Is heart failure survival improving? evidence from 2323 elderly patients hospitalized between 1989–2000

doi:10.1016/S0002-8703(03)00116-9

American Heart Journal

Volume 146, Issue 1, July 2003, Pages 111-114

https://doi.org/10.1016/S0002-8703(03)00116-9 Get rights and content

Abstract

Background

While drug therapy and medical management improved markedly over the last decade, the basic clinical characteristics of the heart failure patient population treated at the study hospital changed little. This offers an excellent opportunity to study potential heart failure survival improvements for a general patient population.

Methods

Vital status follow-up through 2001 was obtained from the Social Security Death Index for all 2323 patients aged ≥65 years at the time of an initial, medically managed heart failure hospitalization between October 1989 and March 2000. Kaplan Meier survival probabilities were compared across 4 time periods in the 1990s. A Cox proportional hazards model was used to estimate age, sex, race and comorbidity-adjusted differences in survival among patients admitted in 1989–1991 and 3 subsequent multi-year periods.

Results

There was an increase in the proportion of older female patients with more chronic conditions. Compared with patients admitted in 1989–1991, survival probabilities for patients admitted in 1999–2000 had improved about 5% at 30 days (to 95%) and 10% at 1 year in 1999–2001 (to 73.5%). For those admitted between 1989–1998, there was a 9% improvement over 1989–1991 at 5 years (to 36%). Hazards model results indicated that patients admitted in 1999–2000 had a relative risk of death only 66% that of patients admitted in 1989–1991 (P < .0001).

Conclusions

These findings provide evidence of modest but significant short-term survival improvements, particularly after 1998, when drug therapy had became optimal in the inpatient setting, patient education and discharge planning became better documented, and inpatient mortality rates had declined substantially.

Section snippets

Patient population and follow-up

The study was approved by the Northwestern University Institutional Review Board. Study data on baseline admissions were derived from computerized hospital case mix files from October 1989 through March 2000. All records for all individuals aged ≥65 years admitted to the study hospital for medically managed heart failure, as defined by Diagnosis Related Group (DRG) 127 were identified. The chronologically first DRG127 admission was then used as the cohort inception point. Patients with a

Results

Table Iprovides baseline data on the initial admissions of all older patients with heart failure by period of admission. There was a small increase in the proportion of older, female patients and those with a Charlson score >2. There was a significant 3.8% increase in the proportion of African American patients. The largest changes were the 24% drop in mean length of stay (P < .0001) and a 4.6% decline in the inpatient death rate between the first and last study periods (P = .01).

Table II

Discussion

This study updates previously reported findings from several large chart review studies conducted at the study institution in the early 1990s.1, 2, 3 Despite major improvements in angiotensin-converting enzyme (ACE) inhibitor, digoxin, diuretic, β-blocker, and calcium-channel blocker therapy since the mid-1980s, analyses of survival and readmission rates found little improvement for patients with either preserved systolic function or systolic dysfunction through 1994. Since 1997, the study

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Literature and new innovations leading to the rise and fall of the Swan-Ganz catheter
2020, Journal of Anesthesia History
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Another study also showed a decrease in in-hospital mortality in patients with PACs with heart failure or cardiogenic shock versus those without PACs.69 It is important to note that the in-hospital mortality for heart failure has also declined over these years due to improved pharmacologic therapies and increased quality of care.70,71 From Frossmann’s self-experimentation case reports to Cournand and Richards’ case series, and the creation of the Swan-Ganz pulmonary artery catheter (see Table 2), the rich history and literature surrounding the Swan-Ganz pulmonary artery catheter rose to being routine in practice in the 1970s to mid-1990s, before the decline in its use.
In 1970, Harold James Charles Swan and William Ganz published their work on the pulmonary artery catheter (PAC or Swan-Ganz catheter). They described the successful bedside use of a flow-directed catheter to continuously evaluate the heart, and it was used extensively in the years following to care for critically ill patients. In recent decades, clinicians have reevaluated the risks and benefits of the PAC.
We acknowledge the contributions of Swan and Ganz and discuss literature, including randomized controlled trials, and new technology surrounding the rise and fall in use of the PAC.
We performed a literature search of retrospective and prospective studies, including randomized controlled trials, and editorials to understand the history and clinical outcomes of the PAC.
In the 1980s, clinicians began to question the benefits of the PAC. In 1996 and 2003, a large observational study and randomized controlled trial, respectively, showed no clear benefits in outcome. Thereafter, use of PACs began to drop precipitously. New less and noninvasive technology can estimate cardiac output and blood pressure continuously.
Swan and Ganz contributed to the bedside understanding of the pathophysiology of the heart. The history of the rise and fall in use of the PAC parallels the literature and invention of less-invasive technology. Although the PAC has not been shown to improve clinical outcomes in large randomized controlled trials, it may still be useful in select patients. New less-invasive and noninvasive technology may ultimately replace it if literature supports it.
Access to heart failure care post emergency department visit: Do we meet established benchmarks and does it matter?
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The Canadian Cardiology Society recommends that patients should be seen within 2 weeks after an emergency department (ED) visit for heart failure (HF). We sought to investigate whether patients who had an ED visit for HF subsequently consult a physician within the current established benchmark, to explore factors related to physician consultation, and to examine whether delay in consultation is associated with adverse events (AEs) (death, hospitalization, or repeat ED visit).
Patients were recruited by nurses at 8 hospital EDs in Québec, Canada, and interviewed by telephone within 6 weeks of discharge and subsequently at 3 and 6 months. Clinical variables were extracted from medical charts by nurses. We used Cox regression in the analysis.
We enrolled 410 patients (mean age 74.9 ± 11.1 years, 53% males) with a confirmed primary diagnosis of HF. Only 30% consulted with a physician within 2 weeks post-ED visit. By 4 weeks, 51% consulted a physician. Over the 6-month follow-up, 26% returned to the ED, 25% were hospitalized, and 9% died. Patients who were followed up within 4 weeks were more likely to be older and have higher education and a worse quality of life. Patients who consulted a physician within 4 weeks of ED discharge had a lower risk of AEs (hazard ratio 0.59, 95% CI 0.35-0.99).
Prompt follow-up post-ED visit for HF is associated with lower risk for major AEs. Therefore, adherence to current HF guideline benchmarks for timely follow-up post-ED visit is crucial.
Long-term outcome after a first episode of heart failure. A prospective 7-year study
2010, International Journal of Cardiology
Citation Excerpt :
Several medical and interventional therapeutic strategies have been proven effective in reducing mortality in patients with HF. It has been reported that HF carries a poor long-term prognosis [2–11]. In Europe, several studies performed in the 1990s have assessed the long-term survival in patients with HF [5–9, 12–14].
Heart failure (HF) is a major issue of public health in contemporary aging populations. The objectives of the present study were to assess the long-term survival of a contemporary cohort of patients discharged after a first hospitalization for HF and identify variables associated with adverse outcome.
We prospectively included consecutive patients (n = 735) discharged from 11 healthcare establishments of the Somme department (France) after a first hospitalization for HF during 2000. The 7-year observed survival was compared with the expected survival of the general population.
Mean age of the study group was 75 ± 12 years and 48% of patients were women. Left ventricular ejection fraction was measured in 628 patients (85%). During the 7-year follow-up, 483 patients (67%) died. The 5- and 7-year observed survival rates were dramatically lower than the expected survival of the matched general population (42% vs. 70%, and 33% vs. 59%, respectively). Relative survival (observed/expected survival) was 60% at 5 years and 55% at 7 years. Multivariable analysis identified cancer, stroke, diabetes, prior myocardial infarction, chronic obstructive pulmonary disease, chronic atrial fibrillation, age, and hyponatraemia as independent predictors of 7-year mortality.
In Europe, the long-term outcome of patients with new-onset HF is still extremely poor. Better implementation of guideline-oriented therapeutic strategies is needed to improve prognosis of this increasingly prevalent condition.
Mortality After Hospitalization for Heart Failure in Blacks Compared to Whites
2010, American Journal of Cardiology
Citation Excerpt :
From these, we identified 95 potentially eligible articles and examined the full text of each. Of the 95 reports, 27 met the eligibility criteria,1–27 and 2 of these articles reported multiple cohorts of hospitalized patients.8,21 This selection resulted in a total of 29 eligible cohorts.
Heart failure (HF) disproportionately affects black compared to white Americans, and overall mortality from HF is greater among blacks. Paradoxically, mortality rates after a hospitalization for HF are lower in black than in white patients. These racial differences might reflect hospital, physician, and patient factors and could have implications for comparative hospital profiles. We identified published studies reporting the posthospitalization mortality for black and white patients with a discharge diagnosis of HF and conducted random-effects meta-analyses with the outcome of all-cause mortality. We included 29 cohorts of hospitalized black and white patients with HF. The unadjusted mean mortality rate after HF hospitalization for black and white patients, respectively, was 6% and 9% for in-hospital, 6% and 10% for 30-day, 10% and 15% for 60- to 180-day, 28% and 34% for 1-year, and 41% and 47% for >1-year follow-up, respectively. The unadjusted combined odds ratios for mortality in black versus white patients ranged from 0.48 for in-hospital (95% confidence interval [CI] 0.45 to 0.51) to 0.77 after >1 year follow-up (95% CI 0.75 to 0.79). In meta-analyses using adjusted data, the combined odds ratio was 0.68 for short-term mortality (95% CI 0.63 to 0.74), and the combined hazard ratio was 0.84 for long-term mortality (95% CI 0.77 to 0.91). In conclusion, mortality after hospitalization for HF was 32% lower during short-term follow-up and 16% lower during long-term follow-up for black than for white patients. The mortality differences imply unmeasured differences by race in clinical severity of illness at hospital admission and might lead to biased hospital mortality profiles.
Consultation with cardiologists for persons with new-onset chronic heart failure: A population-based study
2009, Canadian Journal of Cardiology
It is recommended that persons recently diagnosed with heart failure consult with a specialist in heart failure.
To determine whether patients who were diagnosed with new-onset chronic heart failure (CHF) by a noncardiologist consulted with a cardiologist, and identify the factors associated with delayed consultation.
Physician reimbursement administrative data were obtained for all adults with suspected new-onset CHF in the year 2000 in Quebec, defined operationally as a physician visit for CHF (based on the International Classification of Diseases, 9th Revision diagnostic codes), with no previous physician visit code for CHF in the preceding three years. Among those first diagnosed by a noncardiologist, Cox regression modelling was used to identify patient and physician characteristics associated with time to cardiology consultation.
Of the 13,523 persons coded as having incident CHF, 54.9% consulted a cardiologist within the next 2.5 to 3.5 years, and 67.4% were seen by an internist or cardiologist. Older patients, women, and those with lower comorbidity and socioeconomic status had significantly longer times to cardiology consultation.
The data suggest that many patients with suspected new-onset CHF do not receive prompt cardiology care, as stipulated by current recommendations. Equity of access for women and those with lower socioeconomic status appears to be problematic.
On recommande aux personnes qui viennent de recevoir un diagnostic d’insuffisance cardiaque de consulter un spécialiste en la matière.
Déterminer si les patients qui ont reçu d’un non-cardiologue un diagnostic d’insuffisance cardiaque chronique (ICC) d’apparition récente ont consulté un cardiologue et identifier les facteurs associés au retard de la consultation.
Les données administratives sur la rémunération des médecins ont été obtenues pour toutes les consultations d’adultes soupçonnés de souffrir d’une ICC d’apparition récente au cours l’année 2000 au Québec, définies aux fins de la présente étude comme des consultations médicales pour ICC (selon la Classification internationale des maladies, 9^e révision des codes diagnostiques), sans code de visite médicale pour ICC au cours des trois années précédentes. Parmi les patients qui ont d’abord reçu leur diagnostic d’un non-cardiologue, le modèle de régression de Cox a été appliqué pour identifier les caractéristiques des patients et des médecins pouvant être associées à l’intervalle avant la consultation en cardiologie.
Parmi les 13 523 personnes à qui on a assigné le code d’ICC incidente, 54,9% ont consulté un cardiologue au cours des 2,5 à 3,5 années suivantes et 67,4% ont été vues par un interniste ou un cardiologue. Les patients plus âgés, les femmes et les patients présentant un statut comorbide et socioéconomique plus faible ont consulté significativement plus tardivement en cardiologie.
Les données laissent penser que de nombreux patients soupçonnés de souffrir d’une ICC d’apparition récente ne reçoivent pas de soins cardiologiques rapidement, comme le stipulent les recommandations actuelles. L’équité en matière d’accès aux soins pour les femmes et les personnes de plus faible statut socioéconomique semble problématique.
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All WCH inpatients with CHF International Classification of Diseases, Ninth Revision code in any position of the hospital list discharged alive.
Of 4,545 consecutive CHF admissions, only 10% enrolled and of those only 52.2% made a call. Enrollment in the program was related to: age (OR 0.64 per decade older, 95% CI 0.58-0.70), CHF as the main reason for admission (OR 3.58, 95% CI 2.4-4.8), previous admission for CHF (OR 1.14, 95% CI 1.09-1.2), and shorter hospital stay (OR 0.94 per day longer, 95% CI 0.87-0.99). Among DMP participants mortality rates were lowest in the first month (80/1000 person-years) and increased subsequently. The opposite mortality trend occurred in nonenrolled groups with mortality in the first month of 814 per 1000 person-years in refusers and even higher in ineligible (1569/1000 person-years). This difference remained significant after adjustment. Re-admission rates were lower among participants who called consistently (adjusted incidence rate ratio 0.62, 95% CI 0.52-0.77).
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^☆: Supported in part by a State of Illinois Excellence in Academic Medicine Grant to Northwestern Memorial Hospital.

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Clinical investigations: congestive heart failureIs heart failure survival improving? evidence from 2323 elderly patients hospitalized between 1989–2000☆

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patient population and follow-up

Results

Discussion

Am J Med

Am Heart J

Am Heart J

J Clin Epidemiol

J Chron Dis

Am J Cardiol

Am J Med

Am Heart J

Clinical investigations: congestive heart failure
Is heart failure survival improving? evidence from 2323 elderly patients hospitalized between 1989–2000☆