"I Should Have Come Sooner": A Qualitative Study Describing Care Preferences of Elders with HF

Purpose:  Heart failure (HF) remains the leading cause of hospitalization among adults over the age of 65. The majority of these hospitalizations originate in the emergency department (ED). Hospitalized HF patients are more likely to experience negative health outcomes than outpatients with HF. Experts have suggested that many patients with HF may be safely given treatment in the ED with discharge home and close follow up. Therefore, the purpose of this study was to describe the reasons that elder HF patients present to the ED and explore care preferences including barriers and facilitators to home discharge.

Methods: In this qualitative descriptive study, 13 clinically-stable elders with HF (≥65 years) were enrolled during an ED visit and participated in in-depth interviews about their reason for ED visit, including symptom experience and self-care at home, and HF care preferences. Qualitative data were analyzed using content thematic analysis.

Results:  In this sample (70% male, 77% White, Mean age 81±8; range 67-93 years), the most common reasons for ED visits were dyspnea and leg swelling. All reported ≥1 ED visits for similar symptoms in prior 6 months. Most (n=12) described symptoms that had been present or worsening for ≥2 days; all were admitted. Poor symptom awareness, inadequate resources and fragmented care contributed to delays in seeking treatment. In general, self-care at home was poor including medication nonadherence “I stopped that pill because it gave me <pain>” and failed symptom monitoring “they used to monitor me <at home> and I did ok…but that stopped.” Some (n=4) preferred home discharge from the ED “just get the fluid out…let me go home”; but most believed hospitalization was necessary for symptom management “they have to fix it…change the medication or something” and to improve functional status “…help get strength back.” Barriers to home discharge centered around lack of tangible support “I need help with everything” and general physical deconditioning.

Conclusion:  Many elders with HF struggle with recognizing HF symptom and inadequate support that may delay treatment and lead to emergency situations. Interventions to address recurrent ED admissions in elders should focus on addressing their unique social support and care-coordination needs as well as deficits in self-care.