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Background: Informal caregivers contribute substantially to the self-care of people with heart failure (HF) by helping with concrete and interpersonal tasks. Time perception and management are essential issues among caregivers. However, investigators have not explored this topic in caregivers of people with HF., Objectives: The aim of this study was to describe the perceptions and challenges of the time management experience among caregivers who support the self-care efforts of their relatives with HF., Methods: Adult informal caregivers of patients with HF, taking care of the patient for at least 3 months and without cognitive limitations, were recruited from Spain, Italy, and the Netherlands. Data were collected using semistructured interviews. Maryring's qualitative content analysis strategy with both a deductive and an inductive approach was used for analysis., Results: We enrolled 50 participants (20 Italians, 19 Spanish, and 11 Dutch). Caregivers had a mean (SD) age of 62.8 (12.8) years and were mostly female (84%). They dedicated 31.2 (SD, 21.7) hours per week to providing caring activities for their patients. After extracting 33 codes from their qualitative interview data, we summarized them into 8 categories and identified 4 main themes: (1) time for yourself, (2) house management, (3) time for the patient (dedicated to directing care), and (4) time for own socialization., Conclusion: Caregivers navigate the complexity of time management by balancing dedicated time for supporting patients with HF and their own personal time., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

. The organisation of outpatient medical and nursing clinics for the follow-up of patients after hospitalization for a myocardial infarction or heart failure., Introduction: Guidelines suggest careful monitoring of patients after acute heart failure (AHF) or acute myocardial infarction (AMI)., Objective: To describe the implementation of the 'accompanied discharge' (DIMACC) pathway for patients admitted for AHF or AMI in the Cardiology Department of the Pio XI hospital in Desio, and to evaluate its feasibility., Methods: The DIMACC pathway was built following the recommendations of international guidelines and with the involvement of all the actors., Results: At discharge, the health objectives to be achieved are defined, and outpatient visits during the first year after hospitalization in the District outpatient clinics with the cardiology doctor and family nurses are booked. The patient stays in the outpatient clinic about 1.5 hours to complete at first, in half an hour, questionnaires on measures, symptoms, adherence, quality of life; then, to receive the nursing visit lasting half an hour for the assessment of the questionnaires, measurement of clinical parameters and counseling; and finally, to be visited by the cardiologist. During the pilot phase (6 months of recruitment and 1 year of follow-up) 168 patients (129 AMI and 39 AHF) followed the pathway: 4 (2.4%) patients died during the follow-up, 14 (8.3%) abandoned the pathway and 150 (89.3%) completed it., Conclusions: The implementation of the DIMACC pathway required an investment of time (about a year) and resources but the follow-up is feasible. The next phase will be the evaluation of the patient outcomes.

Background: Patients with heart failure experience high symptom burden, which can be mitigated with adequate self-care. Caregiver contribution to self-care has been theorized to improve patient symptom burden. The mediating role of patient self-care in this relationship has not been tested yet., Objectives: The aim of this study was to test whether ( a ) caregiver contribution to self-care influences patient self-care, ( b ) patient self-care influences symptom burden, and ( c ) patient self-care mediates the relationship between caregiver contribution to self-care and symptom burden., Methods: In this study, the authors conducted a secondary analysis of the baseline and 3-month data from the MOTIVATE-HF trial, which enrolled 510 dyads (patient with heart failure and caregiver) in Italy. Multigroup confirmatory factor analysis was used to test measurement invariance. Autoregressive longitudinal path analysis with contemporaneous mediation was used to test our hypotheses., Results: On average, caregivers were 54 years old and mainly female, whereas patients were 72.4 years old and mainly male. Better caregiver contribution to self-care maintenance was associated with better patient self-care maintenance (β = 0.280, P < .001), which, in turn, was associated with lower symptom burden (β = -0.280, P < .001). Patient self-care maintenance mediated the effect of caregiver contribution to self-care maintenance on symptom burden (β = -0.079; 95% bias-corrected bootstrapped confidence interval, -0.130 to -0.043). Better caregiver contribution to self-care management was associated with better patient self-care management (β = 0.238, P = .006). The model significantly accounted for 37% of the total variance in symptom burden scores ( P < .001)., Conclusions: This study expands the situation-specific theory of caregiver contribution to heart failure self-care and provides new evidence on the role of caregiver contribution to self-care and patient self-care on symptom burden in heart failure., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.)

Background: Heart failure (HF) patients need to follow a strict pharmacological and nonpharmacological regimen in order to counteract the burden of the disease, and informal caregivers are an important resource for HF patients in managing and coping with their disease. Few studies have examined the lived experience of these caregivers with a rigorous phenomenological approach, and none have been conducted in Italy., Aim: To describe the lived experience of the caregivers of HF patients., Methods: A hermeneutic phenomenological method was used. Caregivers were enrolled in a HF clinic in central Italy. Interviews were analysed using a phenomenological approach. Credibility, dependability, confirmability and transferability were adopted in order to strengthen trustworthiness., Findings: Thirty HF caregivers (mean age: 53 years) were enrolled. Of these, 63% of the caregivers were female and 80% were patients' spouses or children. Six themes emerged: (1) fear and worry related to the illness; (2) life changes and restrictions; (3) burden due to caregiving; (4) uncertainty about illness management; (5) helping patients to cope with the illness; and (6) love and affection towards the patient., Conclusion: The findings of our study may help providers to guide interventions for HF caregivers. Providers should be supportive of caregivers and provide them with education in order to reduce their fears and worries about the illness and to handle the course of HF and its symptoms. An empathetic and practical approach with caregivers that considers the patient-caregiver relationship may help caregivers to cope with the changes and restrictions that caregiving brings to their lives and to reduce their burden.

Background: A better understanding of caregiver burden and its determinants is essential to support caregivers. Many instruments have been developed to measure caregiver burden in various illness contexts, but few have been psychometrically tested for caregivers of heart failure patients., Aims: The aim of this study was to test the validity (factorial and concurrent validity) and reliability (internal consistency) of the caregiver burden inventory (CBI) in a cohort of caregivers of heart failure patients., Methods: This was a secondary analysis from a cross-sectional study on heart failure patients and their caregivers enrolled from various Italian outpatient centres. The factorial validity of the CBI was tested with confirmatory factor analysis, and concurrent validity was tested correlating CBI scores with the short form-12 health survey scores. The internal consistency reliability was assessed with Cronbach's alpha., Results: In total, 505 caregivers of heart failure patients (52.2% women, mean age 56.59±14.9 years) were enrolled. Confirmatory factor analyses confirmed the original five-factor model: time-dependence, developmental, physical, social and emotional burden. This model fits the data better than the single-factor model, and the dimensions showed high internal consistency reliability (Cronbach's alpha 0.91 for time-dependence burden, 0.92 for developmental burden, 0.88 for physical burden, 0.89 for social burden and 0.93 for emotional burden; 0.96 for the total score of burden)., Conclusion: The CBI proved to be a good multidimensional instrument for evaluating the burden in caregivers of heart failure patients and can be used in clinical practice and research. This tool can be considered to tailor interventions aimed at improving caregiver outcomes.

Disease self-management is a critical component of maintaining clinical stability for patients with chronic illness. This is particularly evident in the context of heart failure (HF), which is the leading cause of hospitalization for older adults. HF self-management, commonly known as HF self-care, is often performed with the support of informal caregivers. However, little is known about how a HF dyad manages the patient's care together. The purpose of this study was to identify determinants of patient and caregiver contributions to HF self-care maintenance (daily adherence and symptom monitoring) and management (appropriate recognition and response to symptoms), utilizing an approach that controls for dyadic interdependence. This was a secondary analysis of cross-sectional data from 364 dyads of Italian HF patients and caregivers. Multilevel modeling was used to identify determinants of HF self-care within patient-caregiver dyads. Patients averaged 76.2 (SD = 10.7) years old, and a slight majority (56.9%) was male, whereas caregivers averaged 57.4 (SD = 14.6) years old, and about half (48.1%) were male. Most caregivers were adult children (48.4%) or spouses (32.7%) of patients. Both patients and caregivers reported low levels of HF maintenance and management behaviors. Significant individual and dyadic determinants of self-care maintenance and self-care management included gender, quality of life, comorbid burden, impaired ADLs, cognition, hospitalizations, HF duration, relationship type, relationship quality, and social support. These comprehensive dyadic models assist in elucidating the complex nature of patient-caregiver relationships and their influence on HF self-care, leading to more effective ways to intervene and optimize outcomes., (© 2015 Wiley Periodicals, Inc.)

Background: Caregivers play an important role in contributing to heart failure (HF) patients' self-care but no prior studies have examined the caregivers' contributions to HF patients' self-care and no prior studies have examined potential determinants of the caregivers' contribution to HF patients' self-care., Aims: The purpose of this study was to describe the caregivers' contribution to HF patients' self-care and identify its determinants., Methods: The study design involved a secondary analysis of cross-sectional data. Caregivers' contributions were measured with the Caregiver's Contribution to Self-care of HF Index (CC-SCHFI) which measures the caregiver's contribution to self-care maintenance and management and caregiver confidence in contributing to HF patient's self-care. Potential determinants were measured using a socio-demographic questionnaire completed by caregivers and patients, and patient clinical data was obtained from the medical record., Results: Data from 515 caregiver/patient dyads were analyzed. Most (55.5%) patients were male (mean age 75.6 years) and most (52.4%) caregivers were female (mean age, 56.6 years). The caregivers' contribution to patients' self-care maintenance was low in weight monitoring and physical activity but higher in checking ankles, advising on low-salt foods and taking medicines. The caregivers' contribution to patients' self-care management was low in symptom recognition. When symptoms were recognized, caregivers advised patients to reduce fluids and salt and call the provider but rarely advised to take an extra diuretic. Caregiver confidence in the ability to contribute to patient self-care explained a significant amount of variance in the caregiver's contribution., Conclusion: These findings suggest that caregivers in this sample did not contribute meaningfully to HF self-care. Providers should educate both HF patients and caregivers. Interventions that improve caregiver confidence have the potential to successfully increase the caregivers' contribution to patients' self-care., (© The European Society of Cardiology 2014.)

Background: To validate a structured interview designed to evaluate the healthcare and information needs of patients with heart failure (HF), who were also characterized by means of the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the 36-item Short-Form Health Survey (SF-36)., Methods: Forty-five in- and outpatients with HF were administered a structured interview concerning their information and healthcare needs (together with the KCCQ and SF-36) with the aim of investigating the effects of healthcare models on their quality of life (QoL). Twenty-one patients were also involved in a one-week test-retest validity study carried out in order to verify reproducibility and stability by means of concordance and K statistics., Results: The reproducibility of the structured interview was good or very good for all items, with a mean Kw of 0.59; the clarity and acceptability of most of the questions were good. Positive judgements of hospital care inversely related to the patients' New York Heart Association class. The subjects about which the patients sought greater information were diet, sleep, therapies and physical exercise, with cardiologists and general practitioners (GPs) being more involved than nurses. The most frequently discussed subject was diagnostic examinations. The questionnaire scores of our patients were generally lower than those reported in the literature, possibly because of their advanced age. However, it is difficult to believe that the quality of care was extraneous to their generally worse health-related QoL., Conclusions: Our HF patients experienced a 'basic' healthcare model (hospitals, GPs, cardiologists) and judged them acceptable. Their ability to think critically about care was increasingly compromised as HF progressed and their health-related QoL decreased.

Purpose: Project Leonardo represented a feasibility study to evaluate the impact of a disease and care management (D&CM) model and of the introduction of "care manager" nurses, trained in this specialized role, into the primary health care system., Patients and Methods: Thirty care managers were placed into the offices of 83 general practitioners and family physicians in the Apulia Region of Italy with the purpose of creating a strong cooperative and collaborative "team" consisting of physicians, care managers, specialists, and patients. The central aim of the health team collaboration was to empower 1,160 patients living with cardiovascular disease (CVD), diabetes, heart failure, and/or at risk of cardiovascular disease (CVD risk) to take a more active role in their health. With the support of dedicated software for data collection and care management decision making, Project Leonardo implemented guidelines and recommendations for each condition aimed to improve patient health outcomes and promote appropriate resource utilization., Results: Results show that Leonardo was feasible and highly effective in increasing patient health knowledge, self-management skills, and readiness to make changes in health behaviors. Patient skill-building and ongoing monitoring by the health care team of diagnostic tests and services as well as treatment paths helped promote confidence and enhance safety of chronic patient management at home., Conclusion: Physicians, care managers, and patients showed unanimous agreement regarding the positive impact on patient health and self-management, and attributed the outcomes to the strong "partnership" between the care manager and the patient and the collaboration between the physician and the care manager. Future studies should consider the possibility of incorporating a patient empowerment model which considers the patient as the most important member of the health team and care managers as key health care collaborators able to enhance and support services to patients provided by physicians in the primary health care system.

Background: In the last years, the increasing incidence and prevalence, the deterioration of quality of life, the high mortality and the elevated costs related to chronic heart failure represent one of the most important problems of public health care. Multidisciplinary management systems based on specialized nurses teams improve the outcome and reduce the costs of care of these patients. The aim of this study was to analyze the use for 1 year, in an urban or suburban population, of two different nurse-based management systems in addition to usual care for outpatients with congestive heart failure., Methods: We enrolled 102 patients: group A (n = 49) was followed up with a phone-nurse-based system and group B (n = 53) was followed up with a nurse ambulatory system., Results: An improvement in NYHA class was observed in both groups (group A: NYHA class I-II 31 to 38 patients, NYHA class III-IV 18 to 7 patients, p = 0.03; group B: NYHA class I-II 37 to 43 patients, NYHA class III-IV 16 to 6 patients, p = 0.03). An improvement was also observed in the Minnesota Living with Heart Failure Questionnaire (group A: 25 +/- 10 to 15 +/- 9; p <0.01; group B: 29 +/- 13 to 20 +/- 10; p <0.01), and in ejection fraction (group A: from 31 +/- 9 to 37 +/- 12%; p <0.01; group B: from 30 +/- 9 to 35 +/- 13%; p = 0.02). No significant differences were found between the two groups in mortality, hospital readmission, emergency room and day-hospital admissions., Conclusions: Our results confirm the effectiveness of a monitoring management and educational system for heart failure patients. A phone-nurse-based system requires minor staff and has a better flexibility than a nurse ambulatory system; the latter, however, leads to a professional and human complete interaction as well as enables rapid intervention of the cardiologist in case of instability.

Background: Beta-blockers (BB) are under prescribed in elderly heart failure (HF) patients. We analysed predictors of BB treatment in relation to age in community patients seen at an HF clinic with nurse specialist support., Methods: BB prescription was assessed in 357 subjects, in relation to age tertiles:<67 (n=120), 67-73 (n=105) and >or=74 years (n=119)., Results: 305 patients (85%) took BB at a median carvedilol-equivalent daily dose of 12.5 [12.5-25] mg. Patients >or=74 years received significantly less BB (78% vs 93% and 85%, p=0.002) and at lower doses than subjects aged <67 and 67-73 years (12.5 [6.25-20] mg vs 25 [12.5-32] and 12.5 [12.5-25], p=0.002). Older age, chronic obstructive airways disease, amiodarone, digoxin and baseline heart rate were independently associated with non-prescription of BB., Conclusion: Although older age is associated with non-prescription of BB, BB can be implemented in an outpatient HF clinic with nurse specialist support even in elderly patients. although lower doses are achieved than in younger subjects.

Background: Chronic heart failure is the leading cause of hospitalization and readmissions. In the last years many strategies based on the interaction of multi-competence programs have been evaluated to improve its management., Methods: We evaluated the feasibility of an outpatient management program for patients with chronic hearth failure jointly treated by hospital, territorial cardiologists, nurses and primary physicians in a large area of Piedmont. Between January 2001 and January 2005, 122 consecutive patients (26.2% female, mean age 66 +/- 11 years) with chronic heart failure were enrolled in the study. Etiology was: coronary heart disease 40.2%, dilated cardiomyopathy 18%, hypertension 18%, unknown 14%, valvular heart disease 4.9%, other 4.9%. Cardiologists were expected to assess etiology, to perform instrumental examinations and titration of beta-blockers; nurses to reinforce patient education to monitor adherence to pharmacological and dietary therapy. Patients were subsequently followed by primary physicians. The endpoints were to compare: 1) hospitalization and emergency department admissions in the 12 months before the first evaluation and every year after referral; 2) Minnesota questionnaire, NYHA functional class, pharmacological therapies at the referral time and at the end of follow-up., Results: One hundred and fifteen patients were followed for 47 +/- 1.5 months (5.6% drop out). Thirty-four patients died (29.5%), 11 non-cardiac causes, 14 congestive heart failure, 6 sudden cardiac death, 3 cardiac transplantation. Ejection fraction improved from 31 +/- 10 to 36 +/- 12%. Emergency department admissions and hospitalizations decreased from 54 and 56 respectively in the year before the first evaluation to 14 and 21 per year (p < 0.001). NYHA classes I-II improved from 65.5 to 87.7% and NYHA classes III-IV were reduced from 34.5 to 12.3%. The Minnesota score decreased from 25 to 21.9. Patients treated with ACE-inhibitors + angiotensin II receptor blocker therapy increased from 91 to 96%, beta-blockers from 35.2 to 69%, potassium sparing drugs increased from 54 to 64%., Conclusions: Our study showed that a medical and nurse outpatient management program for patients with chronic heart failure, also in a large urban and country area, decrease number of hospitalizations and improve functional class and adherence to medical therapy. These results kept constant over time in the subsequent 4 years.