Patient- and provider-related determinants of generic and specific health-related quality of life of patients with chronic systolic heart failure in primary care: a cross-sectional study

The Effect of Benson's Relaxation Technique on Fatigue and Quality of Life of Patients Diagnosed With Heart Failure

Patients with heart failure (HF) reported poor quality of life (QOL) due to different reasons among which fatigue is the most important. Improving QOL is a crucial objective for patients with HF and their primary health care providers. Managing fatigue with medication is not enough. Benson's relaxation technique (BRT) is a complementary therapy used to manage fatigue among different populations with limited studies checking its effect among patients diagnosed with HF. The purpose of this quasi-experimental study was to check the effect of BRT on fatigue and QOL among 140 (68 intervention and 72 control) patients diagnosed with HF. Intervention group performed BRT for 20 minutes twice a day for 2 months. Control group received regular care from their health care providers. At baseline, there were no differences between intervention and control groups regarding fatigue, physical component summary, and mental component summary. At follow-up, intervention group had higher scores in physical and mental component summaries than control group (45.48 ± 10.52 vs 37.97 ± 14.78) and (46.22 ± 8.39 vs 41.01 ± 10.36), respectively. Also, intervention group had lower levels of fatigue than control group (2.54 ± 0.87 vs 6.33 ± 0.61). In conclusion, the use of BRT as a complementary therapy for patients with HF might decrease fatigue level and improve QOL.

Clinical and economic impact of ferric carboxymaltose treatment for iron deficiency in patients stabilized following acute heart failure: a multinational study

OBJECTIVE

To estimate clinical events and evaluate the financial implications of introducing ferric carboxymaltose (FCM) to treat iron deficiency (ID) at discharge in patients hospitalized for acute heart failure (AHF) with left ventricular ejection fraction (LVEF) <50% in the UK, Switzerland and Italy.

METHODS

A decision analytic cost-offset model was developed to evaluate the costs associated with introducing FCM for all eligible patients in three countries compared to a world without FCM, over a five-year time horizon. Data from AFFIRM-AHF clinical trial were used to model clinical outcomes, using an established cohort state-transition Markov model. Country-specific prevalence estimates were derived using data from real-world studies to extrapolate number of events and consequent cost totals to the population at risk on a national scale.

RESULTS

The cost-offset modeling demonstrated that FCM is projected to be a cost-saving intervention in all three country settings over a five-year time horizon. Savings were driven primarily by reduced hospitalizations and avoided cardiovascular deaths, with net cost savings of -£14,008,238, -CHF25,456,455 and -€105,295,146 incurred to the UK, Switzerland and Italy, respectively.

LIMITATIONS

Although AFFIRM-AHF was a multinational trial, efficacy data per country was not sufficiently large to enable country-specific analysis, therefore overall clinical parameters have been assumed to apply to all countries.

CONCLUSIONS

This study provides further evidence of the potential cost savings achievable by treating ID with FCM at discharge in patients hospitalized for AHF with LVEF <50%. The value of FCM treatment within the healthcare systems of the UK, Switzerland and Italy was demonstrated even within a limited time frame of one year, with consistent cost savings indicated over a longer term.

The association of general practitioners' awareness of depression and anxiety with change in quality of life in heart failure patients: results of the prospective observational RECODE-HF cohort study

BACKGROUND

Depression and anxiety are more prevalent in patients with heart failure (HF) than in the general population and reduce quality of life (QoL); therefore, clinical guidelines recommend screening HF patients for depression/anxiety.

OBJECTIVE

We investigated, whether the general practitioners' (GPs) awareness of patients' symptoms of depression and/or anxiety (psychosocial distress) was associated with a change in QoL.

METHODS

In this prospective observational study, we recruited 3,129 primary care HF patients in Germany. Patients completed baseline and 12-month follow-up questionnaires. Their GPs were interviewed. We identified 666 patients with psychosocial distress and compared 2 groups by analysis of covariance: 235 patients with psychosocial distress whose GP was aware of the psychosocial distress and 431 patients with psychosocial distress whose GP was unaware of such distress. Primary outcome was the change in QoL, assessed by the EQ-5D visual analogue scale.

RESULTS

Patients with psychosocial distress showed lower baseline QoL than those without (45.9 vs 64.1; P < 0.001). Within the patients with psychosocial distress, the GPs' awareness of psychosocial distress was not associated with improvement of QoL (F = 1.285; P = 0.258) or remission of psychosocial distress (odds ratio = 0.887; P = 0.608).

CONCLUSION

We found no association between the GPs' awareness of psychosocial distress and change in QoL. Although data for effective treatments of depression in HF are currently insufficient, psychosocial distress strongly impairs the QoL in HF patients. These findings might influence the development of clinical practice guidelines in HF.

Factors related to self-care behaviors among hospitalized patients with heart failure in Japan, based on the European Heart Failure Self-Care Behaviour Scale

[Purpose] The characteristics of heart failure in hospitalized patients with poor self-care behaviors are unknown. We investigated factors associated with self-care behaviors by using the European Heart Failure Self-Care Behaviour Scale (EHFScBS) in heart failure patients based on three comprehensive concepts. [Participants and Methods] This was a cross-sectional single-center study of heart failure patients hospitalized at a tertiary-care hospital. We investigated age, gender, family living together/apart, employment, and the Specific Activity Scale (SAS). A physical therapist provided the EHFScBS one time to determine the patients’ pre-hospital self-care behavior status. The 12 items of the EHFScBS were classified into the following three categories: Maintenance, Monitoring, and Management. [Results] The median age of the 39 consecutive patients was 81 years. A multiple regression analysis revealed that the factors exhibiting significant associations were the SAS score (β=0.504) for Management and age (β=−0.403) for the total EHFScBS score (adjusted by the number of hospitalizations for heart failure). Maintenance and Monitoring were not significantly associated with the survey items. [Conclusion] These data indicate that self-care education for hospitalized patients with heart failure leads to individualized approaches based on characteristics such as age and physical activity capacity.

[Study of the factors contributing to poor quality of life in chronic heart failure with reduced ejection fraction]

BACKGROUND

The increasing prevalence and poor prognosis associated with chronic heart failure (CHF) have made the improvement of quality of life (QoL) one of the main goals in the treatment of CHF patients. Since little is known about the QoL in Tunisian patients with heart failure (HF), the current study was performed to assess QoL in a sample of Tunisian patients hospitalized with HF and to identify factors related to QoL.

METHODS

In this prospective study, we evaluated patients with CHF attending the cardiology department of Habib Thameur University Hospital in a four-month period. Echocardiography was performed and patients with left ventricular ejection fraction of 45% or less were selected. QoL assessment was performed with a disease-specific instrument: the Minnesota Living with Heart Failure Questionnaire (MLHFQ) in a sample of 100 selected patients. Relationships between health-related QoL and the studied variables were examined with bivariate correlations and binary logistic regression analysis.

RESULTS

In the total sample (n = 100), mean age was 62.7 years. The majority were male (77%), married (76%), with a mean of 2.5 comorbidities, and in a New York Heart Association (NYHA) functional class III to IV (61%). Mean LVEF was 36%. Half of the patients had poor QoL on the total MLHFQ scale (median = 41.5) as well as on its physical (median = 17.5) and emotional (median = 11.25) domains. In univariate analysis, the following variables were related to poor QoL with p < 0.005: not being employed, suffering from hypertension, renal failure, anemia, being under a low-salt diet, having no regular physical activity, having the physical symptoms of HF, higher NYHA class and longer QRS duration. In multiple regression analysis, the main independent predictors of poor QoL on the total scale were higher NYHA functional class and renal dysfunction,. The data provided no evidence of an association between LVEF and QoL.

CONCLUSION

This study has found that higher NHYA functional class and chronic kidney disease are risk factors for impaired QoL, independently of disease severity among patients with heart failure.

Epidemiological profile, cardiopulmonary fitness and health-related quality of life of patients with heart failure: a longitudinal study

BACKGROUND

Heart failure (HF) is a severe and self-limiting syndrome. Its signs and symptoms are believed to predict poorer health-related quality of life scores, which are mainly influenced by deterioration in physical capacity. In the present study we try to analyze the influence of clinical and socioeconomic characteristics and physical capacity on the quality of life of people with HF diagnosis.

METHODS

A longitudinal study was conducted over 2 years with patients diagnosed with HF. To evaluate the patients the method of face-to-face visit and telephone monitoring was used. In the evaluations were applied: the Clinical and Socioeconomic Characterization Questionnaire, the Minnesota Living With Heart Failure Questionnaire (MLHFQ) for quality of life evaluation and the Veterans Specific Activity Questionnaire (VSAQ) for cardiopulmonary fitness analysis. Measures of central tendency, proportion, normality test, confidence intervals, comparison of data through paired Student t test and Wilcoxon or Mann Whitney test were performed and correlations were verified through Spearman coefficient.

RESULTS

The study included 108 patients, most of them female (50.90%) and mean age of 66.62 ± 11.33 years. The median time of HF diagnosis was 5 ± 6 years, being Chagas' disease the main etiologic cause for the disease (57.40%). As for the clinical condition, functional classes II (44.40%) and III (48.10%) of the New York Heart Association (NYHA) were the most frequent. There was a low cardiopulmonary fitness, with loss of capacity to perform daily activities (3 ± 1 to 3 ± 3) over the time of clinical follow-up. There was an increase in the MLHFQ instrument scores, from 50.98 ± 15.52 to 61.76 ± 19.95, over the analysis time. The analysis of correlations demonstrated that variables such as schooling, NYHA class, echocardiographic alterations and the drug profile have a significant relationship with the constructs of quality of life and physical fitness.

CONCLUSION

Individuals in HF have significant impairment of cardiorespiratory capacity and tend to present worsening of QL along the evolution of the disease.

Relación entre la capacidad de agencia de autocuidado y la calidad de vida en personas con insuficiencia cardiaca

Introducción. La persona con insuficiencia cardiaca enfrenta cambios biopsicosociales que deterioran su calidad de vida. Es necesario conocer la relación existente entre el autocuidado y la calidad de vida, lo que puede orientar al profesional de enfermería en el diseño de intervenciones efectivas. Objetivo. Determinar la relación existente entre la capacidad de agencia de autocuidado y la calidad de vida relacionada con la salud en las personas con insuficiencia cardiaca, que son atendidas en el programa multidisciplinario de insuficiencia cardiaca en una institución de salud de cuarto nivel en Bogotá, Colombia. Método. Estudio descriptivo correlacional de corte transversal, realizado entre mayo y agosto de 2018; utilizando los instrumentos Appraisal of Self-care Agency Scale y el Cuestionario de Cardiomiopatía de Kansas City; la muestra correspondió a 107 pacientes, mayores de edad, con insuficiencia cardiaca estadio C y D. Resultados. La capacidad de agencia de autocuidado se encontró en categorías alta con 63.55% y muy alta con 34.57%; la calidad de vida relacionada con la salud se encontró preservada, con un puntaje general de 73.33; la relación existente entre las dos variables, según el coeficiente de correlación de Spearman, fue 0.316 con un valor p = 0.002, relación débil pero significativa. Conclusiones. Existe una relación entre las variables de interés, que se reafirma con las correlaciones significativas identificadas entre las dimensiones que las conforman. Estos hallazgos resaltan la pertinencia de abordar, en las intervenciones, temáticas que fortalezcan la capacidad de agencia de autocuidado, contribuyendo a mejorar la calidad de vida de estas personas.

Association of Cardiac Biomarkers With the Kansas City Cardiomyopathy Questionnaire in Patients With Chronic Kidney Disease Without Heart Failure

Background The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a measure of heart failure (HF) health status. Worse KCCQ scores are common in patients with chronic kidney disease (CKD), even without diagnosed heart failure (HF). Elevations in the cardiac biomarkers GDF-15 (growth differentiation factor-15), galectin-3, sST2 (soluble suppression of tumorigenesis-2), hsTnT (high-sensitivity troponin T), and NT-proBNP (N-terminal pro-B-type natriuretic peptide) likely reflect subclinical HF in CKD. Whether cardiac biomarkers are associated with low KCCQ scores is not known. Methods and Results We studied participants with CKD without HF in the multicenter prospective CRIC (Chronic Renal Insufficiency Cohort) Study. Outcomes included (1) low KCCQ score <75 at year 1 and (2) incident decline in KCCQ score to <75. We used multivariable logistic regression and Cox regression models to evaluate the associations between baseline cardiac biomarkers and cross-sectional and longitudinal KCCQ scores. Among 2873 participants, GDF-15 (adjusted odds ratio 1.42 per SD; 99% CI, 1.19-1.68) and galectin-3 (1.28; 1.12-1.48) were significantly associated with KCCQ scores <75, whereas sST2, hsTnT, and NT-proBNP were not significantly associated with KCCQ scores <75 after multivariable adjustment. Of the 2132 participants with KCCQ ≥75 at year 1, GDF-15 (adjusted hazard ratio, 1.36 per SD; 99% CI, 1.12-1.65), hsTnT (1.20; 1.01-1.44), and NT-proBNP (1.30; 1.08-1.56) were associated with incident decline in KCCQ to <75 after multivariable adjustment, whereas galectin-3 and sST2 did not have significant associations with KCCQ decline. Conclusions Among participants with CKD without clinical HF, GDF-15, galectin-3, NT-proBNP, and hsTnT were associated with low KCCQ either at baseline or during follow-up. Our findings show that elevations in cardiac biomarkers reflect early symptomatic changes in HF health status in CKD patients.

Blended Collaborative Care to Treat Heart Failure and Comorbid Depression: Rationale and Study Design of the Hopeful Heart Trial

OBJECTIVE

Despite numerous improvements in care, morbidity from heart failure (HF) has remained essentially unchanged in recent years. One potential reason is that depression, which is comorbid in approximately 40% of hospitalized HF patients and associated with adverse HF outcomes, often goes unrecognized and untreated. The Hopeful Heart Trial is the first study to evaluate whether a widely generalizable telephone-delivered collaborative care program for treating depression in HF patients improves clinical outcomes.

METHODS

The Hopeful Heart Trial aimed to enroll 750 patients with reduced ejection fraction (HFrEF) (ejection fraction ≤ 45%) including the following: (A) 625 patients who screened positive for depression both during their hospitalization (Patient Health Questionnaire [PHQ-2]) and two weeks following discharge (PHQ-9 ≥ 10); and (B) 125 non-depressed control patients (PHQ-2(-)/PHQ-9 < 5). We randomized depressed patients to either their primary care physician's "usual care" (UC) or to one of two nurse-delivered 12-month collaborative care programs for (a) depression and HFrEF ("blended") or (b) HrEFF alone (enhanced UC). Our co-primary hypotheses will test whether "blended" care can improve mental health-related quality of life versus UC and versus enhanced UC, respectively, on the Mental Component Summary of the Short-Form 12 Health Survey. Secondary hypotheses will evaluate the effectiveness of our interventions on mood, functional status, hospital readmissions, deaths, provision of evidence-based care for HFrEF, and treatment costs.

RESULTS

Not applicable.

CONCLUSIONS

The Hopeful Heart Trial will determine whether "blended" collaborative care for depression and HFrEF is more effective at improving patient-relevant outcomes than collaborative care for HFrEF alone or doctors' UC for HFrEF.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02044211.

General practitioners' awareness of depressive symptomatology is not associated with quality of life in heart failure patients - cross-sectional results of the observational RECODE-HF Study

BACKGROUND

Depression is a common comorbidity in patients with chronic heart failure (HF) and linked to a wider range of symptoms which, in turn, are linked to a decreased health-related quality of life (HRQOL). Treatment of depression might improve HRQOL but detecting depression is difficult due to the symptom overlap between HF and depression. Therefore, clinical guidelines recommend to routinely screen for depression in HF patients. No studies have so far investigated the treatment after getting aware of a depressive symptomatology and its correlation with HRQOL in primary care HF patients. Therefore, we examined the factors linked to depression treatment and those linked to HRQOL in HF patients. We hypothesized that GPs' awareness of depressive symptomatology was associated with depression treatment and HRQOL in HF patients.

METHODS

For this observational study, HF patients were recruited in primary care practices and filled out a questionnaire including PHQ-9 and HADS. A total of 574 patients screened positive for depressive symptomatology. Their GPs were interviewed by phone regarding the patients' comorbidities and potential depression treatment. Descriptive and regression analysis were performed.

RESULTS

GPs reported various types of depression treatments (including dialogue/counselling by the GP him/herself in 31.8% of the patients). The reported rates differed considerably between GP-reported initiated treatment and patient-reported utilised treatment regarding psychotherapy (16.4% vs. 9.5%) and pharmacotherapy (61.2% vs. 30.3%). The GPs' awareness of depressive symptomatology was significantly associated with the likelihood of receiving pharmacotherapy (OR 2.8; p < 0.001) but not psychotherapy. The patient's HRQOL was not significantly associated with the GPs' awareness of depression.

CONCLUSION

GPs should be aware of the gap between GP-initiated and patient-utilised depression treatments in patients with chronic HF, which might lead to an undersupply of depression treatment. It remains to be investigated why GPs' awareness of depressive symptomatology is not linked to patients' HRQOL. We hypothesize that GPs are aware of cases with reduced HRQOL (which improves under depression treatment) and unaware of cases whose depression do not significantly impair HRQOL, resulting in comparable levels of HRQOL in both groups. This hypothesis needs to be further investigated.

Budget impact of intravenous iron therapy with ferric carboxymaltose in patients with chronic heart failure and iron deficiency in Germany

Aims

Treatment of iron deficiency (ID) in patients with heart failure (HF) with intravenous iron substitution [ferric carboxymaltose (FCM)] has previously shown significant improvements in exercise capacity, New York Heart Association (NYHA) functional class, quality of life, and reduction of hospitalization. The aim of this study was to estimate the budget impact of FCM treatment for patients with HF and ID.

Methods and results

Individual patient data from four double‐blind randomized controlled trials were pooled for this analysis. Expected outcomes were modelled for a treatment period of 1 year, using multivariate statistical methods. Associated unit costs were derived from claims data. Budget impact was calculated from the perspective of the Statutory Health Insurance. Multiple deterministic sensitivity analyses were performed. The annual budget impact for therapy with FCM vs. no‐iron therapy was €2 735 505 and €2 695 474 for 1000 patients, respectively, resulting in additional annual costs of €40.03 for each treated patient. Main costs drivers are the FCM treatment cost and cost of hospitalizations due to HF worsening. FCM therapy compared with no‐iron therapy resulted in reduced cost per 1000 patients: for reduced hospitalization due to HF worsening (52 vs. 129 hospitalizations amounting to €230 591 vs. €597 078), for reduced other medication (€1 611 007 vs. €1 679 908), fewer outpatient visits (€332 523 vs. €378 019), and home visits (€29 627 vs. €40 469). Sensitivity analyses showed robustness of the results.

Conclusions

Therapy with FCM has a minimal budget impact of €40 031 per 1000 patients per year. This budget impact translates into reduced and shorter hospitalizations and improved symptomatic status of the patients.

Health-related quality of life in hypertrophic cardiomyopathy patients with implantable defibrillators

Background

Health-related quality of life (HRQL) in hypertrophic cardiomyopathy (HCM) patients with implantable cardioverter-defibrillators (ICDs) is largely unknown. The aim was to assess HRQL, including comparisons between groups, using the questionnaire SF-36, and compare it to a Swedish age- and sex-matched population.

Methods and Results

Validated data on adult HCM patients with ICDs were used. The SF-36 response rate was 82.5 % and 245 patients (mean age 55.9 years, 70.2 % men) were analyzed using the Mann-Whitney U-test, t-test, Spearman correlation and effect size calculations. In all SF-36 domains the patients’ score was lower (p-value of <0.0001) than norms except for bodily pain. The general health domain showed the highest effect size (0.77) and the impact was more pronounced in the SF-36 physical component summary score (0.62) than the mental component summary score (0.46). Older age was correlated with lower scores on the physical component and higher scores on the mental component. Atrial fibrillation and/or systolic heart failure were associated with worse physical health. HRQL was similar in primary vs secondary prevention cases. Inappropriate ICD shock was associated with worse mental health while appropriate therapy trended toward better mental health.

Conclusion

HCM patients with ICDs suffer from poor HRQL regardless of age, sex, or primary vs secondary prevention indication. Atrial fibrillation and systolic heart failure are determinants of poor physical health. Inappropriate shocks, but not appropriate therapies, are associated with poorer mental health.

Self Managing Heart Failure in Remote Australia - Translating Concepts into Clinical Practice

Congestive heart failure (CHF) is an ambulatory health care condition characterized by episodes of decompensation and is usually without cure. It is a leading cause for morbidity and mortality and the lead cause for hospital admissions in older patients in the developed world. The long-term requirement for medical care and pharmaceuticals contributes to significant health care costs. CHF management follows a hierarchy from physician prescription to allied health, predominately nurse-led, delivery of care. Health services are easier to access in urban compared to rural settings. The differentials for more specialized services could be even greater. Remote Australia is thus faced with unique challenges in delivering CHF best practice. Chronic disease self-management programs (CDSMP) were designed to increase patient participation in their health and alleviate stress on health systems. There have been CDSMP successes with some diseases, although challenges still exist for CHF. These challenges are amplified in remote Australia due to geographic and demographic factors, increased burden of disease, and higher incidence of comorbidities. In this review we explore CDSMP for CHF and the challenges for our region.

Bridging the gap between patient needs and quality indicators: a qualitative study with chronic heart failure patients

BACKGROUND

The German National Disease Management Guideline (NDMG) on chronic heart failure (CHF) derived nine clinical quality indicators (QIs) to enable assessment of quality of health care in patients with CHF. These QIs epitomize an evidence-based and somatic point of view of guided treatment, but little is known about the experiences and views of patients with their guideline-based treatment across multiple health care sectors.

OBJECTIVE

The purpose of this qualitative study was to explore patient perspectives on guided treatment of CHF across multiple health care sectors. Furthermore, it was investigated to what extent patient perspectives are represented by the QIs of the German NDMG.

METHODS

Using a qualitative approach, semistructured interviews were carried out with 17 CHF patients. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using qualitative content analysis.

RESULTS

Patient-identified needs focused primarily on aspects like the doctor-patient relationship, communication, quality of individual-tailored information, and professional advice. Patients perceived shortcomings in processes of care such as communication and cooperation across health care sectors, especially at the transition between hospital and outpatient care.

DISCUSSION

From the patient perspectives, the QIs do represent relevant somatic and clinical aims for quality measurement. However, deficits were identified, especially related to communication and cooperation across health care sectors. Given the fact that the inclusion of patient perspectives in quality improvement processes provides an important contribution to patient-centered health care, possible approaches for QI development such as direct and indirect patient involvement or generic vs disease-specific patient-related QIs should be the subject of future discussions.

A Description of Inpatient Palliative Care Actions for Patients With Acute Heart Failure

In a recent randomized trial, inpatient palliative care (PC) visits were associated with improved quality of life and symptom burden for patients with heart failure. To better understand what actions by PC providers may have led to those outcomes, we conducted chart reviews of 101 patients in the intervention group (who received PC). Palliative care actions are described for all patients and for those with higher symptoms. Orders were written for 24% of patients, most frequently for pain. Recommendations to change current care were made for 40% of patients. At least 1 element of future care planning was documented for 99% of patients. Palliative care for inpatients with HF led to additive actions beyond standard care, especially for pain, and promoted HF-specific goals of care discussions.

Quality of Life for Saudi Patients With Heart Failure: A Cross-Sectional Correlational Study

Introduction:

Heart failure is a major public health issue and a growing concern in developing countries, including Saudi Arabia. Most related research was conducted in Western cultures and may have limited applicability for individuals in Saudi Arabia. Thus, this study assesses the quality of life of Saudi patients with heart failure.

Materials and Methods:

A cross-sectional correlational design was used on a convenient sample of 103 patients with heart failure. Data were collected using the Short Form-36 and the Medical Outcomes Study-Social Support Survey.

Results:

Overall, the patients’ scores were low for all domains of Quality of Life. The Physical Component Summary and Mental Component Summary mean scores and SDs were (36.7±12.4, 48.8±6.5) respectively, indicating poor Quality of Life. Left ventricular ejection fraction was the strongest predictor of both physical and mental summaries.

Conclusion:

Identifying factors that impact quality of life for Saudi heart failure patients is important in identifying and meeting their physical and psychosocial needs.

Determinants of Utility Based on the EuroQol Five-Dimensional Questionnaire in Patients with Chronic Heart Failure and Their Change Over Time: Results from the Swedish Heart Failure Registry

BACKGROUND

There is limited information on drivers of utilities in patients with chronic heart failure (CHF).

OBJECTIVES

To analyze determinants of utility in CHF and drivers of change over 1 year in a large sample from clinical practice.

METHODS

We included 5334 patients from the Swedish Heart Failure Registry with EuroQol five-dimensional questionnaire information available following inpatient or outpatient care during 2008 to 2010; 3495 had 1-year follow-up data. Utilities based on Swedish and UK value sets were derived. We applied ordinary least squares (OLS) and two-part models for utility at inclusion and OLS regression for change over 1 year, all with robust standard errors. We assessed the predictive accuracy of both models using cross-validation.

RESULTS

Patients' mean age was 73 years, 65% were men, 19% had a left ventricular ejection fraction of 50% or more, 23% had 40% to 49%, 27% had 30% to 39%, and 31% had less than 30%. For both models and value sets, utility at inclusion was affected by sex, age, New York Heart Association class, ejection fraction, hemoglobin, blood pressure, lung disease, diabetes, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, nitrates, antiplatelets, and diuretics. The OLS model performed slightly better than did the two-part model on a population level and for capturing utility ranges. Change in utility over 1 year was influenced by age, sex, and (measured at inclusion) disease duration, New York Heart Association class, blood pressure, ischemic heart disease, lung disease, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and antiplatelets.

CONCLUSIONS

Utilities in CHF and their change over time are influenced by diverse demographic and clinical factors. Our findings can be used to target clinical interventions and for economic evaluations of new therapies.

Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial

BACKGROUND

Heart failure (HF) is associated with a high symptom burden and reduced quality of life (QOL). Models integrating palliative care (PC) into HF care have been proposed, but limited research is available on the outcomes of such models.

OBJECTIVE

Our aim was to assess if inpatient PC for HF patients is associated with improvements in symptom burden, depressive symptoms, QOL, or differential use of services.

METHODS

Patients hospitalized with acute HF were randomized to receive a PC consult with follow-up as determined by provider or standard care. Two hundred thirty-two patients (116 intervention/116 control) from a large tertiary-care urban hospital were recruited over a 10-month period. Primary outcomes were symptom burden, depressive symptoms, and QOL measured at baseline, 1, and 3 months. Secondary outcomes included advance care planning (ACP), inpatient 30-day readmission, hospice use, and death.

RESULTS

Improvements were greater at both 1 and 3 months in the intervention group for primary outcome summary measures after adjusting for age, gender, and marital status differences between study groups. QOL scores increased by 12.92 points in the intervention and 8 points in the control group at 1 month (difference+4.92, p<0.001). Improvement in symptom burden was 8.39 in the intervention group and 4.7 in the control group at 1 month (+3.69, p<0.001). ACP was the only secondary outcome associated with the intervention (hazard ratio [HR] 2.87, p=0.033).

CONCLUSION

An inpatient PC model for patients with acute HF is associated with short-term improvement in symptom burden, QOL, and depressive symptoms.

Socioeconomic status, cognitive-emotional factors, and health status following myocardial infarction: testing the Reserve Capacity Model

Health disparities by socioeconomic status (SES) exist for many outcomes, including patients' subjective health status after myocardial infarction (MI). The Reserve Capacity Model (RCM), a theoretical means to understand such disparities, was tested to examine the possible mediating effects of cognitive-emotional factors on the association between SES and health status. Data from 2,348 post-MI patients in PREMIER were used. Indicators of SES were collected during hospitalization via personal interviews, while participants completed measures of stress and reserves at 1 month, depressive symptoms at 6 months, and health status at 1 year through telephone interviews. Structural equation model results provide partial support for the RCM, as cognitive-emotional factors partially mediated the association between SES and mental health status. For physical health status, results supported direct rather than indirect effects of SES. Findings suggest psychosocial interventions with patients of low SES will have their greatest effects on appraisals of psychological health status.