A structural equation model examining associations between continuity of care, perceived control, and self-care and their impact on health-related quality of life and rehospitalization in chronically
Authors: Safstrom E , Arestedt K , Liljeroos M , Nordgren L , Jaarsma T , Stromberg A 
Published: October 2022

Abstract

Introduction
Poor health-related quality of life (HRQoL) and high health care utilization are common in more severe cardiac disease. Prior research reveals that continuity of care, self-care, and perceived control are fundamental factors for improving clinical and patient-reported outcomes, especially in the post-hospital period. However, there is a lack of knowledge regarding the complex relationships between these factors and their influence on outcomes such as HRQoL and rehospitalizations.

Aim
To examine if a conceptual model including the associations between continuity of care, perceived control, and self-care could explain variations in HRQoL and rehospitalizations in chronic cardiac conditions after an unplanned hospitalization.

Method
Patients hospitalized due to angina, atrial fibrillation, heart failure, and myocardial infarction and suffering from at least one other co-morbid condition from 4 hospitals were consecutively invited to participate in the study. They completed a battery of questionnaires 6 weeks after discharge. Based on prior research, a conceptual model was formulated, including continuity of care (Patient Continuity of Care Questionnaire 12-item version), perceived control in relation to the heart condition (Item 1 from Control Attitude Scale), self-care (Self Care of Chronic Illness Inventory), and HRQoL (Eq5d-5L) and rehospitalization (Figure 1). The model was evaluated using Structural Equation Modeling, and the criteria for model fit were: root means square error of approximation (RMSEA) ≤0.08, Comparative fit index (CFI) of ≥0.90, Tucker-Lewis index (TLI) of &gt;0.90.

Results
In total, 542 patients were included (mean age 75 years (SD = 9) 37% females). The conceptual model (Figure 2) had an acceptable model fit: RMSEA = 0.058, 90% CI, 0.055–0.061; CFI= 0.903; TLI= 0.896.
As hypothesized, a positive association between continuity of care and self-care was found (β=0.404 p&lt;0.001), indicating that perceiving continuity of care facilitates self-care. Further, continuity of care was associated with perceiving control over the heart condition (β= 0.195 p&lt;0.001), which was positively associated with self-care (β= 0.111 p 0.023), indicating that perceiving control has a positive influence on self-care. Further, self-care was associated with good health-related quality of life (β=−0.232 p&lt;0.0001, and not being rehospitalized (β=−0.189 p=0.033) (Figure 2).

Conclusion
The present study indicates that patients who perceive continuity of care experience a higher perceived control over their heart condition and perform more sufficient self-care, significantly improving health-related quality of life and reducing the risk of rehospitalizations. Our analyses revealed important relationships between continuity of care, perceived control, and self-care and that these concepts are important targets for interventions to improve quality of life and health care utilization.

Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medical Research Council of Southeast Sweden.Center for clinical research Sörmland/Uppsala University