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USE OF MEDICAL RESOURCES AND QUALITY OF LIFE OF PATIENTS WITH CHRONIC HEART FAILURE: A PROSPECTIVE SURVEY IN A LARGE COMMUNITY HOSPITAL IN ITALY *Maria
C. Albanese, MD, #°Michal Plewka MD, #Dario Gregori, PhD,
*Claudio Fresco, MD, +Giorgio Avon, MD, +Donato Caliandro,
MD, +Libero Grassi, MD, +Paolo Rossi, MD, +Paolo
Udina, MD, +Alessandro Bulfoni, MD, +Roberto Colle, MD, *#Paolo
M. Fioretti, MD, PhD, FESC *Department
of Cardiology and +Departments of Internal Medicine, Santa Maria
della Misericordia Hospital and #IRCAB Foundation, Udine, Italy, °Department
of Cardiology, Medical University of Lodz, Poland. Address
for correspondence: Maria C. Albanese, MD Department of Cardiology, Santa Maria della
Misericordia Hospital P.le Santa Maria della
Misericordia, 15, 33-100 Udine, Italy Tel. +39-432-552440 Fax +39-432-482353 E-mail:
ircab@mail.conecta.it Abstract Aims To assess the prevalence, clinical characteristics, use of medical resources and quality of life in consecutive patients with chronic heart failure (CHF) hospitalised in a large community hospital during 3 months. Methods and Results The study group included 354 patients with CHF, admitted in the Departments of Internal Medicine (97%) and Cardiology. Median age was 78 years [72;85], 45% were males. CHF was the main diagnosis in 72%; 28% were in NYHA class III and 49% in class IV; 42% had atrial fibrillation. Median hospital stay was 8 days [5;14], in-hospital mortality 12%. Patients with CHF occupied 15% of the beds, 1330 ECG’s, 389 chest X-rays, 112 echocardiograms and 10 coronary angiograms were performed. A quality of life questionnaire revealed that 82% had problems with mobility, 54% with self-care, 88% with everyday activity. Thirty-nine percent of patients had at least 1 hospitalisation during the previous year. Conclusions Ninety-seven percent of hospitalised patients with CHF are admitted in the Internal Medicine wards and occupy 15% of beds. The majority of the patients are 72 years or older, with severe heart failure. The frequency of rehospitalization(s) and mortality rate in this population remains high. Echocardiography is performed only in 27% of patients. Key words: heart failure, health economics Introduction Chronic heart failure (CHF) is a major public health problem due to the increasing incidence, the high costs of long-term drug treatment and the frequent hospitalisations. Epidemiological data show an incidence in the general population ranging from 1 to 5 new cases/1000/ year, increasing with age to more than 30 new cases/1000/year among people over 75 years (1-5). Heart failure in the elderly may by a different syndrome from that encountered in younger population because of co-morbid disorders, interaction of multiple aetiologies, concomitant medications, compliance and diagnostic difficulty (5). There are many studies on CHF in Cardiology Departments, however a considerable number of patients with CHF are managed in other hospital departments, mainly Internal Medicine and there are few data describing those population (6-9). The aim of the study was a in prospective survey on prevalence, clinical characteristics, treatment, use of medical resources and quality of life in patients hospitalised for CHF in a large community hospital. Methods The study group included consecutive patients with CHF hospitalised in Santa Maria della Misericordia Hospital in Udine, Italy, in four Internal Medicine Departments (total number of beds- 243) and in the Department of Cardiology (33 beds) during a 3 month period between march and may 1998. The diagnosis of CHF was based on presence of at least two major or one major and two minor criteria for heart failure, as previously described (10). Major criteria were: paroxysmal nocturnal dyspnoea, orthopnoea, pulmonary congestion and presence of a third heart sound. Minor criteria were: signs of peripheral venous congestion, dyspnoea, and <400m walk without symptoms during normal daily activity. A questionnaire (including clinical characteristics at admission, in-hospital outcomes, co-morbidities, use of cardiological tests, nursing workload and treatment at discharge) was developed for this study. The data were collected by a dedicated nurse. In addition, patients were asked to answer a quality of life questionnaire (EuroQol; including mobility, self-care, everyday activity, and presence depression or anxiety) and a patient health score (1- the worse health status, 10- the best health status) was collected as well (11). A written informed consent was obtained from each patient. Statistical Methods Extensive exploratory data analysis has been performed on the survey data. Summary statistics for continuous variables were expressed as median values and interquartile difference (first and third quartile). Categorical variables has been analysed in terms of percentages. Significance has been based on a non-parametric approach. In particular the Wilcoxon Rank Sum Test has been used to detect difference among samples. The nominal level of significance has been taken equal to 0.05. Missing values has been excluded from the analysis on a pair-wise base. Computations has been performed in S-plus using the Hmisc and Design libraries (12). Results During 3 months period 354 patients with CHF were hospitalised in the 5 hospital departments, 97% of them in the Departments of Internal Medicine. Demographic and clinical characteristics of the study population at the hospital admission are summarised in Table 1. Median age was 78 years [72; 85], 55% were female. In 42% the aetiology of CHF was ischemic, in 45% non-ischemic and in 13% unknown. Median heart rate was 95 bpm [80; 110], median systolic blood pressure 150 mmHg [124; 170] and median diastolic blood pressure 90 mmHg [70; 90]. Atrial fibrillation was present in 42% of cases. CHF was the primary diagnosis at admission in 72% of patients. Fifty percent of patients were in New York Heart Association (NYHA) class IV, 28% in class III and 22% in class I-II. The hospitalisation was urgent in 94% and elective in 6%. Eighty nine percent of patients were admitted from home, 9% transferred from another department and 2% from another hospital. All patients had at least one co-morbidity (Table 2). The most common were pulmonary diseases (32%). Cardiological tests done during the hospital stay are summarised in Table 3. ECG and chest X-ray were performed in the vast majority of patients (93% and 88%, respectively). Echocardiography was done during present survey in 94 patients (27%), and any echocardiography had been done before hospitalisation in additional 10 patients. Median left ventricular ejection fraction (EF) was 44% [30; 63] In our group 39% of patients had at least 1 hospitalisation because of CHF and 25% had more than one visit in the out-patient clinic during the previous year. During the survey, bed occupacy by patients with CHF was 3811 bed-days (15% of the total bed occupacy) Median length of hospital stay was 8 days [5; 14]. There were no significant differences in length of stay between men and woman and patients with mild/ moderate and severe CHF. Eighty-two percent of patients were discharged from hospital and 6% transferred to another department or hospital. In-hospital mortality was 12% (42/354 patients), ranging from 1% (1/74 patients) in patients in NYHA class I/II to 15% (41/276 patients) in class III/IV (p<0.01). The nursing workload for the individual patients was small in 26%, medium in 49% and high in 22%. Patient’s and family’s education on discharge was made in 88% by physicians and in 12% by nurses, the median time dedicated for this was 3 minutes [1;10]. Pharmacological treatment on discharge is summarised in Table 4. Diuretics were administered to 88% of the patients, ACE-inhibitors to 76%, digitalis to 65%, nitrates to 45%, anticoagulant therapy to 25% , amiodarone to 8% and beta-blockers to 6%. No patients received calcium channel blockers. There were no significant differences in treatment between male and female. The results of the quality of life questionnaire are summarised in Table 5. The questionnaire revealed that 82% of patients with heart failure had problems with mobility, 54% with self-care, 88% with everyday activity, 80% had any kind of pain and 78% were depressed or anxious. Health was described as worse than one year before by 68% responders. Median patient health score (1- the worse health status, 10- the best health status) was 5 points [3; 5]. There was no significant difference in health score between men and women and between patients in NYHA class I-II and class III-IV. Discussion The present study was undertaken to assess the prevalence, clinical characteristics use of medical resources and quality of life in patients with CHF treated in a large community hospital. In the 3-month period 354 patients with CHF were admitted to the Santa Maria della Misericordia Hospital in Udine. Ninety-seven percent of them were treated in the Internal Medicine wards. Heart failure patients occupied 15% of beds in Internal Medicine and Cardiology Departments (3811 bed- days). This is a useful information for health providers, in order to quantify the size of the problem related to heart failure patients not only for cardiological but also internal medicine departments. Infact, the majority of the literature is dedicated to patients admitted in the Cardiology Departments, while present data represent a transmural, unselected hospital survey. Our data suggest, that what is seen in most cardiology wards may only be the top of an iceberg. Epidemiological studies show increasing incidence of CHF in the general population following by growing number of hospital admission (1-5). In Sweden there were about 10000 hospital admissions because of CHF during 1977, 14000 during 1981 and over 32000 during 1989. The admissions resulted in ca. 383000, 608000 and 1500000 days of hospital care, respectively (4). The incidence and the prevalence of heart failure increased markedly with the age. In Italy the prevalence of heart failure in consecutive patients admitted to geriatric departments was 43% in those aged 65-74 and 58% in those over 85 years (13). It has been also estimated that heart failure in Italy accounts for about 777000 days of cardiological bed occupation per year (10). Clinical characteristics As previously mentioned, there is a gap between the clinical characteristics of population studied in pharmacological trials and those seen in Cardiology Departments (5,10). Our study showed that there is a further discrepancy between patients admitted in the Cardiology and Medical Departments. In our study the median age was 78 years and 75% of patients were older than 72 years, 55% were female, 78% were in NYHA class III and IV, but with relatively well preserved left ventricular ejection fraction (EF >40% in 54% of patients, median EF=44%). All patients in our group had at least one co-morbidity. Previous studies show that patients with CHF treated in Cardiology Departments are generally younger (50-70 years) with higher proportion of males, with advanced systolic dysfunction and generally without co- morbidities (5). In the EARISA study - a recent registry of patients hospitalised in Cardiology Departments in Italy- only 34% of 1089 patients with CHF were over 74 years (14). In another Italian survey on 3921 patients (SEOSI) only 25% patients with CHF hospitalised in Cardiology Departments were older than 75 years (10). Also Reis al al (8) reported that internists take usually care of older patients than cardiologists do (mean age 73 vs 69 years in Cardiology Department). Further, we found that the majority of patients admitted in the Internal Medicine Department had a severe CHF (50% in NYHA class IV and 28% in class III). In contrast, the SEOSI study reported only 13% of patients in NYHA class IV and 36% in class III in Cardiology Departments (10). Finally, the patients in Internal Medicine departments in our group had more often atrial fibrillation (42%) than the patients in Cardiology Departments in SEOSI study did (28%). Treatment According to the European Society of Cardiology (ESC) guidelines on the treatment of heart failure (15) the therapeutic approach to systolic left ventricular dysfunction in patients with CHF in the elderly (>75 years) is identical to that in younger heart failure patients but should be applied more cautiously and dosages adapted due to altered pharmacodynamic and pharmacokinetic. Following the guidelines diuretics are essential for symptomatic treatment when fluid overload is present. In our study diuretics were given to 88% of patients. Cardiac glycosides are specifically indicated in patients with heart failure and with atrial fibrillation with a fast ventricular rate, but also reduced the need for hospitalisation relative to placebo (1,917 vs 2,039 hospitalisations, respectively) in patients with heart failure and sinus rhythm (7). In our study 42% of patients had atrial fibrillation and 65% received digoxin. The most proven therapy in heart failure is the treatment with angiotensin converting enzyme (ACE) inhibitors (16-19), however despite the clear evidence of clinical and economic effectiveness (20) there are data in literature that ACE inhibitors are underused, especially in elderly patients (21). In a recently published questionnaire (9) general practitioners (GP’s) reported more frequent use of diuretic agent in mild and moderated CHF; internists were evenly split between diuretics and ACE inhibitors and cardiologists were more likely to use ACE- inhibitors. Cardiologists claimed a higher rate of prescribing three drugs (ACE- inhibitor, diuretics and digoxin) in combination. Reis et al reported that ACE- inhibitors are underused in patients with heart failure hospitalised in medical departments compared to those treated by cardiologists- respectively 46.1 % vs 57.1% of patients received ACE inhibitors at discharge (8). In our study ACE inhibitors were widely used (76% of patients). In patients with mild and moderate (NYHA I-II) and severe (NYHA III-IV) heart failure the percentage of ACE-inhibitors prescribed at discharge was similar, respectively 78% and 76%. Several studies demonstrated benefits with b-blockers therapy in patients with heart failure (22-24). Studies with b1 selective agents such metoprolol or bisoprolol revealed that those drugs could reduce the risk of worsening heart failure. Recent studies have reported a reduction in mortality and hospitalisation in patient with heart failure treated with non-selective b-blocker carvedilol (25). Heidenreich et al.(26) in a meta-analysis of randomised clinical trials found that survival benefits of b-blockers in patients with CHF was slightly higher for carvedilol than for another b-blockers, however the difference did not reach statistical significance. In the present study only 6% of patients were taking b-blockers. In patients in NYHA class I-II nine percent were taking b-blockers, but in patients with severe CHF, who encompassed 78% of our study group, only 3% were treated. As well known, very important in the management of patients with CHF, (especially old patients) is patients and family education about non-medical and medical treatment. We would stress, that time dedicated for this in the present study was extremely short (median- 3 minutes and in 75% of cases lower than 10 minuts).
Diagnostic evaluation of patients with CHF According to the Guidelines of the ESC echocardiography should be routinely used for the optimal diagnosis of heart failure (27). In the SEOSI study (10) echocardiography was the most frequently used technique in patients with heart failure (73%) confirming that in Italian Cardiology Departments ventricular function is preferentially assessed by echocardiography. Edep et al. (9) found that the evaluation of left ventricular function is performed by 92% of cardiologists, but only 69% of internists and 61% of GP’s. In another study only 34% of in-patients treated by generalists underwent echocardiography (8). It was also reported (9) that GP’s and internists use chest X- ray to establish diagnosis of CHF more often than cardiologists (73% vs 68% vs 47% respectively), whereas cardiologists more likely use an echocardiogram in making the initial diagnosis (48% vs 15% for GP’s and 22% for internists). In our group chest-X ray was done in 88 % of patients but any echocardiography only in 27% patients. This is probably due to access problem to echo-equipment in Internal Medicine Department. Coronary angiography was performed during the survey in 10 patients (3%). The rate is lower than reported in Cardiology Departments in the EARISA (14) and the SEOSI (10) study (11% and 7%, respectively), but in the SEOSI study the authors reported all examinations done within the previous 3 months and also those required according to the cardiologist at the visit (and no those done in the reality). In-hospital clinical outcome In the EARISA study the mean length of hospital stay for CHF was 5+/-5 days (14); in another study (8) the mean length of stay was shorter in patients hospitalised in medicine departments comparing to cardiology group (6.0 +- 5.3 days vs 6,9 +-4,7 days). In contrast, in our study the length of hospital stay was longer- median 8 days [5;14]. In addition, the in-hospital all-cause mortality was higher (12%) in our study than in the study of Reis et al (3,1%). This is very likely due to more severe CHF at admission in our patients (78% in NYHA class III and IV in our group and 43% in the study of Reis et al). We found similar very high rehospitalisation rate for heart failure in our hospital (39% of patients had had at least one hospitalisation in the previous year) as Reis et al did ( 44%). Quality of life In most clinical trails, the primary endpoint is mortality while quality of life measurement is often neglected. In our study group a quality of life questionnaire revealed that patients with heart failure had major general problems, like mobility (82%), self-care (54%), everyday activity (88%), any kind of pain (80%) and depression or anxiety (78%). Health was described as better by only 2% responders, compared to the previous year. Health score (1-the worst health status, 10- the best health status) was below 5 points in 75% of patients. Conclusions Ninety-seven percent of patients with congestive heart failure hospitalised in the large community hospital are admitted in the internal medicine wards and occupy 15% of beds. The vast majority of the patients are 72 years or older, with severe heart failure and very frequently one or more co-morbidities. Despite adequate treatment (with the exception of underuse of beta-blockers) the frequency of rehospitalization(s) and mortality rate in this population remains high. The diagnosis is more often based on clinical examination, ECG and chest X- ray than by more objective evaluation of heart function with echocardiography (only 27% of patients had an echocardiography, probably due to access problem). Quality of life questionnaire showed general disability in the great majority. More studies are required to find the most cost-effective strategy for the diagnosis and management of the increasing population with chronic heart failure. Dr M. Plewka was supported by a grant of the IRCAB Foundation, Udine, Italy. Acknowledgments: We would like to thank Mrs Luciana Giraldo for her assistance in the data
collection. References
Table 1. Demographic and clinical characteristics of the study population on admission to the hospital. Continuous variables are expressed as median [first; third quartile] and categorical variables as number of patients and percentage.
Table 2. Prevalence of
co-morbidities (n=354)
Table 3. Cardiological tests performed during the survey (n=354).
Table 4. Medication at discharge (%)
Table 5. Quality of life (n=354).
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