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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