Summary
Background
The incidence of heart failure (HF) is stable in industrialized countries, but its prevalence continues to increase, especially due to the ageing of the population, and mortality remains high.
Objective
To estimate the incidence in France and describe the management and short-term outcome of patients hospitalized for HF for the first time.
Method
The study population comprised French national health insurance general scheme beneficiaries (77% of the French population) hospitalized in 2009 with a principal diagnosis of HF after exclusion of those hospitalized for HF between 2006 and 2008 or with a chronic disease status for HF. Data were collected from the national health insurance information system (SNIIRAM).
Results
A total of 69,958 patients (mean age 78 years; 48% men) were included. The incidence of first hospitalization for HF was 0.14% (≥ 55 years, 0.5%; ≥ 90 years, 3.1%). Compared with controls without HF, patients more frequently presented cardiovascular or other co-morbidities. The hospital mortality rate was 6.4% and the mortality rate during the 30 days after discharge was 4.4% (3.4% without readmission). Among 30-day survivors, all-cause and HF 30-day readmission rates were 18% (< 70 years, 22%; ≥ 90 years, 13%) and 5%, respectively. Reimbursements among 30-day survivors comprised at least a beta-blocker in 54% of cases, diuretics in 85%, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in 67%, a diuretic and ACEI/ARB combination in 23% and a beta-blocker, ACEI/ARB and diuretic combination in 37%.
Conclusion
Patients admitted for HF presented high rates of co-morbidity, readmission and death at 30 days, and there remains room for improvement in their drug treatments; these findings indicate the need for improvement in return-home and therapeutic education programmes.
Résumé
Contexte
L’incidence de l’insuffisance cardiaque (IC) est stable dans les pays industrialisés mais sa prévalence continue d’augmenter, en partie face au vieillissement de la population, et la mortalité reste élevée.
Objectif
Cette étude a pour but d’estimer l’incidence et de décrire la prise en charge et le devenir à court terme des patients hospitalisés une première fois pour IC en France.
Méthode
Parmi les bénéficiaires du régime général de l’Assurance maladie (77 % de la population française) hospitalisés en 2009 avec un diagnostic principal d’IC, ont été exclus ceux hospitalisés pour IC entre 2006 et 2008 ou avec une affection de longue durée pour IC et les informations recueillies à partir du système d’information de l’Assurance maladie (SNIIRAM).
Résultats
Au total, 69 958 patients ont été inclus (âge moyen 78 ans, 48 % d’hommes). L’incidence était de 0,14 % (≥ 55 ans : 0,5 % ; ≥ 90 ans : 3,1 %). Par rapport à des témoins assurés sans IC et avec prise en compte de l’âge, les malades présentaient plus souvent des comorbidités cardiovasculaires ou non. Un décès était retrouvé chez 6,4 % des patients lors de l’hospitalisation et 4,4 % d’entre eux 30 jours après leur sortie (3,4 % sans réhospitalisation). Pour les survivants à 30 jours, 5 % ont été réhospitalisés avec un diagnostic principal d’IC et 18 % tous diagnostics inclus (22 % pour les < 70 ans et 13 % pour les ≥ 90 ans). Parmi les survivants à un mois, 54 % avaient au moins un remboursement d’un médicament de la classe des bêtabloquants, 85 % d’un diurétique, 67 % d’un inhibiteur de l’enzyme de conversion (IEC) ou d’un antagoniste des récepteurs de l’angiotensine 2 (ARA2) et 23 % avaient une association bêtabloquant et IEC/ARA2 et 37 % une telle association avec un diurétique.
Conclusion
Les patients avec une première hospitalisation pour IC ont une fréquence élevée de comorbidités, de réhospitalisations et de décès à 30 jours et l’utilisation des médicaments indiqués pourrait être améliorée. Cela est en faveur d’une réflexion sur la promotion de programmes de retour à domicile et d’éducation thérapeutique.
Background
Heart failure (HF) is a common and disabling syndrome. The incidence of HF is stable in industrialized countries, but its prevalence continues to increase, especially due to the ageing of the population. The incidence of HF is currently estimated to be between 5 and 10 per 1000 subject-years, depending on the cohorts studied; the prevalence is estimated to be between 1% and 3% in industrialized countries . The incidence and prevalence of HF markedly increase with age. For example, the Framingham study reported a prevalence of clinical HF of 0.8% in subjects aged 50–59 years and of 9.1% in those aged 80–89 years in 1993 . The mortality of patients with HF has decreased over the past two decades, but remains high, with a standardized mortality rate in Europe of 32.6/100,000 in 2008 .
HF accounts for 1–2% of all healthcare expenditure and represents the leading cause of hospitalization after the age of 65 years in industrialized countries . This syndrome is characterized by a high rate of hospitalizations, especially for acute decompensation. In France, among all patients hospitalized for HF in 2008, 7.5% died during their hospitalization and 21% were readmitted for HF during the same year . A high readmission rate is observed during the 30 days after discharge; for example, 5.6% of veterans in the USA were readmitted for a diagnosis of HF and 22% for all diagnoses combined between 2002 and 2006 . Sixty-one percent of patients hospitalized for HF in the USA presented at least one factor of decompensation . Based on these findings, disease management programmes before and after hospital discharge, comprising healthcare organization, patient education, training of healthcare professionals and/or home surveillance, have been demonstrated to be effective in many trials and have consequently been included in guidelines .
This study was designed to estimate the incidence and describe the clinical characteristics, treatment and 30-day outcome of patients presenting a first hospitalization for HF in France among national health insurance general scheme beneficiaries, representing 77% of the French population.
Methods
Information system and population
In France, the Système National d’Information Inter-Régimes de l’Assurance Maladie (SNIIRAM; French national inter-regime health insurance information system) comprises an individual and anonymous database concerning the beneficiaries of the various schemes. The database comprehensively records all outpatient prescriptions, services and procedures performed and reimbursed, together with their dates, with historical data limited to a period of 3 years plus the current year. Medications are identified according to Anatomical Therapeutic Classification Code, laboratory tests are identified from the French National Laboratory Test Coding Table and the procedures performed on an outpatient basis or in private institutions are identified according to the Classification Commune des Actes Médicaux (French medical classification for clinical procedures). The SNIIRAM does not contain any clinical information concerning results related to prescriptions or examinations. Nevertheless, it indicates the presence of any ‘affections de longue durée’ (ALD; chronic diseases), such as cardiovascular diseases, which are eligible for 100% reimbursement of healthcare expenditure after application by the attending physician and approval by the national health insurance consultant physician. These chronic diseases are coded according to the International Classification of Diseases (ICD 10). An anonymous unique identification number for each subject links this information to data collected by the Programme de Médicalisation des Systèmes d’Information (national hospital discharge database) in healthcare institutions. During the patient’s stay, principal diagnoses (PDs), related diagnoses and associated diagnoses (ADs) are coded according to ICD 10 and the procedures performed are coded according to the Classification Commune des Actes Médicaux. In 2009, the national health insurance general scheme covered about 77% of the 64 million inhabitants in France, excluding the 13% covered by local mutualist sections (SLM: students, civil servants, etc.). One of the reasons for limiting the study to this population was the availability of vital status and date of death from the National Institute for Statistics and Economic Studies (INSEE). The rest of the French population is covered by the Mutualité Sociale Agricole, the Régime Social des Indépendants and other specific health insurance schemes.
This study was based on the subpopulation covered by the national health insurance general scheme because, at the present time, the patient’s survival status is not precisely indicated in the SNIIRAM for the other health insurance schemes. The first hospitalization in 2009 with a PD of HF (ICD code I50 heart failure) was selected to identify eligible patients. Hospitalizations with the following PDs were not included: I11.0 hypertensive heart disease; I13.0 hypertensive heart and renal disease with (congestive) heart failure; I13.2 hypertensive heart and renal disease with (congestive) heart failure and renal failure; I13.9 hypertensive heart and renal disease, unspecified; K76.1 chronic passive congestion of liver; and J81 pulmonary oedema. Eligible patients hospitalized with a PD of HF between 2006 and 2008, an AD of HF in 2008 and/or ALD chronic disease status for HF before the index hospitalization were then excluded.
Definitions
The search for co-morbidities before the first hospitalization for HF took into account the presence of specific chronic diseases and the presence, during the previous year, of at least one hospitalization with a PD for hypertensive disease, coronary heart disease or cardiomyopathy. ‘Tumour’ chronic diseases were subdivided into tumours of haematopoietic tissues (ICD codes C81 to C96) and breast tumours (C50).
Data reported for the index hospitalization for HF included the number and types of medical units coded in the Programme de Médicalisation des Systèmes d’Information (intensive care, cardiac intensive care, palliative care, etc.). Readmissions were taken into account whatever the reason for admission, when they occurred between 7 and 30 days after discharge, in order to eliminate early transfers. Readmissions were classified according to the presence of a PD or AD code for HF.
Drug treatments were identified by the presence of at least three reimbursements during the 6 months preceding the index hospitalization and by a single reimbursement during the 30 days following discharge. Beta-blockers with marketing authorization for the treatment of HF were grouped under the term ‘specific’. Potassium-sparing diuretics combined with another diuretic in fixed-combination medicinal products were distinguished. Patients with no medicinal product reimbursement, all classes combined, during the 6 months preceding and/or the 30 days following hospitalization (mainly patients living in an institution directly dispensing medicinal products) were excluded from the comparative study of treatments before and after hospitalization.
Echocardiographs were identified by the presence of a specific code, whether they were performed in hospital or on an outpatient basis. Reimbursements for cardiology hospital outpatient and office visits were taken into account. Echocardiography was not systematically coded during a cardiology visit, as the levels of reimbursement may be similar for a visit with or without echocardiography. To compensate for this missing coding, a variable was constructed by combining the existence of at least one visit to the cardiologist or echocardiography.
Laboratory assays such as brain natriuretic peptide (BNP) could not be identified when they were performed in a public hospital, as they are not reimbursed individually.
Statistical analysis
The incidence of a first hospitalization for HF was calculated from all patients selected in 2009 divided by the number of individuals covered by the national health insurance general scheme, apart from SLM, at 31 December 2009, according to age and sex. Regional incidence rates were standardized for age and sex of the general scheme population.
The mortality rate was calculated during hospitalization, during the 30 days after admission and during the 30 days after discharge. Readmissions were expressed as patients with at least one readmission with a diagnosis of HF (as PD and PD or AD) or for all diagnoses combined.
Patient and management characteristics were studied among those patients still alive at 30 days and compared with those of all patients hospitalized. The frequencies of co-morbidities and the consumption of certain medicinal products were compared between these patients and the other subjects covered by the general scheme. A frequency ratio (relative risk [RR]) was calculated according to age for the two groups, with a 95% confidence interval. This ratio was also standardized for age and sex among subjects aged ≥ 55 years.
Statistical analyses were performed with SAS Enterprise Guide software, version 4.3 (SAS Institute Inc., Cary, NC, USA).
Results
In 2009, for 152,601 patients, 200,412 hospital stays with a principal diagnosis of HF were recorded for all of France. Among them, 98,124 patients and 130,333 hospitalizations concerned people covered by the general scheme, excluding SLM. After exclusion of patients previously hospitalized for HF between 2006 and 2008 ( n = 24,047) and the remaining patients with an ALD chronic disease status before hospitalization ( n = 4119), a total of 69,958 patients with a first hospitalization with a PD of HF in 2009 were included in the study. Forty-eight percent of these patients were men; the mean age was 78 years. The mean length of stay was 9 days and the median length of stay was 8 days. Patients with a first hospitalization in 2009 totalled 1.2% of all patients hospitalized in 2009 (1.3% for men and 1.2% for women), 2.6% of those aged 70–79 years, 6.2% of those aged 80–89 years and 10.9% of those aged ≥ 90 years.
Incidence of first hospitalization for heart failure
The incidence of a first hospitalization for HF was 0.14% for the whole population (all ages combined) and 0.5% for patients aged ≥ 55 years ( Fig. 1 ). This incidence increased considerably after the age of 70 years and was > 3% after the age of 90 years. Men presented a slightly higher incidence than women for all age groups considered (0.55% vs. 0.48% for patients aged ≥ 55 years). The age- and sex-standardized incidence according to region ranged between 0.11% and 0.18% ( Fig. 2 ); it was higher in northern and north-western regions, Corsica and Réunion, and lower in south-eastern and Île-de-France regions.
Outcome of hospitalized patients: death and readmissions
The hospital mortality rate was 6.4% ( Table 1 ). After standardization for age, this rate was slightly higher in men than in women (6.7% vs. 5.9%). The hospital mortality rate was 2.0% in patients aged < 55 years and 12.8% in patients aged ≥ 90 years. The mortality rate during the 30 days after discharge was 4.4%, without readmission for three-quarters of cases.
| < 55 years | 55–69 years | 70–79 years | 80–89 years | ≥ 90 years | Women a | Men a | Total | |
|---|---|---|---|---|---|---|---|---|
| First hospitalization ( n ) | 4005 | 10,731 | 17,600 | 28,888 | 8734 | 33,408 | 36,550 | 69,958 |
| Death (%) | ||||||||
| During and 30 days after hospitalization | 3.7 | 5.1 | 7.3 | 12.7 | 21.6 | 10.1 | 11.8 | 10.8 |
| During hospitalization | 2.0 | 2.9 | 4.3 | 7.6 | 12.8 | 5.9 | 6.7 | 6.4 |
| During the 30 days after discharge | 1.7 | 2.2 | 3.0 | 5.1 | 8.8 | 4.2 | 5.1 | 4.4 |
| With readmission for HF as PD | 0.1 | 0.1 | 0.2 | 0.3 | 0.4 | 0.2 | 0.3 | 0.3 |
| With readmission for HF as PD or AD | 0.1 | 0.3 | 0.4 | 0.7 | 0.7 | 0.5 | 0.6 | 0.5 |
| With readmission: all diagnoses | 0.2 | 0.7 | 0.8 | 1.3 | 1.2 | 0.9 | 1.2 | 1.0 |
| Without readmission | 1.4 | 1.5 | 2.2 | 3.8 | 7.6 | 3.2 | 3.9 | 3.4 |
| Survivors at 30 days ( n ) | 3858 | 10,184 | 16,309 | 25,225 | 6841 | 32,365 | 30,052 | 62,417 |
| Readmission (%) | ||||||||
| With HF as PD | 5.0 | 5.6 | 5.2 | 5.1 | 4.5 | 4.8 | 5.4 | 5.1 |
| With HF as PD or AD | 9.9 | 10.1 | 9.6 | 8.8 | 7.4 | 8.3 | 9.8 | 9.1 |
| All diagnoses | 21.7 | 21.7 | 19.8 | 16.3 | 12.7 | 16.7 | 19.5 | 18.0 |
For patients surviving 30 days after discharge, at least one readmission (all diagnoses combined) was reported within 30 days for 18% of patients, with HF as the PD or AD in 9% of patients and HF as the PD in 5% of patients. Among patients readmitted, more than half had a cardiovascular disease as a PD, 12% had a factor influencing health status and contact with health services, 7% had a pulmonary disease and 4% had cancer. These readmission rates were higher among the youngest patients, especially for all-cause readmissions (21.7% for patients aged < 69 years and 12.7% for patients aged ≥ 90 years).
Pre- and post-hospitalization management of patients surviving 30 days after discharge
During the year preceding hospitalization, almost 46% of patients had undergone at least one echocardiography or had consulted a cardiologist, and at least one BNP assay had been reimbursed for 40% of them ( Table 2 ). Eighteen percent of these patients were hospitalized in a private hospital, 21% in a university hospital (36% of patients aged < 55 years) and 61% in a public hospital. More than one quarter of patients were admitted to an intensive care unit or intermediate care unit (almost 40% of patients aged < 55 years). At the time of discharge, 79% of patients returned home and 21% were transferred to another unit, including a rehabilitation unit in one half of cases. Thirty days after discharge from hospital, 29% of patients had had at least one echocardiography or had attended a cardiology follow-up visit; 16% had had at least one BNP assay. No medicinal product reimbursement (all classes combined) was observed for 4.9% of patients during the year preceding hospitalization (5.2% for patients aged ≥ 90 years) and for 12.7% of patients during the 30 days after discharge (19.7% for patients aged ≥ 90 years).
| Survivors at 30 days | Hospitalized | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| < 55 years | 55–69 years | 70–79 years | 80–89 years | ≥ 90 years | Women a | Men a | Total | ||
| Number of patients ( n ) | 3858 | 10,184 | 16,309 | 25,225 | 6841 | 32,365 | 30,052 | 62,417 | 69,958 |
| Mean age (years) | – | – | – | – | – | 80.1 | 73.7 | 77.0 | 77.7 |
| Men (%) | 65.4 | 67.7 | 56.4 | 41.4 | 24.3 | – | – | 49.4 | 47.8 |
| One year before hospitalization (%) | |||||||||
| At least one reimbursement | |||||||||
| Echocardiography | 35.5 | 42.5 | 45.0 | 38.9 | 25.9 | 37.6 | 42.1 | 39.4 | 38.4 |
| Cardiologist visit or echocardiography | 44.1 | 50.3 | 52.5 | 44.3 | 30.0 | 43.3 | 49.5 | 45.9 | 44.6 |
| BNP assay | 27.1 | 36.7 | 42.7 | 42.5 | 38.3 | 38.5 | 42.5 | 40.2 | 40.0 |
| Hospitalization with a PD | |||||||||
| Hypertensive disease | 1.1 | 1.0 | 0.9 | 1.0 | 0.9 | 1.2 | 0.7 | 1.0 | 1.0 |
| Coronary heart disease or cardiomyopathy | 11.0 | 10.3 | 8.8 | 5.9 | 2.7 | 5.9 | 8.7 | 7.4 | 7.2 |
| Chronic disease (ALD) | |||||||||
| No chronic disease | 52.2 | 32.4 | 23.8 | 25.7 | 33.0 | 29.8 | 26.6 | 28.7 | 28.2 |
| Severe hypertension | 4.5 | 12.2 | 16.5 | 18.8 | 19.6 | 17.9 | 14.0 | 16.3 | 16.4 |
| Coronary heart disease | 7.1 | 13.7 | 15.8 | 16.8 | 15.8 | 10.4 | 20.4 | 15.3 | 15.3 |
| Serious arrhythmias | 1.2 | 2.8 | 5.1 | 6.1 | 5.0 | 5.2 | 4.7 | 4.9 | 4.8 |
| Serious valvular heart disease | 3.3 | 4.0 | 4.0 | 3.7 | 2.8 | 4.3 | 3.5 | 3.7 | 3.7 |
| Diabetes | 10.5 | 25.7 | 26.9 | 17.7 | 8.9 | 20.6 | 19.8 | 20.0 | 19.8 |
| Chronic respiratory failure | 1.9 | 3.7 | 4.4 | 3.4 | 2.0 | 2.9 | 4.1 | 3.5 | 3.6 |
| Serious chronic kidney disease | 2.9 | 2.0 | 1.5 | 0.9 | 0.7 | 1.3 | 1.5 | 1.3 | 1.3 |
| Malignant tumour | 4.7 | 9.2 | 13.0 | 12.7 | 9.6 | 10.2 | 13.6 | 11.4 | 11.7 |
| Haematopoietic tissues | 1.4 | 1.3 | 1.3 | 1.0 | 0.6 | 1.2 | 1.1 | 1.1 | 1.1 |
| Breast (women) | 4.3 | 6.8 | 5.7 | 4.7 | 3.4 | 5.1 | – | 4.9 | 4.8 |
| Alzheimer’s disease | 0.0 | 0.1 | 1.0 | 3.2 | 5.5 | 2.6 | 1.3 | 2.2 | 2.5 |
| Parkinson’s disease | 0.0 | 0.3 | 0.8 | 1.0 | 1.2 | 0.8 | 0.8 | 0.8 | 0.9 |
| Chronic liver disease | 1.5 | 1.3 | 0.9 | 0.4 | 0.1 | 0.7 | 0.7 | 0.7 | 0.7 |
| Psychiatric illness | 6.0 | 4.3 | 2.8 | 1.9 | 1.5 | 3.8 | 1.8 | 2.7 | 2.7 |
| Antipsychotics reimbursed | 4.8 | 3.6 | 3.0 | 2.9 | 4.6 | 4.2 | 2.5 | 3.3 | 3.5 |
| No medicinal product reimbursed | 12.5 | 7.5 | 3.7 | 3.5 | 5.2 | 4.5 | 4.8 | 4.9 | 5.0 |
| Index hospitalization (%) | |||||||||
| Hospital category | |||||||||
| Private hospital | 15.2 | 20.0 | 19.9 | 18.4 | 14.9 | 17.3 | 19.9 | 18.4 | 18.1 |
| University hospital | 35.7 | 24.6 | 20.5 | 18.9 | 20.5 | 21.5 | 21.1 | 21.5 | 21.2 |
| General hospital | 49.1 | 55.5 | 59.6 | 62.7 | 64.6 | 61.2 | 58.9 | 60.1 | 60.8 |
| Medical units frequented | |||||||||
| 1 | 57.4 | 56.9 | 58.6 | 59.8 | 65.7 | 58.6 | 60.3 | 59.5 | 59.6 |
| 2 | 29.2 | 31.5 | 30.8 | 31.7 | 29.2 | 31.6 | 30.4 | 31.0 | 30.6 |
| ≥ 3 | 13.5 | 11.6 | 10.6 | 8.4 | 5.1 | 9.8 | 9.4 | 9.5 | 9.8 |
| Stay in | |||||||||
| Intensive care unit | 5.3 | 4.0 | 2.9 | 1.5 | 0.6 | 2.4 | 2.3 | 2.4 | 2.8 |
| Cardiac intensive care unit | 27.9 | 26.8 | 21.5 | 16.8 | 9.1 | 18.8 | 20.5 | 19.5 | 19.5 |
| Intermediate care unit | 5.4 | 5.2 | 5.4 | 5.0 | 3.9 | 5.0 | 5.2 | 5.0 | 5.2 |
| Palliative care unit | 1.1 | 2.0 | 2.4 | 2.6 | 3.0 | 2.4 | 2.3 | 2.4 | 2.5 |
| Length of stay (nights) | |||||||||
| < 2 | 15.8 | 10.2 | 7.2 | 6.4 | 8.4 | 7.9 | 7.9 | 8.0 | 9.1 |
| 2–5 | 33.3 | 30.7 | 25.9 | 21.9 | 21.9 | 23.1 | 26.9 | 25.1 | 24.9 |
| 6–10 | 29.1 | 34.2 | 36.9 | 36.6 | 34.7 | 36.0 | 35.5 | 35.6 | 34.3 |
| 11–15 | 12.5 | 14.4 | 16.7 | 19.5 | 19.3 | 18.4 | 16.5 | 17.5 | 17.2 |
| ≥ 16 | 9.3 | 10.5 | 13.2 | 15.6 | 15.7 | 14.5 | 13.2 | 13.8 | 14.5 |
| Mean (days) | 7.4 | 8.2 | 9.0 | 9.8 | 9.6 | 9.4 | 8.9 | 9.2 | 9.2 |
| Mode of discharge | |||||||||
| Home | 79.0 | 82.0 | 81.9 | 77.1 | 73.6 | 77.6 | 81.0 | 78.9 | |
| Transfer | 21.0 | 18.0 | 18.1 | 22.9 | 26.4 | 22.3 | 18.9 | 21.1 | |
| To a rehabilitation unit | 3.9 | 4.0 | 6.3 | 11.7 | 14.8 | 10.0 | 7.3 | 8.9 | |
| 30 days after hospitalization (%) | |||||||||
| At least one reimbursement | |||||||||
| Echocardiography | 15.1 | 14.5 | 12.4 | 9.4 | 6.1 | 10.7 | 11.6 | 11.0 | |
| Cardiology visit or echocardiography | 29.9 | 34.0 | 32.1 | 27.1 | 18.5 | 27.5 | 30.7 | 28.8 | |
| GP visit | 62.3 | 68.3 | 74.0 | 72.5 | 70.5 | 71.9 | 71.7 | 71.4 | |
| BNP assay | 12.8 | 15.6 | 16.5 | 16.7 | 15.6 | 15.5 | 17.0 | 16.1 | |
| Serum creatinine | 38.9 | 48.1 | 51.3 | 49.4 | 44.3 | 46.7 | 50.4 | 48.5 | |
| Potassium | 22.6 | 27.2 | 29.0 | 29.7 | 27.6 | 28.8 | 28.2 | 28.5 | |
| No medicinal product reimbursed (%) | 10.9 | 8.4 | 9.8 | 14.7 | 19.7 | 13.9 | 10.8 | 12.7 | |
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