心臟衰竭病人需求評估、心理健康與生活品質

Abstract

(一)研究背景與目的：心臟衰竭為不同心臟疾病最終的結果，病患除經常經歷多重症狀的症候群外，甚至因疾病惡化或出現其他合併症等疾病歷程，造成病患與照顧者有身心靈社會層面的適應障礙，影響其生活品質，可能與未被滿足的照護需求有關。心臟衰竭與癌症病患在疾病軌跡上有相似的生理、心理與靈性需求，需求評估目前較少運用在心臟衰竭病人上，因此本研究主要目的是想了解國內心臟衰竭病患需求現況，並評估是否與焦慮憂鬱程度與生活品質有關。 (二)方法：本研究為橫斷式相關性研究，於北部某醫學中心心臟內科門診與病房進行資料收集，採結構性問卷調查法，問卷內容包含人口學基本資料、疾病特性、心臟衰竭需求評估問卷(Heart Failure Need Assessment Questionnaire, HFNAQ)、華人健康問卷(Chinese Health Questionnaire, CHQ-12)、病人健康問卷(Patient Health Questionnaire, PHQ-9)、明尼蘇達心臟衰竭生活品質量表(Minnesota Living With Heart Failure Questionnaire, MLHFQ)。 (三)結果：2020年5月至7月共收集109位心臟衰竭病患，年齡平均61.03±16.27歲、多為男性(73.4%)、已婚(67.9%)、與家人同住(87.2%)、New York Heart Association (NYHA) 分級Ⅰ/Ⅱ(64.2%/32.1%)，罹患心臟衰竭時間平均49.75±50.86個月，LVEF平均48.12±13.79%；HFNAQ需求程度平均總分為58±13.03分，需求程度排序為社會與人際關係、靈性與現存性問題、生理症狀、心理與認知層面；心衰病人的生活品質衝擊平均分數為13.13±11.29分。運用多元迴歸分析探討心臟衰竭衝擊生活品質的相關因素包含年齡低於60歲或大於78歲、BMI小於等於23.87 kg/m2、曾抽菸現已戒菸、研究所或以上之高教育者、最近一次LVEF小於等於45.12%，NYHA分級第二級與第三級、PHQ分數較高、HFNAQ社會與人際關係需求為中度需要、COVID-19防疫行為多、共存高尿酸血症、共存糖尿病、共存攝護腺肥大、使用支氣管擴張劑、使用藥品數量超過7種等生活品質較差，而使用利尿劑、抗凝血劑、降膽固醇藥物者，則生活品質相對較佳，罹患心臟衰竭超過74個月，生活品質也相對較佳，模型整體可解釋總變異量(R2)為88.7% (F=32.51, p<0.001)。 (四)結論與臨床實務建議：對於特定心臟衰竭病患有社區適應上的需求如：年齡小於60歲或年齡大於78歲、過去抽菸現在戒菸者等其他社區適應困難問題，應主動深入了解並協助克服障礙。在共病症與多重用藥方面，應教導管理與控制共存慢性疾病，並運用跨團隊整合照護模式照護病患，除與醫師、藥師協同整合病患用藥處方，更可邀請其他專科醫師或個管師(如：糖尿病、慢性阻塞性肺疾病)互相分享資訊，共同照顧病患。在心理健康方面，適時運用適當的量表(例如:PHQ-9)篩檢憂鬱症狀，以利早期發現與治療並長期追蹤病人憂鬱狀態之變化。在社會與人際關係需求層面，提供病患病友支持團體或是門診進行團體衛教關於藥物、共病症與心臟衰竭疾病照護知識，以滿足病患需求。最後不論在門診或住院心臟衰竭病患照護上應重視整體需求評估，例如可使用有良好信效度之中文版心臟衰竭需求評估問卷(HFNAQ)了解病患在不同層面的需求程度，依照其個別性需求，提供以病患為中心的照護計畫。

Background and purpose: Heart failure (HF) often is the final result of different heart diseases. Patient often have multiple and clinical symptoms, and even experience disease deterioration or other comorbidities, causing patients and caregivers to suffer burdens and barriers at the physical, psychosocial and spiritual level, which affect the quality of life. All such burdens and barriers may be related to unmet needs. Patients with heart failure, similar to the cancer patients, have various physical, psychological and spiritual needs in the disease trajectory. Needs assessment is important but less applied to the heart failure patients. The main purpose of this study was to understand the needs of heart failure patients in Taiwan and to explore its related factors as well as to evaluate the associations among unmeet needs, quality of life and levels of anxiety and depression. Method: This was a correlational study by using structural questionnaires to collect data from the outpatient clinics and Cardiology inpatient units in a medical center located in the northern Taiwan. The questionnaires included socio-demographic information, diseases-related clinical information, Chinese version of Heart Failure Needs Assessment Questionnaire (HFNAQ), Chinese Health Questionnaire (CHQ-12), Patient Health Questionnaire (PHQ-9), and Chinese version of Minnesota Living with Heart Failure Questionnair (MLHFQ). Results: A sample of 109 patients with heart failure were collected from May to July, 2020. They were averaged 61.03±16.27 years old, mostly male (73.4%), married (67.9%), living with family members (87.2%), and New York Heart Association (NYHA) classification I/II (64.2%/32.1%). The averaged months since the first HF diagnosis was 49.75±50.86. The most recent left ventricle ejection fraction (LVEF) was 48.12±13.79%. For the needs assessment, the averaged score of HFNAQ was 58±13.03 points. The HFNAQ’s subscales demonstrated the highest needs in the social interpersonal interactions domain, followed by the existential/spirit, physical symptom, and psychological cognitive function domains. We used the multiple linear regression analysis to explore the factors related to the impact of heart failure on the quality of life. The significant factors associated with the quality of life impacted by heart failure were the age under 60 or over 78, BMI under 23.87 kg/m2, smoking quiters, graduate-level educated, ≦ 45.12% LVEF, NYHA level 2 and level 3, high PHQ score, moderate levels of the HFNAQ social and interpersonal relationship needs, extansive COVID19 epidemic precauciosu behaviors, coexisting hyperuricemia, coexisting diabetes, coexisting prostate hypertrophy, applying bronchodilators, and concurrently using more than 7 drugs. The HF impact quality of life was relatively better once the patients used diuretics, anticoagulants, or cholesterol-lowering drugs, and their HF last for 74 months or longer. The entire multivariate linear regression model was accounted for 88.7% of the variance (F=32.51, p<0.001). Conclusions and clinical implications: The current study found that the impact on quality of life in heart failure patients were associated with various factors. HF patients with an impacted quality of life were associated with different backgrounds, such as younger than 60 or older than 78 years old, past smokers, and higher educated ones. It is necessary to actively understand and assist patients to overcome the obstacles resulted from HF. Through teamwork, the nurses can cooperate with phsicinas and pharmacists to manage patients’ comorbidities and to simplify the comlex uses of the medications. In addition, it is also recomand to invite specialists or case managers to share information and together handle chronic comorbidities, such as diabetes, chronic obstructive pulmonary disease, etc. In terms of mental health, the PHQ-9 scale can be used to screen depression symptoms in a timely manner to facilitate early detection, proper treatment and long-term follow-up for the HF patients. The nurses can provide selfcare knowledge and management skills via supporting groups or educational clinics to fulfill the HF patients’ unmet needs. The 30-items Chinese version of the Heart Failure Needs Assessment Questionnaire (HFNAQ) has satisfactray reliability and validity and can be used to understand the different domain of needs from the HF patients as well as to provide patient-centered care plans to meet individual needs.