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The recent publication of the 2009/10 national heart failure audit report on over 21000 patients hospitalised with heart failure1 has not been lost on either the tabloids or broadsheets,2 3 where cries of ‘unnecessary deaths’ and a ‘lottery’ of care are not without justification. What we learn from the more measured terms of Cleland et al4 (see page 876), based on the 2008/09 audit, and data from just over six thousand patients hospitalised with decompensated heart failure, is a not dissimilar and equally salutary message. The overall mortality during an index admission with heart failure is 12%, but whereas in those patients who are looked after on a specialist cardiovascular ward this figure drops, it increases for those whose care continues on general medical wards. This translates into a twofold increase in the risk of death for those whose care does not include management on cardiovascular wards. Even when adjustments were made for age and other predictors of poor outcome this relationship held.
The impact of this index inpatient care also determined longer term outcomes: patients who went home from general medical wards being less likely to survive than those who had been cared for on specialised cardiovascular wards, with a median follow-up of 158 days. With the modelling of 12 month outcomes, where adjustments were made for identified predictors of outcome, the relationship between index ward of care and likelihood of death persisted. This influence only disappeared when the model adjusted for the influence of follow-up by cardiology/heart failure services.
Age is identified as a powerful predictor of mortality during the index admission, so it is of interest that patients managed on cardiovascular wards tended to be younger and more often male. They were also more likely to have an ejection fraction below 40% which did not predict …