Discussion
The current study examined a new scale for measuring patient confidence
in self-management of AF. Initial reliability and validity metrics were
promising and suggest potential utility though further validation
testing is warranted. The CALM measure containing 16 self-report items
underwent principle component analysis and a four-factor solution was
identified. The major aspects included scales of external support,
awareness of change, self-care and relief, and safety. Additional
analyses indicated that a total confidence score could be derived and
was psychometrically sound. Confidence in AF was similar between men and
women, but significantly different between patients with and without a
documented anxiety disorder, those with the experience of cardioversion,
and those who have taken anti-arrhythmic medication.
These data suggest that background experiential variables may exert some
influence on perceptions of AF and QOL. Previous studies have linked the
experience of cardioversion with better QOL reports and the presence of
anxiety to worse QOL.16,17 The utility of the CALM was
further established, as total confidence was a significant predictor of
AF QOL, but only accounted for 14% of the variance. Therefore, this
initial work indicates that the CALM provides a brief, easy-to-use
in-clinic measure of patient confidence in AF self-management with some
promising validity that should be used in conjunction with QOL measures.
With additional validation and testing, AF confidence may serve as a
target for clinical interventions and ongoing clinical care. Confidence
in AF self-management could provide a process measure for achieving
successful self-care and better QOL.
Patient confidence or self-efficacy in managing chronic disease has been
well-examined and generally confidence tends to diminish as the illness
burden increases.18 This finding is particularly
relevant as patients with AF are likely to have multiple co-morbidities,
multiple treatment modalities, and multiple risk factors to address
suggesting a high degree of management burden.11Previous examination of confidence in AF self-management was completed
by employing an online survey of women with AF.10Results indicated that the most salient item of the survey emphasized,
“taking active role in my health is important in how I feel.”
Confidence in cardiovascular conditions has not been as well-studied but
when the construct of confidence was studied, researchers generally
focused on confidence in one target behavior.9
The awareness and measurement of patient attitudes and patient
confidence represents a new avenue for cardiac electrophysiology. The
history of cardiac electrophysiology has primarily focused on
technologic advances and procedural based improvements. The emergence of
data related to the potential value of risk factor management in AF has
prompted increased attention to multi-disciplinary care to improve
outcomes regardless of treatment strategy.19 The
identification of cardiac fitness, obesity, alcohol use, sleep apnea,
and other risk factors indicates that patients increasingly must be
equal partners with cardiac electrophysiology teams.20Psychological confidence represents a necessary, but not sufficient,
component of achieving better health outcomes. The introduction of a
brief, clinic-ready AF confidence measure (i.e. CALM measure) could
provide information about how patients perceive their capability and
potentially how patient education, and behavioral intervention are
likely to be effective. In short, patients who do not believe that they
are capable of acquiring sufficient social and informational support,
making changes, engaging in effective self-care and feeling safe again
to return to physical activities are probably less likely to benefit
without targeted intervention. Future research must examine this notion
empirically, but it seems plausible.
Despite the promise the CALM holds for understanding patient confidence
in self-management of AF, the study has some limitations. First, it
should be noted that the sample was mostly white (97%) with only one
Hispanic and two African American participants. Convenience sampling was
solely utilized in this round of testing of the CALM. Future studies
using the CALM should focus on more diverse samples in order to test the
generalizability of the findings. Secondly, the study was conducted
during COVID-19, therefore we cannot entirely exclude unknown potential
confounding effects of the pandemic. Patient experience and self-care
behaviors may not accurately represent this population’s reality under
non-pandemic conditions. Social support may be limited and may have
affected that set of items on the measure. Thus, continued research
using the CALM to understand patient confidence in self-management of AF
is needed considering the complexity of self-care, clinical management,
and understanding of AF. Further research is needed to establish
clinically meaningful cut-off scores to indicate the need for
intervention.
The current study establishes the reliability and validity of a new
patient reported outcome measure of confidence in atrial fibrillation,
The C onfidence in A trial FibriL lationM anagement (CALM) scale, providing a total score and subscales
of confidence. Additional analyses indicate that AF confidence is a
significant predictor of AF QOL. As multidisciplinary care for AF
continues to mature, greater attention and intervention on the patient
experience and psychological functioning will likely become important.
Preliminary data suggests the new measure, CALM, will benefit from
additional psychometric testing. We seek to make the measure widely
available for use at no charge for future research as we hope it becomes
a useful addition to understanding the patient experience alongside AF
QOL.
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