Heart Failure Home Management Challenges and Reasons for Readmission: a Qualitative Study to Understand the Patient's Perspective
Heart Failure Home Management Challenges and Reasons for Readmission: a Qualitative Study to Understand the Patient's Perspective
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DOI：
10.1007/s11606-018-4542-3
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发表时间：
2018-10-01
影响因子：
5.7
通讯作者：
Kimmel, Stephen E.
中科院分区：
文献类型：
--
作者：
Sevilla-Cazes, Jonathan;Ahmad, Faraz S.;Kimmel, Stephen E.
心力衰竭患者的30天再入院率很高。旨在防止再入院的干预措施取得了好坏参半的成功。通过患者的经验了解心力衰竭家庭管理可能会重新定义再入院“问题”，最终，了解患者和护理人员对心力衰竭家庭管理的挑战以及再入院的原因。观察性定性研究。心力衰竭患者来自两家医院，包括30天内因心力衰竭住院至少两次的患者和在第一次心力衰竭入院后最近出院。开放式，半结构化访谈。采用焦点小组的方法验证结论：对31名患者的半结构式访谈揭示了身体和社会情绪对患者家庭心力衰竭管理的综合影响。确定的主要主题是家庭管理作为坚持和适应之间的斗争，和医院再入院作为一个理性的选择，在应对令人痛苦的症状。患者确定不确定性的建议，不明确的指示和行为和症状发作之间的时间不一致。这种不确定性削弱了他们做出日常管理决策的能力，导致了一个循环的极限测试和减少遵守。患者报告说，在感知功能状态恶化时，他们会感到绝望和沮丧。这导致一些人陷入绝望的循环，其特征是不断恶化的坚持和负面情绪。随着这些周期的进展和痛苦的症状恶化，患者认为医院是最安全的恢复场所，而不是一个“负面”的结果。极限测试和绝望的周期代表了重要的以患者为中心的斗争，在管理心力衰竭。由此产生的痛苦和恐惧使再入院成为患者的理性选择，而不是负面结果。干预措施（例如，姑息治疗），重点是解决这些以病人为中心的因素的方法，而不是减少再入院的方法，应进一步研究。
Heart failure patients have high 30-day hospital readmission rates. Interventions designed to prevent readmissions have had mixed success. Understanding heart failure home management through the patient's experience may reframe the readmission "problem" and, ultimately, inform alternative strategies.To understand patient and caregiver challenges to heart failure home management and perceived reasons for readmission.Observational qualitative study.Heart failure patients were recruited from two hospitals and included those who were hospitalized for heart failure at least twice within 30 days and those who had been recently discharged after their first heart failure admission.Open-ended, semi-structured interviews. Conclusions vetted using focus groups.Semi-structured interviews with 31 patients revealed a combination of physical and socio-emotional influences on patients' home heart failure management. Major themes identified were home management as a struggle between adherence and adaptation, and hospital readmission as a rational choice in response to distressing symptoms. Patients identified uncertainty regarding recommendations, caused by unclear instructions and temporal incongruence between behavior and symptom onset. This uncertainty impaired their competence in making routine management decisions, resulting in a cycle of limit testing and decreasing adherence. Patients reported experiencing hopelessness and frustration in response to perceiving a deteriorating functional status. This led some to a cycle of despair characterized by worsening adherence and negative emotions. As these cycles progressed and distressing symptoms worsened, patients viewed the hospital as the safest place for recovery and not a "negative" outcome.Cycles of limit testing and despair represent important patient-centered struggles in managing heart failure. The resulting distress and fear make readmission a rational choice for patients rather than a negative outcome. Interventions (e.g., palliative care) that focus on methods to address these patient-centered factors should be further studied rather than methods to reduce hospital readmissions.