40%) reported very much to extreme difficulty in work, daily activities, or relationships due to depression symptoms.

The mean score on the GAD-7 was 7.9 (SD = 6.0, α = 0.90, Table 2). The prevalence of moderate to severe symptoms of anxiety (scores ≥ 10) was 36.4% (n = 28). Fourteen patients with moderate to severe symptoms (50%) reported that anxiety symptoms created some difficulty in work, daily activities, or relationships. Twelve patients (43%) reported that symptoms created very much to extreme difficulty in work, daily activities, or relationships. Fifteen patients (29%) with moderate to severe symptoms of anxiety or depression exhibited comorbid anxiety and depression.

The mean Physical Component Summary score on the SF-36 was 53.6 (SD = 24.1, α = 0.94, Table 2). The prevalence of impaired to very impaired HRQL in the physical domain was 17% (n = 13). The mean Mental Component Summary score on the SF-36 for the sample was 50.1 (SD = 23.7, α = 0.93), with a prevalence of 16% (n = 12) in the impaired to very impaired range for HRQL in the mental domain.

The mean number of barriers from the barriers checklist was 9.2 (SD = 10.1) out of 53 possible. Sixty-five participants (86%) reported at least 1 barrier to accessing health care (Table 2). The most frequently cited barriers to care were provider knowledge and attitudes, followed by transportation, insurance, and access to services (eg, hours and location of services). Less frequently cited barriers to care were individual barriers, including memory, health literacy and motivation, as well as those related to SCD itself, ie, fatigue and pain.

Sociodemographic Variables, Emotional Distress, and Health-Related Quality of Life

Symptoms of anxiety and depression were highly correlated with one another, as would be expected (r = 0.75, P < 0.001). Physical and mental HRQL were significantly correlated with symptoms of depression (r = –0.67, P < 0.001 for physical HRQL component and r = –0.70 for mental HRQL component, P < 0.001), with impaired HRQL in both domains correlated with greater symptoms of depression. Physical and Mental Component Summary scores were significantly correlated with symptoms of anxiety (r = –0.58, P < 0.001 for the physical component and r = –0.62 for the mental component, P < 0.001), with impaired HRQL in both domains correlated with greater symptoms of anxiety. Ratings of difficulty with daily functioning from depressive symptoms were correlated with impaired HRQL in the physical (r = –0.46, P < 0.01) and mental domains (r = –0.52, P < 0.001). Ratings of difficulty with daily functioning from anxiety symptoms were also correlated with impaired HRQL in the physical (r = –0.58, P < 0.001) and mental domains (r = –0.63, P < 0.001). Reports of more barriers to health care were significantly correlated with reports of more depressive and anxiety symptoms (r = 0.53, P < 0.001 and r = 0.48, P < 0.001), with lower Mental Component Summary scores (r = –0.43, P < 0.05), and with more ED visits in the past year (r = 0.43, P < 0.05).

Relations Between Independent Variables and Outcomes

Results of regression analyses (Table 3) indicated that a model including depression symptoms, age, ED utilization, anxiety symptoms and sex predicted the physical component of HRQL (R² = 0.55, F(5, 66) = 15.8, P < 0.001). Increased symptoms of depression, older age and 3 or more ED visits in the previous 12 months were independently associated with lower ratings of physical HRQL, controlling for anxiety and sex. A model including depression symptoms, barriers to care, insurance status, lifetime complications of SCD and sex predicted the mental component of HRQL (R2 = 0.56, F(5, 66) = 16.7, P < 0.001). Increased symptoms of depression were independently associated with lower ratings of mental HRQL, controlling for barriers to care, insurance status, lifetime complications of SCD, and sex.

 

Discussion

Results of this study showed that as expected, symptoms of depression were independently associated with the mental component of HRQL, controlling for other variables. Symptoms of depression were also independently associated with the physical component of HRQL. The effect size for both models was moderate but comparable to effect sizes of other studies of predictive models of physical and mental HRQL in SCD [49]. Our findings were consistent with previous literature, with older age and increased ED utilization independently associated with lower ratings of physical HRQL, with sex and anxiety symptoms entering into the predictive model [15–18,44,45]. Contrary to our hypotheses, barriers to accessing health care were not independently associated with physical or mental HRQL but did contribute to the model for mental HRQL, as did clinical complications and private insurance status.

While our sample was similar to previous samples in mean age and percentage of women participants, our patients reported significantly higher physical HRQL scores, and a wider range of HRQL scores (eg, 53.6,
SD = 24.1 compared with 39.6, SD = 10.0 [16]). The mean Physical Component Summary score was in fact similar to the general population mean of 50. This may reflect improvements in quality of care and subsequent overall improved patient health and HRQL given that these data were collected in year 2 of the HRSA SCDTDP. As an SCDTDP grantee, we implemented goals to improve coordination of service delivery and to increase access to care. However, it should also be considered that there was a selection bias in our study, in favor of those with better HRQL. Nevertheless, as already noted, our findings are consistent with previous literature with regard to inter-relations between variables, ie, associations between lower physical HRQL ratings and symptoms of depression, older age, and increased ED utilization [15]. Future studies in SCD that directly evaluate reported access to a medical home in relation to HRQL are needed to assess the impact of access to care and care coordination on HRQL ratings.

Our use of a data collection tool that focused on lifetime rather than acute history of complications may have contributed to our failure to find a relation between clinical manifestations and physical HRQL. Further, we were not able to assess the effects of pain separately from other complications, since almost every participant reported a lifetime history of pain. However, our findings were consistent with those of researchers who have found psychosocial and sociodemographic factors, versus clinical manifestations, to be major influences on both physical and mental HRQL for individuals with SCD and other chronic and life-threatening conditions [15, 16, 50]. Our confidence is increased in this finding, given that we were able to verify self-reports of clinical manifestations with our clinical database. Our results contribute to the developing body of knowledge that emphasizes the importance of understanding the broad impact on the lives of adults of living with SCD, not just the physical symptomatology.

There has been limited research on barriers to accessing health care as associated with HRQL for SCD populations. Health care barriers have been identified for ethnic minorities, even within patient-centered medical homes, with minority status moderating the effect of barriers to care on HRQL [30]. Our findings that barriers to health care were correlated with depression and anxiety symptoms, mental HRQL, and greater ED utilization support the need to view SCD care within a biobehavioral framework. Health care provider negative attitudes and lack of knowledge were the most frequently cited barriers for adults in our study, particularly in the context of ED and inpatient care. These findings are similar to other studies that have highlighted the impact of these provider variables on quality of care [26,51]. We were not able to separate out effects of ethnic minority status, given that our patients were predominantly African American.

Contributors to poor HRQL that have been identified in SCD are poverty [42] and public insurance status [49]. While over half of our participants had family incomes of less than $30,000, despite a mean household size of 3 members, we did not find that income contributed to either of our models predicting physical or mental HRQL. Over half of our patients were well educated, which could have moderated the effect of their low incomes, but we did not measure other potential moderators such as active coping and supportive relationships [19]. These analyses were beyond the scope of our existing database, but future studies are needed on such resilience factors and processes. Our adults were predominantly on public insurance and we did find that private insurance status was positively associated with higher ratings of mental HRQL, consistent with other SCD research [49]. Taken together, our findings underscore the importance of considering the interplay between emotional distress, sociodemographic and clinical factors and quality of care in order to address risk factors for poor patient-reported outcomes [52,53].

 

There have not been previous reports of symptoms of emotional distress in SCD using the PHQ-9 and GAD-7, but both measures have been used widely for depression and anxiety screening, including with African-American populations. We selected these over other measures for their brevity, free availability, and psychometric properties. Our prevalence of moderate to severe depression and anxiety symptoms in the present study was similar to what has been found using other tools [2–8]. The PHQ-9 and GAD-7 also provide ratings of symptom interference on daily functioning, and we found that these ratings were associated with impaired physical and mental HRQL. Given that there generally are limited mental health resources in the communities where individuals with SCD reside and are treated, ratings of emotional distress and HRQL can be taken together to stratify those patients with the most immediate need for interventions. Further, screening can be used for early detection with the goal to intervene and prevent the progression of symptoms of emotional distress to long-term, disabling mental health disorders [54]. There is a need for innovative and cost-effective strategies for assessment and treatment of mental health symptoms and disorders for patients with SCD. One model for evidence-based practice in the management of emotional distress for patients with in SCD is the collaborative care model.

The collaborative care model integrates physical and mental health care in the patient-centered medical home and focuses on treating the whole person and family [55]. In this model, a care management staff (eg, nurse, social worker, psychologist) is integrated with the primary care team. The care management staff, in consultation with a psychiatrist, provides evidence-based care coordination, brief behavioral interventions, and support for other treatments, including medications. The effectiveness of collaborative care programs has been demonstrated for ethnic minority and safety net populations such as the SCD population, which is disproportionately low-income and on public insurance [56, 57]. Future research with SCD populations should investigate such interventions as the collaborative care model that addresses both emotional distress and barriers to care.

Limitations

Our results need to be interpreted with caution given the small sample size and the potential bias introduced by  non-random sampling. In addition, as our patients are from an urban setting, findings might not generalize to rural populations. This study was cross sectional so no inferences can be made with regard to causality and temporal relations between anxiety symptoms, barriers to care, and HRQL. Our strategy for measuring total clinical complications and barriers to care conserved power but it was not possible to evaluate if specific complications or barriers may have exerted a greater impact on HRQL compared with others. Similarly, other studies have examined specific domains of HRQL, while we limited our analysis to the Physical and Mental Component Summary scores. The utilization questionnaire was designed to assess only lifetime complications, not complications more proximal to the HRQL ratings.

Patient-reported outcomes, now widely accepted as outcome measures, elicit patients’ descriptions of the impact of their condition on their day-to-day lives [34, 58–60]. However, measures of mental health symptoms and HRQL may be subject to recall bias, measurement error, and confounding [61,62]. Nevertheless, a range of studies support the idea that mental health symptoms and  HRQL are distinct constructs, and that patients with physical and mental health symptoms are vulnerable to lower ratings of HRQL [63,64]. Disease-modifying therapies such as hydroxyurea can contribute to improved ratings of HRQL [44,65], but we were not able to evaluate the contribution of hydroxyurea to HRQL as it appears to have been underutilized in our sample.

Conclusion

We evaluated emotional distress and other variables in the context of a biobehavioral model of HRQL outcomes for adults with SCD. Integrating the patient's perspective of the impact of the disease and its treatment with assessment of clinical indications is critical to implementing and evaluating effective therapies [25]. However, there are conceptual challenges in determining what actually contributes to HRQL from the patient’s perspective in the context of genetic disorders such as SCD [50]. Our findings highlight the importance of incorporating comprehensive psychosocial screening in order to support optimal HRQL in SCD. Providers may be reluctant to include such screening if, as is often the case, mental health services are difficult to access. Models such as the collaborative care model, which include mental health interventions within the sickle cell center or primary care provider’s office, should be implented. Barriers to care and HRQL should also be routinely evaluated for patients with SCD. Use of disease-specific tools, such as the Adult Sickle Cell Quality of Life measurement system [66], may increase the specificity needed to detect differences within adults with SCD and improvements related to interventions, whether medical or psychosocial. Contributors to HRQL in SCD go beyond clinical manifestations to include psychological and social factors, as well as provider and health system variables. Research conducted within the framework of a comprehensive conceptual model of broad clinical and life effects associated with SCD can inform clinical applications that ultimately enhance HRQL for patients with SCD.

 

Acknowledgment: The authors wish to thank San Keller, PhD, for her helpful comments on a previous version of this manuscript.

Corresponding author: Marsha J. Treadwell, PhD, Hematology/Oncology Dept., UCSF Benioff Children’s Hospital Oakland, 747 52nd St., Oakland, CA 94609, mtreadwell@mail.cho.org.

Funding/support: This research was conducted as part of the National Initiative for Children’s Healthcare Quality (NICHQ) Working to Improve Sickle Cell Healthcare (WISCH) project. Further support came from a grant from the Health Resources and Services Administration (HRSA) Sickle Cell Disease Treatment Demonstration Project Grant No. U1EMC16492 and from the National Institutes of Health (NIH) Clinical and Translational Science Award UL1 RR024131. The views expressed in this publication do not necessarily reflect the views of WISCH, NICHQ, HRSA or NIH.

Financial disclosures: None.

Author contributions: conception and design, MJT; analysis and interpretation of data, MJT, GG; drafting of article, MJT, GG; critical revision of the article, MJT, KK, FB; statistical expertise, GG; obtaining of funding, MJT; administrative or technical support, KK, FB; collection and assembly of data, KK, FB.

From the UCSF Benioff Children’s Hospital Oakland, Oakland, CA

 

Abstract

• Objective: Emotional distress may adversely affect the course and complicate treatment for individuals with sickle cell disease (SCD). We evaluated variables associated with physical and mental components of health-related quality of life (HRQL) in SCD in the context of a biobehavioral model.
• Methods: We conducted a cross-sectional cohort study of 77 adults with SCD (18–69 years; 60% female; 73% Hgb SS) attending an urban, academic medical center.  We measured emotional distress (Patient Health Questionnaire–9, Generalized Anxiety Disorder 7-item scale), clinical complications and utilization, barriers to health care, sociodemo-graphics and HRQL (SF-36 Health Survey). We developed models predictive of physical and mental HRQL by conducting stepwise regression analyses.
• Results: Sample prevalence of moderate to severe depression and anxiety symptoms was 33% and 36%, respectively; prevalence of impaired physical and mental HRQL was 17% and 16%, respectively. Increased symptoms of depression, older age, and ≥ 3 emergency department visits in the previous 12 months were independently associated with lower ratings of physical HRQL, controlling for anxiety and sex.  Increased symptoms of depression were independently associated with lower ratings of mental HRQL, controlling for barriers to care, insurance status, lifetime complications of SCD, and sex.
• Conclusion: Emotional distress is an important contributor to both physical and mental HRQL for adults with SCD, although sociodemographic variables and barriers to care must also be considered. Innovative approaches that integrate mental health interventions with SCD clinical care are needed.

 

Emotional distress, including symptoms of depression and anxiety, may adversely affect the course and complicate the treatment of chronic physical conditions [1]. For patients with sickle cell disease (SCD), a group of inherited red blood cell conditions, symptoms of depression and anxiety are more prevalent compared with rates found in the general population [2–8]. The most common symptom of SCD is acute pain events, and other complications range from mild to life-threatening, including anemia, increased risk of infection, acute chest syndrome, stroke, skin ulcers, and pulmonary hypertension [9]. Depression in adults with SCD has been associated with increased sickle cell vaso-occlusive pain events, poor pain control, multiple blood transfusions, and prescription of the disease-modifying therapy hydroxyurea [4]. Adults with SCD and comorbid depression and anxiety had more daily pain and greater distress and interference from pain compared with those who did not have comorbid depression or anxiety [10]. Patients have linked emotional distress and episodes of illness [11], and research has found a relation between pain episodes and depression [12]. In a diary study, negative mood was significantly higher on pain days compared with non-pain days [13].

Studies examining the consequences of emotional distress on health-related quality of life (HRQL) for patients with SCD are emerging. Depressed adults with SCD rated their quality of life on the SF-36 Health Survey [14] as significantly poorer in all areas compared with non-depressed adults with SCD [15].  In regression models, depression was a stronger predictor of SF-36 scores than demographics, hemoglobin type, and pain measures. In a multi-site study [16], 1046 adults with SCD completed the SF-36. Increasing age was associated with significantly lower scores on all subscales except mental health, while female sex additionally contributed to diminished physical function and vitality scale scores in multivariate models [16]. The presence of a mood disorder was associated with bodily pain, and diminished vitality, social functioning, emotional role, and the mental component of HRQL. Medical complications other than pain were not associated with impaired HRQL. Anie and colleagues [17,18] have highlighted the contributions of sickle cell–related pain to diminished mood and HRQL, both in the acute hospital phase and 1 week post discharge.

A comprehensive literature review of patient-reported outcomes for adults with SCD revealed broad categories of the impact of SCD and its treatment on the lives of adults [19]. Categories included pain and pain management, emotional distress, poor social role functioning, diminished overall quality of life, and poor quality of care. Follow-up individual and group interviews with adults with SCD (n = 122) as well as individual interviews with their providers (n = 15) revealed findings consistent with the literature review on the major effects of pain on the lives of adults with SCD, interwoven with emotional distress, poor quality of care, and stigmatization [19].

In the present study, our goal was to describe variables associated with physical and mental HRQL in SCD within the context of the recently published comprehensive conceptual model of broad clinical and life effects associated with SCD [19]. The present analysis uses an existing clinical database and evaluates the effects of the relations between clinical complications of SCD, emotional distress, health care utilization, and HRQL. Our model includes barriers to health care that might prevent vulnerable patients from accessing needed health care services. Sociodemographic variables including ethnic and racial minority status and lower socioeconomic status and educational attainment may create barriers to health care for patients with SCD, as they do for individuals with other chronic conditions [20–23]. Over 60% of patients with SCD are on public insurance [24] and can have difficulties with accessing quality health care [25]. Negative provider attitudes and stigmatization when patients are seeking care for acute pain episodes have been highlighted by patients as major barriers to seeking health care [19,26–28]. In a qualitative study, 45 youth with SCD reported that competing school or peer-group activities, “feeling good,” poor patient-provider relationships, adverse clinic experiences, and forgetting were barriers to clinic attendance [29]. Limited research suggests that barriers to accessing health care are associated with poorer HRQL [30,31]; however no studies were identified that directly evaluated the relation between barriers to care and HRQL for populations with SCD.

We hypothesized that clinical complications of SCD, including pain, and barriers to accessing health care would be independently associated with the physical component of HRQL for adult patients with SCD, controlling for demographic variables. Further, we hypothesized that emotional distress, clinical complications of SCD, and barriers to accessing health care would be independently associated with the mental component of HRQL for adult patients with SCD, controlling for demographic variables.

 

Methods

Patient Recruitment

Participants were 18 years and older and were a subgroup selected from a larger prospective cohort enrolled in the Sickle Cell Disease Treatment Demonstration Program (SCDTDP) funded by the Health Resources and Services Administration (HRSA). As 1 of 7 SCDTDP grantees, our network collected common demographic, disease-related, and HRQL data as the other grantees to examine sickle cell health and health care [32]. Enrollment at our site was n = 115 from birth through adult, with data collection occurring at baseline in 2010 and annually through 2014. Participants were eligible for enrollment if they had any confirmed diagnosis of SCD and if they were seen at any facility treating SCD in the San Francisco Bay Area region. Interpreter services were available where English was a second language; however, no participant requested those services. The data collection site was an urban comprehensive sickle cell center. Participants were recruited through mailings, posted flyers, or were introduced to the project by their clinical providers. The institutional review boards of the sponsoring hospitals approved all procedures. This report describes analyses from the baseline data collected in 2010 and excludes pediatric patients under the age of 18 years, as we developed our conceptual model based on the adult SCD literature.

Procedures

Patients directly contacted the project coordinator or were introduced by their health care provider. The project coordinator explained the study in more detail, and if the patient agreed to participate, the project coordinator obtained thier informed consent. Participants completed the study materials in a private space in the clinic immediately after or were scheduled for a separate visit at a convenient time and location. Participants with known or observed difficulties with reading completed the questionnaires as an interview. We allowed participants who were unable to complete the forms in one visit to take them home or schedule a follow-up visit to complete them. We asked participants who took the questionnaires home to return them within 2 business days and provided them with a stamped addressed envelope. Participants were compensated with gift cards for their involvement.

Measures

Demographics and Clinical Characteristics

Participants completed an Individual Utilization Questionnaire created for the SCDTDP grantees [32], either as an interview or in paper and pencil format. Participants indicated their age, race and ethnicity, education level, type of insurance, and annual household income. They indicated the type of SCD, number of hospital days and emergency department (ED) visits in the previous 12 months, disease-modifying therapies including hydroxyurea or transfusions, and lifetime incidence of sickle cell–related complications. Complications included pain, acute chest syndrome, fever, severe infection, stroke, kidney damage, gallbladder attack, spleen problems and priapism. Medical data was verified by reviewing medical records when possible; the clinical databases in the hematology/oncology department at the sponsoring hospital are maintained using Microsoft SQL Server, a relational database management system designed for the enterprise environment. However, not all of the participating institutions were linked via this common clinical database or by an electronic health record at the time the study was conducted.

Barriers to Care

We modified a checklist of barriers to accessing health care for patients with a range of chronic conditions [33] to create a SCD-specific checklist [34]. The final checklist consists of 53 items organized into 8 categories including insurance, transportation, accommodations and accessibility, provider knowledge and attitudes, social support, individual barriers such as forgetting or difficulties understanding instructions, emotional barriers such as fear or anger, and barriers posed by SCD itself (eg, pain, fatigue). Participants check off any applicable barrier, yielding a total score ranging from 0 to 53. The checklist overall has demonstrated face validity and test-retest reliability (Pearson  r = 0.74, P < 0.05).

Depressive Symptoms

Adults with SCD completed the PHQ-9, the 9-item depression scale of the Patient Health Questionnaire [35]. The PHQ-9 is a tool for assisting primary care clinicians in assessing symptoms of depression, based on criteria from the Diagnostic and Statistical Manual 4th edition (DSM-IV [36]). The PHQ-9 asks about such symptoms as sleep disturbance and difficulty concentrating over the past 2 weeks with scores ranging from 0 (Not at all) to 3 (Every day). The total symptom count is based on the number of items in which the respondent answered as “more than half of days” or greater, and scores are categorized as reflecting no (< 10), mild (10–14), moderate (15–19) or severe (≥ 20) symptoms of depression. Respondents indicate how difficult the symptoms make it for them to engage in daily activities from 0 (Not difficult at all) to 3 (Extremely difficult). The sensitivity and diagnostic and criterion validity of the PHQ-9 have been established [37]. The internal consistency of the PHQ-9 is high, with α > 0.85 in several studies and 48-hour test-retest reliability of 0.84. The PHQ has been used widely, including with African-American and Hispanic populations, and with individuals with chronic conditions [38].

 

Symptoms of Anxiety

Participants completed the Generalized Anxiety Disorder 7-item (GAD-7) questionnaire for screening and measuring severity of generalized anxiety disorder [39]. The GAD-7 asks about such symptoms as feeling nervous, anxious, or on edge over the past two weeks. Scores from all 7 items are added to obtain a total score [40]. Cut-points of 5, 10, and 15 represent mild, moderate, and severe levels of anxiety symptoms. Respondents indicate how difficult the symptoms make it for them to engage in daily activities from 0 (Not difficult at all) to 3 (Extremely difficult). The internal consistency of the GAD-7 is excellent (α = 0.92). Test-retest reliability is also good (Pearson r = 0.83) as is procedural validity (intraclass correlation = 0.83). The GAD-7 has excellent sensitivity and specificity to identify generalized anxiety disorder [41].

Health-Related Quality of Life

Participants completed the SF-36, which asks about the patient’s health status in the past week [14]. Eight subscales include physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. Two summary measures, the Physical Component Summary and the Mental Component Summary, are calculated from 4 scales each. Use of the summary measures has been shown to increase the reliability of scores and improve the validity of scores in discriminating between physical and psychosocial outcomes [14]. Higher scores represent better HRQL, with a mean score of 50 (SD = 50) for the general population. Internal consistency estimates for the component summary scores are α > 0.89, item discriminant validity estimates are greater than 92.5% and 2-week test-retest reliability was excellent. Scores on the SF-36 have been divided into categories of HRQL functioning [42,43]. Participants in the impaired to very impaired category have scores ≤ mean – 1 SD while participants with average to above average functioning have scores > mean – 1 SD.

The SF-36 has been used extensively in observational and randomized studies for a range of illness conditions. In SCD, some aspects of HRQL as measured by the SF-36 improved for adult patients who responded to hydroxyurea [44]. Participants in the Pain in Sickle Cell Epidemiology Study scored lower than national norms on all SF-36 subscales except psychosocial functioning [45]. HRQL decreased significantly as daily pain intensity increased [45]. Further, women reported worse bodily pain compared with men [46].

Data Analyses

All biostatistical analyses were conducted using Stata 13 [47]. Continuous variables were examined for normality with measures of skewness and peakedness. All variables satisfied the assumptions of normality with the exception of barriers to health care and ED utilization. The variable barriers to health care was transformed using a square root transformation, resulting in a more normally distributed variable. ED utilization was dichotomized as 0–2 versus 3 or more ED visits in the previous 12 months, based on the distribution of utilization in the sample. The cutpoint of ≥ 3 annual ED visits is consistent with other literature on SCD clinical severity [48].

Descriptive statistics were computed to include means, standard deviations and frequencies. Sociodemographic variables (age, sex, insurance status [public or private] and income) were examined as potential covariates using Pearson correlations and t tests. Associations among emotional distress (anxiety and depression symptoms), clinical complications and ED utilization, barriers to health care, and the outcomes of the Physical and Mental Component Summary scores from the SF-36 were examined using Pearson correlations. We conducted stepwise regression with forward selection to determine models predictive of physical and mental HRQL. We tested the addition of each chosen variable (anxiety symptoms, depression symptoms, clinical complications, ED utilization, barriers to health care, age, sex, insurance status, and income), adding the variables (if any) that were most correlated with the outcome, and repeated the process until the model was not improved. A significance level of 0.05 was used for all statistical tests.

Results

Demographic and Clinical Characteristics

Table 1 shows the demographic characteristics of the 77 participating adults with SCD. Sixty percent were female. Patients ranged in age from 18 to 69 years, with a mean age of 31.6 (SD = 13.1) years. Consistent with the general SCD population, participants were predominantly black/African American. Over 66% of families reporting had a median household income of less than $30,000 annually, although the mean household size was 3 to 4 persons. The majority of the participants (57%) had some college and beyond, although 14% had not completed high school. Over 80% of participants were on public insurance.

The majority of patients (73%) were diagnosed with Hgb SS disease and the most common lifetime complication was pain, reported by almost all of participants (Table 1). The next most common complication was fever, followed by acute chest syndrome. Twenty-seven percent of participants were currently on the disease-modifying therapy hydroxyurea, while 61% had a lifetime history of transfusion therapy. These data were verified with information from the clinical database for 73 participants (95%).

The median number of ED visits in the previous year was 1 (range, 0–50), with 19 patients (25%) with zero visits. The median number of hospital days in the previous year was 13 (range, 0–81). Twenty-nine patients (38%) had no hospital days in the previous year. These data were verified with information from the clinical database for 53 participants (69%), since hospital and ED visits occurred at institutions not always linked with the clinical databases at the sponsoring hospitals.

Emotional Distress, Barriers to Care, and Health-Related Quality of Life

The mean score for the sample on the PHQ-9 was 7.2 (SD = 5.6, α = 0.86, Table 2). The prevalence of moderate to severe symptoms of depression (ie, scores ≥ 10) was 33% (n = 25). Twelve patients with moderate to severe symptoms (48%) reported that symptoms of depression created some difficulty in work, daily activities, or relationships, while 10 patients (40%) reported very much to extreme difficulty in work, daily activities, or relationships due to depression symptoms.

The mean score on the GAD-7 was 7.9 (SD = 6.0, α = 0.90, Table 2). The prevalence of moderate to severe symptoms of anxiety (scores ≥ 10) was 36.4% (n = 28). Fourteen patients with moderate to severe symptoms (50%) reported that anxiety symptoms created some difficulty in work, daily activities, or relationships. Twelve patients (43%) reported that symptoms created very much to extreme difficulty in work, daily activities, or relationships. Fifteen patients (29%) with moderate to severe symptoms of anxiety or depression exhibited comorbid anxiety and depression.

The mean Physical Component Summary score on the SF-36 was 53.6 (SD = 24.1, α = 0.94, Table 2). The prevalence of impaired to very impaired HRQL in the physical domain was 17% (n = 13). The mean Mental Component Summary score on the SF-36 for the sample was 50.1 (SD = 23.7, α = 0.93), with a prevalence of 16% (n = 12) in the impaired to very impaired range for HRQL in the mental domain.

The mean number of barriers from the barriers checklist was 9.2 (SD = 10.1) out of 53 possible. Sixty-five participants (86%) reported at least 1 barrier to accessing health care (Table 2). The most frequently cited barriers to care were provider knowledge and attitudes, followed by transportation, insurance, and access to services (eg, hours and location of services). Less frequently cited barriers to care were individual barriers, including memory, health literacy and motivation, as well as those related to SCD itself, ie, fatigue and pain.

Sociodemographic Variables, Emotional Distress, and Health-Related Quality of Life

Symptoms of anxiety and depression were highly correlated with one another, as would be expected (r = 0.75, P < 0.001). Physical and mental HRQL were significantly correlated with symptoms of depression (r = –0.67, P < 0.001 for physical HRQL component and r = –0.70 for mental HRQL component, P < 0.001), with impaired HRQL in both domains correlated with greater symptoms of depression. Physical and Mental Component Summary scores were significantly correlated with symptoms of anxiety (r = –0.58, P < 0.001 for the physical component and r = –0.62 for the mental component, P < 0.001), with impaired HRQL in both domains correlated with greater symptoms of anxiety. Ratings of difficulty with daily functioning from depressive symptoms were correlated with impaired HRQL in the physical (r = –0.46, P < 0.01) and mental domains (r = –0.52, P < 0.001). Ratings of difficulty with daily functioning from anxiety symptoms were also correlated with impaired HRQL in the physical (r = –0.58, P < 0.001) and mental domains (r = –0.63, P < 0.001). Reports of more barriers to health care were significantly correlated with reports of more depressive and anxiety symptoms (r = 0.53, P < 0.001 and r = 0.48, P < 0.001), with lower Mental Component Summary scores (r = –0.43, P < 0.05), and with more ED visits in the past year (r = 0.43, P < 0.05).

Relations Between Independent Variables and Outcomes

Results of regression analyses (Table 3) indicated that a model including depression symptoms, age, ED utilization, anxiety symptoms and sex predicted the physical component of HRQL (R² = 0.55, F(5, 66) = 15.8, P < 0.001). Increased symptoms of depression, older age and 3 or more ED visits in the previous 12 months were independently associated with lower ratings of physical HRQL, controlling for anxiety and sex. A model including depression symptoms, barriers to care, insurance status, lifetime complications of SCD and sex predicted the mental component of HRQL (R2 = 0.56, F(5, 66) = 16.7, P < 0.001). Increased symptoms of depression were independently associated with lower ratings of mental HRQL, controlling for barriers to care, insurance status, lifetime complications of SCD, and sex.

 

Discussion

Results of this study showed that as expected, symptoms of depression were independently associated with the mental component of HRQL, controlling for other variables. Symptoms of depression were also independently associated with the physical component of HRQL. The effect size for both models was moderate but comparable to effect sizes of other studies of predictive models of physical and mental HRQL in SCD [49]. Our findings were consistent with previous literature, with older age and increased ED utilization independently associated with lower ratings of physical HRQL, with sex and anxiety symptoms entering into the predictive model [15–18,44,45]. Contrary to our hypotheses, barriers to accessing health care were not independently associated with physical or mental HRQL but did contribute to the model for mental HRQL, as did clinical complications and private insurance status.

While our sample was similar to previous samples in mean age and percentage of women participants, our patients reported significantly higher physical HRQL scores, and a wider range of HRQL scores (eg, 53.6,
SD = 24.1 compared with 39.6, SD = 10.0 [16]). The mean Physical Component Summary score was in fact similar to the general population mean of 50. This may reflect improvements in quality of care and subsequent overall improved patient health and HRQL given that these data were collected in year 2 of the HRSA SCDTDP. As an SCDTDP grantee, we implemented goals to improve coordination of service delivery and to increase access to care. However, it should also be considered that there was a selection bias in our study, in favor of those with better HRQL. Nevertheless, as already noted, our findings are consistent with previous literature with regard to inter-relations between variables, ie, associations between lower physical HRQL ratings and symptoms of depression, older age, and increased ED utilization [15]. Future studies in SCD that directly evaluate reported access to a medical home in relation to HRQL are needed to assess the impact of access to care and care coordination on HRQL ratings.

Our use of a data collection tool that focused on lifetime rather than acute history of complications may have contributed to our failure to find a relation between clinical manifestations and physical HRQL. Further, we were not able to assess the effects of pain separately from other complications, since almost every participant reported a lifetime history of pain. However, our findings were consistent with those of researchers who have found psychosocial and sociodemographic factors, versus clinical manifestations, to be major influences on both physical and mental HRQL for individuals with SCD and other chronic and life-threatening conditions [15, 16, 50]. Our confidence is increased in this finding, given that we were able to verify self-reports of clinical manifestations with our clinical database. Our results contribute to the developing body of knowledge that emphasizes the importance of understanding the broad impact on the lives of adults of living with SCD, not just the physical symptomatology.

There has been limited research on barriers to accessing health care as associated with HRQL for SCD populations. Health care barriers have been identified for ethnic minorities, even within patient-centered medical homes, with minority status moderating the effect of barriers to care on HRQL [30]. Our findings that barriers to health care were correlated with depression and anxiety symptoms, mental HRQL, and greater ED utilization support the need to view SCD care within a biobehavioral framework. Health care provider negative attitudes and lack of knowledge were the most frequently cited barriers for adults in our study, particularly in the context of ED and inpatient care. These findings are similar to other studies that have highlighted the impact of these provider variables on quality of care [26,51]. We were not able to separate out effects of ethnic minority status, given that our patients were predominantly African American.

Contributors to poor HRQL that have been identified in SCD are poverty [42] and public insurance status [49]. While over half of our participants had family incomes of less than $30,000, despite a mean household size of 3 members, we did not find that income contributed to either of our models predicting physical or mental HRQL. Over half of our patients were well educated, which could have moderated the effect of their low incomes, but we did not measure other potential moderators such as active coping and supportive relationships [19]. These analyses were beyond the scope of our existing database, but future studies are needed on such resilience factors and processes. Our adults were predominantly on public insurance and we did find that private insurance status was positively associated with higher ratings of mental HRQL, consistent with other SCD research [49]. Taken together, our findings underscore the importance of considering the interplay between emotional distress, sociodemographic and clinical factors and quality of care in order to address risk factors for poor patient-reported outcomes [52,53].

 

There have not been previous reports of symptoms of emotional distress in SCD using the PHQ-9 and GAD-7, but both measures have been used widely for depression and anxiety screening, including with African-American populations. We selected these over other measures for their brevity, free availability, and psychometric properties. Our prevalence of moderate to severe depression and anxiety symptoms in the present study was similar to what has been found using other tools [2–8]. The PHQ-9 and GAD-7 also provide ratings of symptom interference on daily functioning, and we found that these ratings were associated with impaired physical and mental HRQL. Given that there generally are limited mental health resources in the communities where individuals with SCD reside and are treated, ratings of emotional distress and HRQL can be taken together to stratify those patients with the most immediate need for interventions. Further, screening can be used for early detection with the goal to intervene and prevent the progression of symptoms of emotional distress to long-term, disabling mental health disorders [54]. There is a need for innovative and cost-effective strategies for assessment and treatment of mental health symptoms and disorders for patients with SCD. One model for evidence-based practice in the management of emotional distress for patients with in SCD is the collaborative care model.

The collaborative care model integrates physical and mental health care in the patient-centered medical home and focuses on treating the whole person and family [55]. In this model, a care management staff (eg, nurse, social worker, psychologist) is integrated with the primary care team. The care management staff, in consultation with a psychiatrist, provides evidence-based care coordination, brief behavioral interventions, and support for other treatments, including medications. The effectiveness of collaborative care programs has been demonstrated for ethnic minority and safety net populations such as the SCD population, which is disproportionately low-income and on public insurance [56, 57]. Future research with SCD populations should investigate such interventions as the collaborative care model that addresses both emotional distress and barriers to care.

Limitations

Our results need to be interpreted with caution given the small sample size and the potential bias introduced by  non-random sampling. In addition, as our patients are from an urban setting, findings might not generalize to rural populations. This study was cross sectional so no inferences can be made with regard to causality and temporal relations between anxiety symptoms, barriers to care, and HRQL. Our strategy for measuring total clinical complications and barriers to care conserved power but it was not possible to evaluate if specific complications or barriers may have exerted a greater impact on HRQL compared with others. Similarly, other studies have examined specific domains of HRQL, while we limited our analysis to the Physical and Mental Component Summary scores. The utilization questionnaire was designed to assess only lifetime complications, not complications more proximal to the HRQL ratings.

Patient-reported outcomes, now widely accepted as outcome measures, elicit patients’ descriptions of the impact of their condition on their day-to-day lives [34, 58–60]. However, measures of mental health symptoms and HRQL may be subject to recall bias, measurement error, and confounding [61,62]. Nevertheless, a range of studies support the idea that mental health symptoms and  HRQL are distinct constructs, and that patients with physical and mental health symptoms are vulnerable to lower ratings of HRQL [63,64]. Disease-modifying therapies such as hydroxyurea can contribute to improved ratings of HRQL [44,65], but we were not able to evaluate the contribution of hydroxyurea to HRQL as it appears to have been underutilized in our sample.

Conclusion

We evaluated emotional distress and other variables in the context of a biobehavioral model of HRQL outcomes for adults with SCD. Integrating the patient's perspective of the impact of the disease and its treatment with assessment of clinical indications is critical to implementing and evaluating effective therapies [25]. However, there are conceptual challenges in determining what actually contributes to HRQL from the patient’s perspective in the context of genetic disorders such as SCD [50]. Our findings highlight the importance of incorporating comprehensive psychosocial screening in order to support optimal HRQL in SCD. Providers may be reluctant to include such screening if, as is often the case, mental health services are difficult to access. Models such as the collaborative care model, which include mental health interventions within the sickle cell center or primary care provider’s office, should be implented. Barriers to care and HRQL should also be routinely evaluated for patients with SCD. Use of disease-specific tools, such as the Adult Sickle Cell Quality of Life measurement system [66], may increase the specificity needed to detect differences within adults with SCD and improvements related to interventions, whether medical or psychosocial. Contributors to HRQL in SCD go beyond clinical manifestations to include psychological and social factors, as well as provider and health system variables. Research conducted within the framework of a comprehensive conceptual model of broad clinical and life effects associated with SCD can inform clinical applications that ultimately enhance HRQL for patients with SCD.

 

Acknowledgment: The authors wish to thank San Keller, PhD, for her helpful comments on a previous version of this manuscript.

Corresponding author: Marsha J. Treadwell, PhD, Hematology/Oncology Dept., UCSF Benioff Children’s Hospital Oakland, 747 52nd St., Oakland, CA 94609, mtreadwell@mail.cho.org.

Funding/support: This research was conducted as part of the National Initiative for Children’s Healthcare Quality (NICHQ) Working to Improve Sickle Cell Healthcare (WISCH) project. Further support came from a grant from the Health Resources and Services Administration (HRSA) Sickle Cell Disease Treatment Demonstration Project Grant No. U1EMC16492 and from the National Institutes of Health (NIH) Clinical and Translational Science Award UL1 RR024131. The views expressed in this publication do not necessarily reflect the views of WISCH, NICHQ, HRSA or NIH.

Financial disclosures: None.

Author contributions: conception and design, MJT; analysis and interpretation of data, MJT, GG; drafting of article, MJT, GG; critical revision of the article, MJT, KK, FB; statistical expertise, GG; obtaining of funding, MJT; administrative or technical support, KK, FB; collection and assembly of data, KK, FB.

Several hematology drugs approved by the US Food and Drug Administration (FDA) have recently undergone label changes to reflect newly reported adverse events.

Changes have been made to the labels for the JAK1/2 inhibitor ruxolitinib (Jakafi), the anti-CD20 monoclonal antibody obinutuzumab (Gazyva), the factor Xa inhibitor rivaroxaban (Xarelto), and the hematopoietic stem cell mobilizer plerixafor (Mozobil).

Plerixafor

Plerixafor is FDA-approved for use in combination with granulocyte-colony stimulating factor to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin lymphoma and multiple myeloma.

The product’s label was changed to include a new entry under the “Adverse Reactions” heading. Postmarketing experience suggested the drug may cause abnormal dreams and nightmares.

Rivaroxaban

Rivaroxaban is a factor Xa inhibitor that’s FDA-approved to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), to reduce the risk of recurrent DVT and PE, and to prevent DVT, which may lead to PE, in patients undergoing knee or hip replacement surgery.

Postmarketing experience has led to two changes to the “Adverse Reactions” section of rivaroxaban’s label. Thrombocytopenia has been added as an adverse reaction, and the term “cytolytic hepatitis” has been replaced with “hepatitis (including hepatocellular injury).”

Obinutuzumab

Obinutuzumab is a CD20-directed cytolytic antibody that is FDA-approved in combination with chlorambucil to treat patients with previously untreated chronic lymphocytic leukemia.

The “Warnings and Precautions” section of obinutuzumab’s label has been changed to reflect that fatal infections have been reported in patients who received the drug.

The label has also been changed to coincide with changes in trial data. The label now states that obinutuzumab caused grade 3 or 4 neutropenia in 33% of patients and grade 3 or 4 thrombocytopenia in 10% of patients.

Ruxolitinib

Ruxolitinib is a JAK1/JAK2 inhibitor that’s FDA-approved to treat patients with polycythemia vera (PV) who cannot tolerate or don’t respond to hydroxyurea, as well as patients with intermediate or high-risk myelofibrosis.

Ruxolitinib’s label now includes a warning that symptoms of myeloproliferative neoplasms may return about a week after discontinuing treatment. The label also advises healthcare professionals to discourage patients form interrupting or discontinuing ruxolitinib without consulting their physician.

In addition, a warning about the risk of non-melanoma skin cancer associated with ruxolitinib, as well as advice for informing patients of this risk, have been added to ruxolitinib’s label.

The label has undergone significant changes in sections 6.1, “Clinical Trials Experience in Myelofibrosis” and 6.2 “Clinical Trial Experience in Polycythemia Vera.” It now includes additional information on the risk of thrombocytopenia, anemia, and neutropenia.

Under the “Special Populations” heading, recommendations were added to reduce the drug’s dose in patients with PV and moderate or severe renal impairment, as well as PV patients with hepatic impairment.

Several hematology drugs approved by the US Food and Drug Administration (FDA) have recently undergone label changes to reflect newly reported adverse events.

Changes have been made to the labels for the JAK1/2 inhibitor ruxolitinib (Jakafi), the anti-CD20 monoclonal antibody obinutuzumab (Gazyva), the factor Xa inhibitor rivaroxaban (Xarelto), and the hematopoietic stem cell mobilizer plerixafor (Mozobil).

Plerixafor

Plerixafor is FDA-approved for use in combination with granulocyte-colony stimulating factor to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin lymphoma and multiple myeloma.

The product’s label was changed to include a new entry under the “Adverse Reactions” heading. Postmarketing experience suggested the drug may cause abnormal dreams and nightmares.

Rivaroxaban

Rivaroxaban is a factor Xa inhibitor that’s FDA-approved to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), to reduce the risk of recurrent DVT and PE, and to prevent DVT, which may lead to PE, in patients undergoing knee or hip replacement surgery.

Postmarketing experience has led to two changes to the “Adverse Reactions” section of rivaroxaban’s label. Thrombocytopenia has been added as an adverse reaction, and the term “cytolytic hepatitis” has been replaced with “hepatitis (including hepatocellular injury).”

Obinutuzumab

Obinutuzumab is a CD20-directed cytolytic antibody that is FDA-approved in combination with chlorambucil to treat patients with previously untreated chronic lymphocytic leukemia.

The “Warnings and Precautions” section of obinutuzumab’s label has been changed to reflect that fatal infections have been reported in patients who received the drug.

The label has also been changed to coincide with changes in trial data. The label now states that obinutuzumab caused grade 3 or 4 neutropenia in 33% of patients and grade 3 or 4 thrombocytopenia in 10% of patients.

Ruxolitinib

Ruxolitinib is a JAK1/JAK2 inhibitor that’s FDA-approved to treat patients with polycythemia vera (PV) who cannot tolerate or don’t respond to hydroxyurea, as well as patients with intermediate or high-risk myelofibrosis.

Ruxolitinib’s label now includes a warning that symptoms of myeloproliferative neoplasms may return about a week after discontinuing treatment. The label also advises healthcare professionals to discourage patients form interrupting or discontinuing ruxolitinib without consulting their physician.

In addition, a warning about the risk of non-melanoma skin cancer associated with ruxolitinib, as well as advice for informing patients of this risk, have been added to ruxolitinib’s label.

The label has undergone significant changes in sections 6.1, “Clinical Trials Experience in Myelofibrosis” and 6.2 “Clinical Trial Experience in Polycythemia Vera.” It now includes additional information on the risk of thrombocytopenia, anemia, and neutropenia.

Under the “Special Populations” heading, recommendations were added to reduce the drug’s dose in patients with PV and moderate or severe renal impairment, as well as PV patients with hepatic impairment.

Several hematology drugs approved by the US Food and Drug Administration (FDA) have recently undergone label changes to reflect newly reported adverse events.

Changes have been made to the labels for the JAK1/2 inhibitor ruxolitinib (Jakafi), the anti-CD20 monoclonal antibody obinutuzumab (Gazyva), the factor Xa inhibitor rivaroxaban (Xarelto), and the hematopoietic stem cell mobilizer plerixafor (Mozobil).

Plerixafor

Plerixafor is FDA-approved for use in combination with granulocyte-colony stimulating factor to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin lymphoma and multiple myeloma.

The product’s label was changed to include a new entry under the “Adverse Reactions” heading. Postmarketing experience suggested the drug may cause abnormal dreams and nightmares.

Rivaroxaban

Rivaroxaban is a factor Xa inhibitor that’s FDA-approved to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), to reduce the risk of recurrent DVT and PE, and to prevent DVT, which may lead to PE, in patients undergoing knee or hip replacement surgery.

Postmarketing experience has led to two changes to the “Adverse Reactions” section of rivaroxaban’s label. Thrombocytopenia has been added as an adverse reaction, and the term “cytolytic hepatitis” has been replaced with “hepatitis (including hepatocellular injury).”

Obinutuzumab

Obinutuzumab is a CD20-directed cytolytic antibody that is FDA-approved in combination with chlorambucil to treat patients with previously untreated chronic lymphocytic leukemia.

The “Warnings and Precautions” section of obinutuzumab’s label has been changed to reflect that fatal infections have been reported in patients who received the drug.

The label has also been changed to coincide with changes in trial data. The label now states that obinutuzumab caused grade 3 or 4 neutropenia in 33% of patients and grade 3 or 4 thrombocytopenia in 10% of patients.

Ruxolitinib

Ruxolitinib is a JAK1/JAK2 inhibitor that’s FDA-approved to treat patients with polycythemia vera (PV) who cannot tolerate or don’t respond to hydroxyurea, as well as patients with intermediate or high-risk myelofibrosis.

Ruxolitinib’s label now includes a warning that symptoms of myeloproliferative neoplasms may return about a week after discontinuing treatment. The label also advises healthcare professionals to discourage patients form interrupting or discontinuing ruxolitinib without consulting their physician.

In addition, a warning about the risk of non-melanoma skin cancer associated with ruxolitinib, as well as advice for informing patients of this risk, have been added to ruxolitinib’s label.

The label has undergone significant changes in sections 6.1, “Clinical Trials Experience in Myelofibrosis” and 6.2 “Clinical Trial Experience in Polycythemia Vera.” It now includes additional information on the risk of thrombocytopenia, anemia, and neutropenia.

Under the “Special Populations” heading, recommendations were added to reduce the drug’s dose in patients with PV and moderate or severe renal impairment, as well as PV patients with hepatic impairment.

New guidelines on nail psoriasis address four clinical manifestations of the disease. The recommendations by the Medical Board of the National Psoriasis Foundation appeared as a consensus statement in the January issue of JAMA Dermatology.

Limitations in clinical trial data make comparing treatments difficult, noted lead author Dr. Jeffrey J. Crowley of Bakersfield (Calif.) Dermatology and his associates. “There are limited data to evaluate or support the use of combination therapy in nail psoriasis. Thus, treatment options recommended in this review are monotherapy,” the guidelines authors added (JAMA Dermatol. 2015;151:87-94).

©Jim Pruitt/thinkstockphotos.com

To develop the guidelines, the research team searched PubMed for articles on nail psoriasis dating from Jan. 1, 1947 through May 11, 2014. They evaluated these studies for level of evidence based on recommendations for writing guidelines from Dr. Paul G. Shekelle of the VA West Los Angeles Medical Center and his associates (BMJ 1999;318:593-6).

They also polled the Medical Board of the National Psoriasis Foundation regarding their treatment approach for four clinical presentations of nail psoriasis:

• For treatment-naive patients with psoriasis of the nails only (affecting at least 3 of 10 fingernails), the board recommended initial treatment with high-potency topical corticosteroids (with or without calcipotriol), with intralesional corticosteroids as a secondary option. Intralesional corticosteroids have been used for decades, but clinical data supporting their use are “extremely limited,” the guidelines state.

• For extensive nail psoriasis (affecting at least five fingernails and causing moderate to severe pain) that has failed topical treatment, the board recommended adalimumab most enthusiastically, followed by etanercept, intralesional corticosteroids, ustekinumab, methotrexate sodium, and acitretin in decreasing order.

• For concurrent skin and nail disease without joint involvement (defined as skin disease on at least 8% of the body surface and moderately to severely painful dystrophy of at least 5 of 10 nails), the board strongly recommended adalimumab, etanercept, and ustekinumab, and also recommended methotrexate, acitretin, infliximab, and apremilast.

• For concurrent nail, skin, and joint involvement (defined as skin disease on 8% of the body surface, a history of dactylitis and morning stiffness (psoriatic arthritis), and severe, painful involvement of at least 5 of 10 nails), the board most strongly recommended adalimumab, followed by etanercept, ustekinumab, infliximab, methotrexate, apremilast, and golimumab.

Because nails grow slowly, psoriatic joint and skin disease often improve before nail psoriasis does, the authors noted. “Few studies show any significant improvement before 12 weeks, and several studies with etanercept, infliximab, and ustekinumab demonstrate continued improvement beyond 6 months,” they wrote.

About half of patients with psoriasis have some amount of nail involvement, and about 70% of patients with psoriatic arthritis have nail disease, according to the literature review. Dermatophyte infections can further complicate treatment of nail psoriasis, and immunosuppressive therapies can lead to onychomycosis in patients whose psoriasis includes the toenails, the authors added.

Dr. Crowley reported speaker and consulting honoraria from AbbVie, Abbott, and Amgen, and research funding from Abbott, AbbVie, Amgen, AstraZeneca, Celgene, Eli Lilly, Janssen Pharmaceutica, Merck, Pfizer, and Regeneron Pharmaceuticals. Four coauthors reported advisory, consulting, or financial relationships with Amgen, Abbott, Janssen Biotech Inc., Celgene, Novartis International AG, Abbvie, Merck, Celgene, Leo Pharma, Eli Lilly, Pfizer, and the National Psoriasis Foundation.

New guidelines on nail psoriasis address four clinical manifestations of the disease. The recommendations by the Medical Board of the National Psoriasis Foundation appeared as a consensus statement in the January issue of JAMA Dermatology.

Limitations in clinical trial data make comparing treatments difficult, noted lead author Dr. Jeffrey J. Crowley of Bakersfield (Calif.) Dermatology and his associates. “There are limited data to evaluate or support the use of combination therapy in nail psoriasis. Thus, treatment options recommended in this review are monotherapy,” the guidelines authors added (JAMA Dermatol. 2015;151:87-94).

©Jim Pruitt/thinkstockphotos.com

To develop the guidelines, the research team searched PubMed for articles on nail psoriasis dating from Jan. 1, 1947 through May 11, 2014. They evaluated these studies for level of evidence based on recommendations for writing guidelines from Dr. Paul G. Shekelle of the VA West Los Angeles Medical Center and his associates (BMJ 1999;318:593-6).

They also polled the Medical Board of the National Psoriasis Foundation regarding their treatment approach for four clinical presentations of nail psoriasis:

• For treatment-naive patients with psoriasis of the nails only (affecting at least 3 of 10 fingernails), the board recommended initial treatment with high-potency topical corticosteroids (with or without calcipotriol), with intralesional corticosteroids as a secondary option. Intralesional corticosteroids have been used for decades, but clinical data supporting their use are “extremely limited,” the guidelines state.

• For extensive nail psoriasis (affecting at least five fingernails and causing moderate to severe pain) that has failed topical treatment, the board recommended adalimumab most enthusiastically, followed by etanercept, intralesional corticosteroids, ustekinumab, methotrexate sodium, and acitretin in decreasing order.

• For concurrent skin and nail disease without joint involvement (defined as skin disease on at least 8% of the body surface and moderately to severely painful dystrophy of at least 5 of 10 nails), the board strongly recommended adalimumab, etanercept, and ustekinumab, and also recommended methotrexate, acitretin, infliximab, and apremilast.

• For concurrent nail, skin, and joint involvement (defined as skin disease on 8% of the body surface, a history of dactylitis and morning stiffness (psoriatic arthritis), and severe, painful involvement of at least 5 of 10 nails), the board most strongly recommended adalimumab, followed by etanercept, ustekinumab, infliximab, methotrexate, apremilast, and golimumab.

Because nails grow slowly, psoriatic joint and skin disease often improve before nail psoriasis does, the authors noted. “Few studies show any significant improvement before 12 weeks, and several studies with etanercept, infliximab, and ustekinumab demonstrate continued improvement beyond 6 months,” they wrote.

About half of patients with psoriasis have some amount of nail involvement, and about 70% of patients with psoriatic arthritis have nail disease, according to the literature review. Dermatophyte infections can further complicate treatment of nail psoriasis, and immunosuppressive therapies can lead to onychomycosis in patients whose psoriasis includes the toenails, the authors added.

Dr. Crowley reported speaker and consulting honoraria from AbbVie, Abbott, and Amgen, and research funding from Abbott, AbbVie, Amgen, AstraZeneca, Celgene, Eli Lilly, Janssen Pharmaceutica, Merck, Pfizer, and Regeneron Pharmaceuticals. Four coauthors reported advisory, consulting, or financial relationships with Amgen, Abbott, Janssen Biotech Inc., Celgene, Novartis International AG, Abbvie, Merck, Celgene, Leo Pharma, Eli Lilly, Pfizer, and the National Psoriasis Foundation.

New guidelines on nail psoriasis address four clinical manifestations of the disease. The recommendations by the Medical Board of the National Psoriasis Foundation appeared as a consensus statement in the January issue of JAMA Dermatology.

Limitations in clinical trial data make comparing treatments difficult, noted lead author Dr. Jeffrey J. Crowley of Bakersfield (Calif.) Dermatology and his associates. “There are limited data to evaluate or support the use of combination therapy in nail psoriasis. Thus, treatment options recommended in this review are monotherapy,” the guidelines authors added (JAMA Dermatol. 2015;151:87-94).

©Jim Pruitt/thinkstockphotos.com

To develop the guidelines, the research team searched PubMed for articles on nail psoriasis dating from Jan. 1, 1947 through May 11, 2014. They evaluated these studies for level of evidence based on recommendations for writing guidelines from Dr. Paul G. Shekelle of the VA West Los Angeles Medical Center and his associates (BMJ 1999;318:593-6).

They also polled the Medical Board of the National Psoriasis Foundation regarding their treatment approach for four clinical presentations of nail psoriasis:

• For treatment-naive patients with psoriasis of the nails only (affecting at least 3 of 10 fingernails), the board recommended initial treatment with high-potency topical corticosteroids (with or without calcipotriol), with intralesional corticosteroids as a secondary option. Intralesional corticosteroids have been used for decades, but clinical data supporting their use are “extremely limited,” the guidelines state.

• For extensive nail psoriasis (affecting at least five fingernails and causing moderate to severe pain) that has failed topical treatment, the board recommended adalimumab most enthusiastically, followed by etanercept, intralesional corticosteroids, ustekinumab, methotrexate sodium, and acitretin in decreasing order.

• For concurrent skin and nail disease without joint involvement (defined as skin disease on at least 8% of the body surface and moderately to severely painful dystrophy of at least 5 of 10 nails), the board strongly recommended adalimumab, etanercept, and ustekinumab, and also recommended methotrexate, acitretin, infliximab, and apremilast.

• For concurrent nail, skin, and joint involvement (defined as skin disease on 8% of the body surface, a history of dactylitis and morning stiffness (psoriatic arthritis), and severe, painful involvement of at least 5 of 10 nails), the board most strongly recommended adalimumab, followed by etanercept, ustekinumab, infliximab, methotrexate, apremilast, and golimumab.

Because nails grow slowly, psoriatic joint and skin disease often improve before nail psoriasis does, the authors noted. “Few studies show any significant improvement before 12 weeks, and several studies with etanercept, infliximab, and ustekinumab demonstrate continued improvement beyond 6 months,” they wrote.

About half of patients with psoriasis have some amount of nail involvement, and about 70% of patients with psoriatic arthritis have nail disease, according to the literature review. Dermatophyte infections can further complicate treatment of nail psoriasis, and immunosuppressive therapies can lead to onychomycosis in patients whose psoriasis includes the toenails, the authors added.

Dr. Crowley reported speaker and consulting honoraria from AbbVie, Abbott, and Amgen, and research funding from Abbott, AbbVie, Amgen, AstraZeneca, Celgene, Eli Lilly, Janssen Pharmaceutica, Merck, Pfizer, and Regeneron Pharmaceuticals. Four coauthors reported advisory, consulting, or financial relationships with Amgen, Abbott, Janssen Biotech Inc., Celgene, Novartis International AG, Abbvie, Merck, Celgene, Leo Pharma, Eli Lilly, Pfizer, and the National Psoriasis Foundation.

CHICAGO – A single set of intramuscular injections of stromal cell–derived factor-1 in patients with critical limb ischemia showed safety as well as evidence of efficacy through 12 months of follow-up in the STOP-CLI trial.

“Patients treated with JVS-100 demonstrated dose-dependent improvement across multiple patient-centered outcomes, including pain, quality of life, and wound healing, with less change in macrovascular objective measures in this small study,” Dr. Melina R. Kibbe reported at the American Heart Association scientific sessions. JVS-100 is a nonviral plasmid encoding human stromal cell–derived factor-1 (SDF-1), a natural chemokine protein that promotes angiogenesis by recruiting endothelial progenitor cells from the bone marrow to ischemic sites, explained Dr. Kibbe, professor and vice chair of surgical research and deputy director of the Simpson Querrey Institute for BioNanotechnology at Northwestern University, Chicago.

STOP-CLI was an exploratory, phase IIa, double-blind, first-in-humans study involving 48 patients with Rutherford classification 4 or 5 critical climb ischemia (CLI). All had an ankle-brachial index of 0.4 or lower, an ankle systolic blood pressure of 70 mm Hg or less or a toe systolic blood pressure of 50 or less, and were poor candidates for surgical revascularization. None had Buerger’s disease.

Participants were randomized to one of four study arms, and within each study arm further randomized 3:1 to stromal cell–derived factor-1 (SDF-1) or placebo injections. The patients received either 8 or 16 injections, each containing either 0.5 or 1.0 mg of SDF-1 or placebo. The injections, given in a single session, were placed at least 0.5 cm apart throughout the ischemic area of the affected limb.

By chance, most patients randomized to the placebo group were Rutherford 4, a category of CLI defined by rest pain, while the majority in the active treatment arms were Rutherford 5, a more severe disease manifestation characterized by ulcers. As a consequence, the SDF-1 recipients also had far larger nonhealing wounds, with an average area of 6.4 cm^2, compared with 1.5 cm^2, in controls.

The SDF-1 injections proved safe and were well tolerated, with no treatment-related serious adverse events and no safety signals evident in the laboratory results.

Turning to efficacy endpoints, Dr. Kibbe said self-rated visual analog scale pain scores showed clear, dose-dependent improvement over time in the SDF-1 treatment cohorts and no change in controls.

Similarly, the active treatment groups showed improved quality of life scores on all domains of the Short Form-36: physical functioning, bodily pain, general health, social functioning, energy/fatigue, emotional well-being, and overall physical and mental health, the surgeon continued.

Wound area decreased significantly in the SDF-1-treated groups, with the biggest reduction – more than 8 cm² – being noted in the three patients who received eight 1-mg injections. That was also the group with the largest wounds at baseline, with an average area of 11.4 cm².

Of note, the major limb amputation rate was “remarkably low” for patients with such severe CLI, according to Dr. Kibbe. The rate was less than 10% over the course of 12 months, with one patient in each of the four active treatment arms having a major amputation at time intervals of 58-112 days post injection. No major limb amputations occurred in the control group.

There was a hint of improvement with SDF-1 therapy over placebo in ankle-brachial index and transcutaneous oxygen pressure, but the between-group differences were too narrow in this study to allow for any conclusions. That must await planned much larger phase III trials, according to Dr. Kibbe.

Audience members, citing the numerous failures of once-promising stem cell therapies for CLI at phase III testing over the last 10-15 years, wondered why Dr. Kibbe thinks SDF-1 will fare any better.

“This is much debated and discussed among all the people involved in these kinds of trials,” she replied. “I’d say, briefly, that a lot of it has to do with patient selection. I think when you have a mixed bag of patients in a trial, including patients with Buerger’s disease, treated in multiple different countries, using different definitions of when to amputate, all those things come into play and could account for why those phase III trials were not successful.”

“Having been involved in lots of the different gene- and cell-based therapy trials, I think one of the unique benefits of this therapy is that it kind of bridges between the two. SDF-1 basically homes your endothelial progenitor cells to the site of ischemic injury for enhanced vasculogenesis. But SDF-1 also has direct effects on endothelial cells, including stimulating proliferation and preventing apoptosis,” she added.

 

JVS-100 has also successfully completed a phase II clinical trial for the treatment of heart failure. In addition, the agent is being developed as a treatment for acute MI, chronic angina, and for muscle regeneration.

The STOP-CLI study was sponsored by Juventas Therapeutics. Dr. Kibbe reported serving as a consultant to Johnson & Johnson/Cordis and Pluristem.

bjancin@frontlinemedcom.com

CHICAGO – A single set of intramuscular injections of stromal cell–derived factor-1 in patients with critical limb ischemia showed safety as well as evidence of efficacy through 12 months of follow-up in the STOP-CLI trial.

“Patients treated with JVS-100 demonstrated dose-dependent improvement across multiple patient-centered outcomes, including pain, quality of life, and wound healing, with less change in macrovascular objective measures in this small study,” Dr. Melina R. Kibbe reported at the American Heart Association scientific sessions. JVS-100 is a nonviral plasmid encoding human stromal cell–derived factor-1 (SDF-1), a natural chemokine protein that promotes angiogenesis by recruiting endothelial progenitor cells from the bone marrow to ischemic sites, explained Dr. Kibbe, professor and vice chair of surgical research and deputy director of the Simpson Querrey Institute for BioNanotechnology at Northwestern University, Chicago.

STOP-CLI was an exploratory, phase IIa, double-blind, first-in-humans study involving 48 patients with Rutherford classification 4 or 5 critical climb ischemia (CLI). All had an ankle-brachial index of 0.4 or lower, an ankle systolic blood pressure of 70 mm Hg or less or a toe systolic blood pressure of 50 or less, and were poor candidates for surgical revascularization. None had Buerger’s disease.

Participants were randomized to one of four study arms, and within each study arm further randomized 3:1 to stromal cell–derived factor-1 (SDF-1) or placebo injections. The patients received either 8 or 16 injections, each containing either 0.5 or 1.0 mg of SDF-1 or placebo. The injections, given in a single session, were placed at least 0.5 cm apart throughout the ischemic area of the affected limb.

By chance, most patients randomized to the placebo group were Rutherford 4, a category of CLI defined by rest pain, while the majority in the active treatment arms were Rutherford 5, a more severe disease manifestation characterized by ulcers. As a consequence, the SDF-1 recipients also had far larger nonhealing wounds, with an average area of 6.4 cm^2, compared with 1.5 cm^2, in controls.

The SDF-1 injections proved safe and were well tolerated, with no treatment-related serious adverse events and no safety signals evident in the laboratory results.

Turning to efficacy endpoints, Dr. Kibbe said self-rated visual analog scale pain scores showed clear, dose-dependent improvement over time in the SDF-1 treatment cohorts and no change in controls.

Similarly, the active treatment groups showed improved quality of life scores on all domains of the Short Form-36: physical functioning, bodily pain, general health, social functioning, energy/fatigue, emotional well-being, and overall physical and mental health, the surgeon continued.

Wound area decreased significantly in the SDF-1-treated groups, with the biggest reduction – more than 8 cm² – being noted in the three patients who received eight 1-mg injections. That was also the group with the largest wounds at baseline, with an average area of 11.4 cm².

Of note, the major limb amputation rate was “remarkably low” for patients with such severe CLI, according to Dr. Kibbe. The rate was less than 10% over the course of 12 months, with one patient in each of the four active treatment arms having a major amputation at time intervals of 58-112 days post injection. No major limb amputations occurred in the control group.

There was a hint of improvement with SDF-1 therapy over placebo in ankle-brachial index and transcutaneous oxygen pressure, but the between-group differences were too narrow in this study to allow for any conclusions. That must await planned much larger phase III trials, according to Dr. Kibbe.

Audience members, citing the numerous failures of once-promising stem cell therapies for CLI at phase III testing over the last 10-15 years, wondered why Dr. Kibbe thinks SDF-1 will fare any better.

“This is much debated and discussed among all the people involved in these kinds of trials,” she replied. “I’d say, briefly, that a lot of it has to do with patient selection. I think when you have a mixed bag of patients in a trial, including patients with Buerger’s disease, treated in multiple different countries, using different definitions of when to amputate, all those things come into play and could account for why those phase III trials were not successful.”

“Having been involved in lots of the different gene- and cell-based therapy trials, I think one of the unique benefits of this therapy is that it kind of bridges between the two. SDF-1 basically homes your endothelial progenitor cells to the site of ischemic injury for enhanced vasculogenesis. But SDF-1 also has direct effects on endothelial cells, including stimulating proliferation and preventing apoptosis,” she added.

 

JVS-100 has also successfully completed a phase II clinical trial for the treatment of heart failure. In addition, the agent is being developed as a treatment for acute MI, chronic angina, and for muscle regeneration.

The STOP-CLI study was sponsored by Juventas Therapeutics. Dr. Kibbe reported serving as a consultant to Johnson & Johnson/Cordis and Pluristem.

bjancin@frontlinemedcom.com

CHICAGO – A single set of intramuscular injections of stromal cell–derived factor-1 in patients with critical limb ischemia showed safety as well as evidence of efficacy through 12 months of follow-up in the STOP-CLI trial.

“Patients treated with JVS-100 demonstrated dose-dependent improvement across multiple patient-centered outcomes, including pain, quality of life, and wound healing, with less change in macrovascular objective measures in this small study,” Dr. Melina R. Kibbe reported at the American Heart Association scientific sessions. JVS-100 is a nonviral plasmid encoding human stromal cell–derived factor-1 (SDF-1), a natural chemokine protein that promotes angiogenesis by recruiting endothelial progenitor cells from the bone marrow to ischemic sites, explained Dr. Kibbe, professor and vice chair of surgical research and deputy director of the Simpson Querrey Institute for BioNanotechnology at Northwestern University, Chicago.

STOP-CLI was an exploratory, phase IIa, double-blind, first-in-humans study involving 48 patients with Rutherford classification 4 or 5 critical climb ischemia (CLI). All had an ankle-brachial index of 0.4 or lower, an ankle systolic blood pressure of 70 mm Hg or less or a toe systolic blood pressure of 50 or less, and were poor candidates for surgical revascularization. None had Buerger’s disease.

Participants were randomized to one of four study arms, and within each study arm further randomized 3:1 to stromal cell–derived factor-1 (SDF-1) or placebo injections. The patients received either 8 or 16 injections, each containing either 0.5 or 1.0 mg of SDF-1 or placebo. The injections, given in a single session, were placed at least 0.5 cm apart throughout the ischemic area of the affected limb.

By chance, most patients randomized to the placebo group were Rutherford 4, a category of CLI defined by rest pain, while the majority in the active treatment arms were Rutherford 5, a more severe disease manifestation characterized by ulcers. As a consequence, the SDF-1 recipients also had far larger nonhealing wounds, with an average area of 6.4 cm^2, compared with 1.5 cm^2, in controls.

The SDF-1 injections proved safe and were well tolerated, with no treatment-related serious adverse events and no safety signals evident in the laboratory results.

Turning to efficacy endpoints, Dr. Kibbe said self-rated visual analog scale pain scores showed clear, dose-dependent improvement over time in the SDF-1 treatment cohorts and no change in controls.

Similarly, the active treatment groups showed improved quality of life scores on all domains of the Short Form-36: physical functioning, bodily pain, general health, social functioning, energy/fatigue, emotional well-being, and overall physical and mental health, the surgeon continued.

Wound area decreased significantly in the SDF-1-treated groups, with the biggest reduction – more than 8 cm² – being noted in the three patients who received eight 1-mg injections. That was also the group with the largest wounds at baseline, with an average area of 11.4 cm².

Of note, the major limb amputation rate was “remarkably low” for patients with such severe CLI, according to Dr. Kibbe. The rate was less than 10% over the course of 12 months, with one patient in each of the four active treatment arms having a major amputation at time intervals of 58-112 days post injection. No major limb amputations occurred in the control group.

There was a hint of improvement with SDF-1 therapy over placebo in ankle-brachial index and transcutaneous oxygen pressure, but the between-group differences were too narrow in this study to allow for any conclusions. That must await planned much larger phase III trials, according to Dr. Kibbe.

Audience members, citing the numerous failures of once-promising stem cell therapies for CLI at phase III testing over the last 10-15 years, wondered why Dr. Kibbe thinks SDF-1 will fare any better.

“This is much debated and discussed among all the people involved in these kinds of trials,” she replied. “I’d say, briefly, that a lot of it has to do with patient selection. I think when you have a mixed bag of patients in a trial, including patients with Buerger’s disease, treated in multiple different countries, using different definitions of when to amputate, all those things come into play and could account for why those phase III trials were not successful.”

“Having been involved in lots of the different gene- and cell-based therapy trials, I think one of the unique benefits of this therapy is that it kind of bridges between the two. SDF-1 basically homes your endothelial progenitor cells to the site of ischemic injury for enhanced vasculogenesis. But SDF-1 also has direct effects on endothelial cells, including stimulating proliferation and preventing apoptosis,” she added.

 

JVS-100 has also successfully completed a phase II clinical trial for the treatment of heart failure. In addition, the agent is being developed as a treatment for acute MI, chronic angina, and for muscle regeneration.

The STOP-CLI study was sponsored by Juventas Therapeutics. Dr. Kibbe reported serving as a consultant to Johnson & Johnson/Cordis and Pluristem.

bjancin@frontlinemedcom.com

Patients with atrial fibrillation who had CHA₂DS₂-VASc scores of 1 were at lower risk of ischemic stroke than previously reported, according to a retrospective analysis of hospital registry data. The research appeared online January 19 in the Journal of American College of Cardiology.

Depending on the definition of stroke used, risk was 0.1% to 0.2% in women and 0.5% to 0.7% in men – so low that oral anticoagulants (OACs) would not be expected to benefit patients of either sex, said Dr. Leif Friberg at the Karolinska Institute in Stockholm and his associates. Past studies had potentially overestimated the risk of stroke in this population, which “may have led to unnecessary, and potentially harmful, OAC treatment of low-risk patients,” they said.

European and U.S. guidelines both recommend using the CHA₂DS₂-VASc (heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female) scoring system to assess stroke risk in patients with atrial fibrillation (AF). But past studies have reported a threefold variation (ranging from 0.6% to greater than 2.0%) in stroke risk among AF patients with CHA₂DS₂-VASc scores of 1 who were not receiving OAC, the researchers noted. Anticoagulation therapy is likely to benefit AF patients whose annual risk of stroke exceeds 1%, but not patients whose risk is only 0.6%, they added.

Their study, which included 140,420 patients in Sweden with nonvalvular AF, assessed the effect of varying definitions of stroke on estimates of stroke risk. Using a broad definition that included ischemic stroke, transient ischemic attack (TIA), and pulmonary embolism led to a 44% greater annual risk of stroke than if only ischemic strokes were considered, the investigators reported. They disagreed with classifying pulmonary embolism events and TIAs as strokes, as some past studies have done. “Primary prevention of pulmonary embolism among patients with AF has, to the best of our knowledge, not been studied and is not an approved indication for OAC treatment,” they said. “We also did not find it relevant to count TIA as an endpoint in studies that describe stroke risk. As a diagnosis, TIA is difficult to validate.”

Several Swedish foundations supported the study. Dr. Friberg reported no relevant financial conflicts of interest.

Patients with atrial fibrillation who had CHA₂DS₂-VASc scores of 1 were at lower risk of ischemic stroke than previously reported, according to a retrospective analysis of hospital registry data. The research appeared online January 19 in the Journal of American College of Cardiology.

Depending on the definition of stroke used, risk was 0.1% to 0.2% in women and 0.5% to 0.7% in men – so low that oral anticoagulants (OACs) would not be expected to benefit patients of either sex, said Dr. Leif Friberg at the Karolinska Institute in Stockholm and his associates. Past studies had potentially overestimated the risk of stroke in this population, which “may have led to unnecessary, and potentially harmful, OAC treatment of low-risk patients,” they said.

European and U.S. guidelines both recommend using the CHA₂DS₂-VASc (heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female) scoring system to assess stroke risk in patients with atrial fibrillation (AF). But past studies have reported a threefold variation (ranging from 0.6% to greater than 2.0%) in stroke risk among AF patients with CHA₂DS₂-VASc scores of 1 who were not receiving OAC, the researchers noted. Anticoagulation therapy is likely to benefit AF patients whose annual risk of stroke exceeds 1%, but not patients whose risk is only 0.6%, they added.

Their study, which included 140,420 patients in Sweden with nonvalvular AF, assessed the effect of varying definitions of stroke on estimates of stroke risk. Using a broad definition that included ischemic stroke, transient ischemic attack (TIA), and pulmonary embolism led to a 44% greater annual risk of stroke than if only ischemic strokes were considered, the investigators reported. They disagreed with classifying pulmonary embolism events and TIAs as strokes, as some past studies have done. “Primary prevention of pulmonary embolism among patients with AF has, to the best of our knowledge, not been studied and is not an approved indication for OAC treatment,” they said. “We also did not find it relevant to count TIA as an endpoint in studies that describe stroke risk. As a diagnosis, TIA is difficult to validate.”

Several Swedish foundations supported the study. Dr. Friberg reported no relevant financial conflicts of interest.

Patients with atrial fibrillation who had CHA₂DS₂-VASc scores of 1 were at lower risk of ischemic stroke than previously reported, according to a retrospective analysis of hospital registry data. The research appeared online January 19 in the Journal of American College of Cardiology.

Depending on the definition of stroke used, risk was 0.1% to 0.2% in women and 0.5% to 0.7% in men – so low that oral anticoagulants (OACs) would not be expected to benefit patients of either sex, said Dr. Leif Friberg at the Karolinska Institute in Stockholm and his associates. Past studies had potentially overestimated the risk of stroke in this population, which “may have led to unnecessary, and potentially harmful, OAC treatment of low-risk patients,” they said.

European and U.S. guidelines both recommend using the CHA₂DS₂-VASc (heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female) scoring system to assess stroke risk in patients with atrial fibrillation (AF). But past studies have reported a threefold variation (ranging from 0.6% to greater than 2.0%) in stroke risk among AF patients with CHA₂DS₂-VASc scores of 1 who were not receiving OAC, the researchers noted. Anticoagulation therapy is likely to benefit AF patients whose annual risk of stroke exceeds 1%, but not patients whose risk is only 0.6%, they added.

Their study, which included 140,420 patients in Sweden with nonvalvular AF, assessed the effect of varying definitions of stroke on estimates of stroke risk. Using a broad definition that included ischemic stroke, transient ischemic attack (TIA), and pulmonary embolism led to a 44% greater annual risk of stroke than if only ischemic strokes were considered, the investigators reported. They disagreed with classifying pulmonary embolism events and TIAs as strokes, as some past studies have done. “Primary prevention of pulmonary embolism among patients with AF has, to the best of our knowledge, not been studied and is not an approved indication for OAC treatment,” they said. “We also did not find it relevant to count TIA as an endpoint in studies that describe stroke risk. As a diagnosis, TIA is difficult to validate.”

Several Swedish foundations supported the study. Dr. Friberg reported no relevant financial conflicts of interest.

CHICAGO– A single set of intramuscular injections of stromal cell–derived factor-1 in patients with critical limb ischemia showed safety as well as evidence of efficacy through 12 months of follow-up in the STOP-CLI trial.

“Patients treated with JVS-100 demonstrated dose-dependent improvement across multiple patient-centered outcomes, including pain, quality of life, and wound healing, with less change in macrovascular objective measures in this small study,” Dr. Melina R. Kibbe reported at the American Heart Association scientific sessions. JVS-100 is a nonviral plasmid encoding human stromal cell–derived factor-1 (SDF-1), a natural chemokine protein that promotes angiogenesis by recruiting endothelial progenitor cells from the bone marrow to ischemic sites, explained Dr. Kibbe, professor and vice chair of surgical research and deputy director of the Simpson Querrey Institute for BioNanotechnology at Northwestern University, Chicago.

STOP-CLI was an exploratory, phase IIa, double-blind, first-in-humans study involving 48 patients with Rutherford classification 4 or 5 critical climb ischemia (CLI). All had an ankle-brachial index of 0.4 or lower, an ankle systolic blood pressure of 70 mm Hg or less or a toe systolic blood pressure of 50 or less, and were poor candidates for surgical revascularization. None had Buerger’s disease.

Participants were randomized to one of four study arms, and within each study arm further randomized 3:1 to stromal cell–derived factor-1 (SDF-1) or placebo injections. The patients received either 8 or 16 injections, each containing either 0.5 or 1.0 mg of SDF-1 or placebo. The injections, given in a single session, were placed at least 0.5 cm apart throughout the ischemic area of the affected limb.

By chance, most patients randomized to the placebo group were Rutherford 4, a category of CLI defined by rest pain, while the majority in the active treatment arms were Rutherford 5, a more severe disease manifestation characterized by ulcers. As a consequence, the SDF-1 recipients also had far larger nonhealing wounds, with an average area of 6.4 cm^2, compared with 1.5 cm^2, in controls.

The SDF-1 injections proved safe and were well tolerated, with no treatment-related serious adverse events and no safety signals evident in the laboratory results.

Turning to efficacy endpoints, Dr. Kibbe said self-rated visual analog scale pain scores showed clear, dose-dependent improvement over time in the SDF-1 treatment cohorts and no change in controls.

Similarly, the active treatment groups showed improved quality of life scores on all domains of the Short Form-36: physical functioning, bodily pain, general health, social functioning, energy/fatigue, emotional well-being, and overall physical and mental health, the surgeon continued.

Wound area decreased significantly in the SDF-1-treated groups, with the biggest reduction – more than 8 cm² – being noted in the three patients who received eight 1-mg injections. That was also the group with the largest wounds at baseline, with an average area of 11.4 cm².

Of note, the major limb amputation rate was “remarkably low” for patients with such severe CLI, according to Dr. Kibbe. The rate was less than 10% over the course of 12 months, with one patient in each of the four active treatment arms having a major amputation at time intervals of 58-112 days post injection. No major limb amputations occurred in the control group.

There was a hint of improvement with SDF-1 therapy over placebo in ankle-brachial index and transcutaneous oxygen pressure, but the between-group differences were too narrow in this study to allow for any conclusions. That must await planned much larger phase III trials, according to Dr. Kibbe.

Audience members, citing the numerous failures of once-promising stem cell therapies for CLI at phase III testing over the last 10-15 years, wondered why Dr. Kibbe thinks SDF-1 will fare any better.

“This is much debated and discussed among all the people involved in these kinds of trials,” she replied. “I’d say, briefly, that a lot of it has to do with patient selection. I think when you have a mixed bag of patients in a trial, including patients with Buerger’s disease, treated in multiple different countries, using different definitions of when to amputate, all those things come into play and could account for why those phase III trials were not successful.”

“Having been involved in lots of the different gene- and cell-based therapy trials, I think one of the unique benefits of this therapy is that it kind of bridges between the two. SDF-1 basically homes your endothelial progenitor cells to the site of ischemic injury for enhanced vasculogenesis. But SDF-1 also has direct effects on endothelial cells, including stimulating proliferation and preventing apoptosis,” she added.

 

JVS-100 has also successfully completed a phase II clinical trial for the treatment of heart failure. In addition, the agent is being developed as a treatment for acute MI, chronic angina, and for muscle regeneration.

The STOP-CLI study was sponsored by Juventas Therapeutics. Dr. Kibbe reported serving as a consultant to Johnson & Johnson/Cordis and Pluristem.

bjancin@frontlinemedcom.com

CHICAGO– A single set of intramuscular injections of stromal cell–derived factor-1 in patients with critical limb ischemia showed safety as well as evidence of efficacy through 12 months of follow-up in the STOP-CLI trial.

“Patients treated with JVS-100 demonstrated dose-dependent improvement across multiple patient-centered outcomes, including pain, quality of life, and wound healing, with less change in macrovascular objective measures in this small study,” Dr. Melina R. Kibbe reported at the American Heart Association scientific sessions. JVS-100 is a nonviral plasmid encoding human stromal cell–derived factor-1 (SDF-1), a natural chemokine protein that promotes angiogenesis by recruiting endothelial progenitor cells from the bone marrow to ischemic sites, explained Dr. Kibbe, professor and vice chair of surgical research and deputy director of the Simpson Querrey Institute for BioNanotechnology at Northwestern University, Chicago.

STOP-CLI was an exploratory, phase IIa, double-blind, first-in-humans study involving 48 patients with Rutherford classification 4 or 5 critical climb ischemia (CLI). All had an ankle-brachial index of 0.4 or lower, an ankle systolic blood pressure of 70 mm Hg or less or a toe systolic blood pressure of 50 or less, and were poor candidates for surgical revascularization. None had Buerger’s disease.

Participants were randomized to one of four study arms, and within each study arm further randomized 3:1 to stromal cell–derived factor-1 (SDF-1) or placebo injections. The patients received either 8 or 16 injections, each containing either 0.5 or 1.0 mg of SDF-1 or placebo. The injections, given in a single session, were placed at least 0.5 cm apart throughout the ischemic area of the affected limb.

By chance, most patients randomized to the placebo group were Rutherford 4, a category of CLI defined by rest pain, while the majority in the active treatment arms were Rutherford 5, a more severe disease manifestation characterized by ulcers. As a consequence, the SDF-1 recipients also had far larger nonhealing wounds, with an average area of 6.4 cm^2, compared with 1.5 cm^2, in controls.

The SDF-1 injections proved safe and were well tolerated, with no treatment-related serious adverse events and no safety signals evident in the laboratory results.

Turning to efficacy endpoints, Dr. Kibbe said self-rated visual analog scale pain scores showed clear, dose-dependent improvement over time in the SDF-1 treatment cohorts and no change in controls.

Similarly, the active treatment groups showed improved quality of life scores on all domains of the Short Form-36: physical functioning, bodily pain, general health, social functioning, energy/fatigue, emotional well-being, and overall physical and mental health, the surgeon continued.

Wound area decreased significantly in the SDF-1-treated groups, with the biggest reduction – more than 8 cm² – being noted in the three patients who received eight 1-mg injections. That was also the group with the largest wounds at baseline, with an average area of 11.4 cm².

Of note, the major limb amputation rate was “remarkably low” for patients with such severe CLI, according to Dr. Kibbe. The rate was less than 10% over the course of 12 months, with one patient in each of the four active treatment arms having a major amputation at time intervals of 58-112 days post injection. No major limb amputations occurred in the control group.

There was a hint of improvement with SDF-1 therapy over placebo in ankle-brachial index and transcutaneous oxygen pressure, but the between-group differences were too narrow in this study to allow for any conclusions. That must await planned much larger phase III trials, according to Dr. Kibbe.

Audience members, citing the numerous failures of once-promising stem cell therapies for CLI at phase III testing over the last 10-15 years, wondered why Dr. Kibbe thinks SDF-1 will fare any better.

“This is much debated and discussed among all the people involved in these kinds of trials,” she replied. “I’d say, briefly, that a lot of it has to do with patient selection. I think when you have a mixed bag of patients in a trial, including patients with Buerger’s disease, treated in multiple different countries, using different definitions of when to amputate, all those things come into play and could account for why those phase III trials were not successful.”

“Having been involved in lots of the different gene- and cell-based therapy trials, I think one of the unique benefits of this therapy is that it kind of bridges between the two. SDF-1 basically homes your endothelial progenitor cells to the site of ischemic injury for enhanced vasculogenesis. But SDF-1 also has direct effects on endothelial cells, including stimulating proliferation and preventing apoptosis,” she added.

 

JVS-100 has also successfully completed a phase II clinical trial for the treatment of heart failure. In addition, the agent is being developed as a treatment for acute MI, chronic angina, and for muscle regeneration.

The STOP-CLI study was sponsored by Juventas Therapeutics. Dr. Kibbe reported serving as a consultant to Johnson & Johnson/Cordis and Pluristem.

bjancin@frontlinemedcom.com

CHICAGO– A single set of intramuscular injections of stromal cell–derived factor-1 in patients with critical limb ischemia showed safety as well as evidence of efficacy through 12 months of follow-up in the STOP-CLI trial.

“Patients treated with JVS-100 demonstrated dose-dependent improvement across multiple patient-centered outcomes, including pain, quality of life, and wound healing, with less change in macrovascular objective measures in this small study,” Dr. Melina R. Kibbe reported at the American Heart Association scientific sessions. JVS-100 is a nonviral plasmid encoding human stromal cell–derived factor-1 (SDF-1), a natural chemokine protein that promotes angiogenesis by recruiting endothelial progenitor cells from the bone marrow to ischemic sites, explained Dr. Kibbe, professor and vice chair of surgical research and deputy director of the Simpson Querrey Institute for BioNanotechnology at Northwestern University, Chicago.

STOP-CLI was an exploratory, phase IIa, double-blind, first-in-humans study involving 48 patients with Rutherford classification 4 or 5 critical climb ischemia (CLI). All had an ankle-brachial index of 0.4 or lower, an ankle systolic blood pressure of 70 mm Hg or less or a toe systolic blood pressure of 50 or less, and were poor candidates for surgical revascularization. None had Buerger’s disease.

Participants were randomized to one of four study arms, and within each study arm further randomized 3:1 to stromal cell–derived factor-1 (SDF-1) or placebo injections. The patients received either 8 or 16 injections, each containing either 0.5 or 1.0 mg of SDF-1 or placebo. The injections, given in a single session, were placed at least 0.5 cm apart throughout the ischemic area of the affected limb.

By chance, most patients randomized to the placebo group were Rutherford 4, a category of CLI defined by rest pain, while the majority in the active treatment arms were Rutherford 5, a more severe disease manifestation characterized by ulcers. As a consequence, the SDF-1 recipients also had far larger nonhealing wounds, with an average area of 6.4 cm^2, compared with 1.5 cm^2, in controls.

The SDF-1 injections proved safe and were well tolerated, with no treatment-related serious adverse events and no safety signals evident in the laboratory results.

Turning to efficacy endpoints, Dr. Kibbe said self-rated visual analog scale pain scores showed clear, dose-dependent improvement over time in the SDF-1 treatment cohorts and no change in controls.

Similarly, the active treatment groups showed improved quality of life scores on all domains of the Short Form-36: physical functioning, bodily pain, general health, social functioning, energy/fatigue, emotional well-being, and overall physical and mental health, the surgeon continued.

Wound area decreased significantly in the SDF-1-treated groups, with the biggest reduction – more than 8 cm² – being noted in the three patients who received eight 1-mg injections. That was also the group with the largest wounds at baseline, with an average area of 11.4 cm².

Of note, the major limb amputation rate was “remarkably low” for patients with such severe CLI, according to Dr. Kibbe. The rate was less than 10% over the course of 12 months, with one patient in each of the four active treatment arms having a major amputation at time intervals of 58-112 days post injection. No major limb amputations occurred in the control group.

There was a hint of improvement with SDF-1 therapy over placebo in ankle-brachial index and transcutaneous oxygen pressure, but the between-group differences were too narrow in this study to allow for any conclusions. That must await planned much larger phase III trials, according to Dr. Kibbe.

Audience members, citing the numerous failures of once-promising stem cell therapies for CLI at phase III testing over the last 10-15 years, wondered why Dr. Kibbe thinks SDF-1 will fare any better.

“This is much debated and discussed among all the people involved in these kinds of trials,” she replied. “I’d say, briefly, that a lot of it has to do with patient selection. I think when you have a mixed bag of patients in a trial, including patients with Buerger’s disease, treated in multiple different countries, using different definitions of when to amputate, all those things come into play and could account for why those phase III trials were not successful.”

“Having been involved in lots of the different gene- and cell-based therapy trials, I think one of the unique benefits of this therapy is that it kind of bridges between the two. SDF-1 basically homes your endothelial progenitor cells to the site of ischemic injury for enhanced vasculogenesis. But SDF-1 also has direct effects on endothelial cells, including stimulating proliferation and preventing apoptosis,” she added.

 

JVS-100 has also successfully completed a phase II clinical trial for the treatment of heart failure. In addition, the agent is being developed as a treatment for acute MI, chronic angina, and for muscle regeneration.

The STOP-CLI study was sponsored by Juventas Therapeutics. Dr. Kibbe reported serving as a consultant to Johnson & Johnson/Cordis and Pluristem.

bjancin@frontlinemedcom.com