Summary
Background
Heart failure is the leading cause of hospital admissions and an economic burden. In accordance with European guidelines, a dedicated heart failure unit was created in René Dubos Hospital (Pontoise, France) in 2002.
Aim
To evaluate the impact of an in-hospital heart failure management unit on heart failure prognosis.
Methods
We conducted a descriptive study of all-cause in-hospital mortality and heart failure related readmission rates in the year after the first admission for heart failure, from January 1997 to December 2007. The Chi 2 test, a trend test and linear regression were performed.
Results
There were no significant differences in patient characteristics (age, sex, diabetes mellitus, left ventricular ejection fraction < 45%) other than renal insufficiency, in patients admitted for heart failure from 1997 to 2007. After the creation of the heart failure unit, we observed a significant decrease in heart failure related readmission rate from 21.7% in 2002 to 15.6% in 2007 ( p < 0.0001), whereas there was no difference in this rate before the creation of the unit (34.3% in 1997 and in 2001; p = 0.90). All-cause in-hospital mortality rate decreased from 9.3% in 1997 to 5.1% in 2007 ( p < 0.0001) and showed a tendency to decrease after the creation of the heart failure unit ( p = 0.06).
Conclusion
Heart failure related readmission rates in new patients in the year after the first admission for heart failure reduced dramatically after the creation of the heart failure unit. All-cause in-hospital mortality in heart failure patients decreased over the 10-year study period.
Résumé
Introduction
L’insuffisance cardiaque (IC) est une des causes majeures d’hospitalisation et représente un fardeau économique important. En accord avec les recommandations européennes, une unité thérapeutique d’insuffisance cardiaque (UTIC) a été créée en 2002 à l’hôpital René Dubos (Pontoise, France).
Objectif
Évaluer l’impact de la création d’une UTIC sur le pronostic des patients hospitalisés pour IC.
Méthodes
Nous avons réalisé une étude descriptive du taux de mortalité intrahospitalière toutes causes confondues chez les patients hospitalisés pour IC ainsi que du taux de réhospitalisation pour IC dans l’année suivant la première hospitalisation pour IC, de janvier 1997 à décembre 2007. Le test du Chi 2 , le test de tendance et une régression linéaire ont été utilisés.
Résultats
Entre 1997 et 2007, les caractéristiques des patients hospitalisés pour IC n’étaient pas significativement différentes (âge, sexe, diabète, FEVG < 45 %), exception faite de l’insuffisance rénale. Après la création de l’UTIC en 2002, nous avons observé une diminution significative du taux de réhospitalisations pour IC de 21,7 % en 2002 à 15,6 % en 2007 ( p < 0,0001) alors que ce taux ne différait pas avant la création de l’UTIC (34,3 % en 1997 et 2001; p = 0,90). Le taux de mortalité intrahospitalière toutes causes confondues a diminué en passant de 9,3 % en 1997 à 5,1 % en 2007 ( p < 0,0001) avec une tendance à la diminution suite à la création de l’UTIC ( p = 0,06).
Conclusion
Le taux de réhospitalisations pour IC dans l’année suivant la première hospitalisation pour IC a diminué significativement après la création de l’UTIC. La mortalité intrahospitalière toutes causes confondues chez les patients insuffisants cardiaques a diminué significativement durant ces dix dernières années.
Abbreviations
BNP
B-type natriuretic peptide
CI
confidence interval
ESC
European Society of Cardiology
HF
heart failure
LVEF
left ventricular ejection fraction
RCT
randomized controlled trials
Background
In many industrialized countries, HF is the leading cause of hospitalization for patients over 65 years of age and about 40% of patients are readmitted in the year after their first admission for HF . The overall prognosis for systolic HF is poor and the 1-year survival rate for severe HF is lower than that for most cancers . HF also presents a huge economic burden . In developed countries, mainly because of readmissions, HF accounts for up to 1–2% of total health costs and this is expected to continue to increase in the future . Studies from different settings have shown that non-compliance with medication, diet or symptom monitoring causes the majority of readmissions due to HF .
Over the past decade, we have seen an explosion of new treatment options for patients with HF, with a documented benefit for clinical outcome. As described recently in the updated guidelines from the ESC , management of chronic HF is a complex issue and an organized system of specialist HF care should be established to improve the outcome of patients with HF.
Since the introduction of the first HF programme in Europe , different models have been developed in several European countries, organized and delivered according to local and national healthcare needs. Several RCTs have compared these kinds of programmes for HF with usual care , and meta-analyses have confirmed that they reduce mortality and hospital readmissions and indicate strong potential improvements in quality of life and cost savings .
Unfortunately, only a few European countries have a large number of organized structures for HF care and follow-up : of the 33 RCTs included in the last meta-analysis , only five involved multidisciplinary and in-hospital approaches. All other RCTs involved nurse-led or pharmacist-led education or after-discharge management. This emphasizes the importance of creating an in-hospital HF management programme, in terms of efficacy for patients.
In order to guide and stimulate the further development of HF management programmes in France, the aim of this study was to evaluate the impact of an in-hospital HF unit (that included an in-patient hospitalization unit, an outpatient unit and an education structure) on all-cause in-hospital mortality rates and HF-related readmission rates in the year after the first admission for HF.
Methods
Data sources
Each patient admitted to René Dubos Hospital (Pontoise, France) from January 1997 to December 2007 was recorded. Furthermore, as part of standard procedure, information from patient case records was used, at the time of hospital discharge, to code diagnoses according to the 10th Revision of the World Health Organization International Classification of Diseases . A single cardiologist coded the diagnoses to enable each individual’s hospitalization record since 1997 to be analysed with a high degree of accuracy. This cardiologist reviewed all charts and certified the diagnosis. The present analysis was planned retrospectively to find differences in HF-related readmission rates and all-cause in-hospital mortality rates after the initiation of the HF management unit.
Patients
All patients were scheduled for a full clinical examination and control of medication and comorbidity. In all patients, the New York Heart Association class was estimated. Blood chemistry was analysed by standard methods and BNP was measured during outpatient hospitalization (scheduled within 1 month of the index hospitalization) by an in vitro immunoassay using a triage R meter (Biosite ® Inc., San Diego, CA, USA). Transthoracic echocardiography was performed during the index hospitalization using a Philips/Hewlett-Packard Sonos 5500 ® echocardiography system (Philips ® , Amsterdam, Netherlands). LVEF was calculated according to the recommendations of the ESC .
According to the recommendations , all patients with HF class II–IV (New York Heart Association) and left ventricular dysfunction assessed by transthoracic echocardiography after medical stabilization were eligible for inclusion.
HF main diagnosis was assessed from information in the hospital records at discharge. Recorded admissions from January 1997 to December 2007 were screened to identify and select only those patients with a first admission caused primarily by the following (International Classification of Diseases): HF (I50), congestive HF (I50.0), left ventricular dysfunction (I50.1), cardiogenic shock (R57.0). We then excluded all patients who had a previous hospital admission for HF according to their medical records and after a reliable anamnesis.
HF management unit
An HF management unit was created in January 2002 in René Dubos Hospital (Pontoise, France). Each patient with a new diagnosis of HF was included directly in the HF management programme at discharge.
An outpatient hospitalization was scheduled within 1 month of the first hospital discharge. The multidisciplinary programme involved cardiologists, nurses, dieticians and physiotherapists, and included patient education, drug titration, diagnostic testing, telephone consultation, physical examination and diagnostic tests. Patient education included a combination of verbal and written information. Intensive pharmacological treatment was based on evidence-based guidelines current at the time of study . Drug titration was mainly protocol-led and included diuretics, beta-blockers, angiotensin-converting enzyme-inhibitors, angiotensin II receptor blockers and aldosterone receptor antagonists. Diagnostic tests were routine laboratory tests (creatinine, potassium), BNP concentration, electrocardiogram and 6-minute walk test. All patients underwent a complete transthoracic echocardiography assessment in the left lateral position. Parasternal long and short axis, and apical two- and four-chamber views were recorded. Colour flow and Doppler measurements were undertaken for assessment of valves.
Left ventricular systolic dysfunction was measured by the Simpson method. Left ventricular diastolic dysfunction was assessed according to evidence-based guidelines current at the time of study (presence of normal or only mildly abnormal left ventricular systolic function; evidence of abnormal left ventricular relaxation, filling, diastolic distensibility or diastolic stiffness) .
HF was diagnosed using the ESC criteria, i.e. symptoms of HF, objective evidence of left ventricular dysfunction and/or response to treatment directed towards HF.
A follow-up plan was devised for each patient, aiming for monthly visits alternating between the general practitioner and HF unit, although the patients were free to see their general practitioner whenever they wished. Subsequently, group education sessions were planned for within 6 weeks of hospital discharge. These sessions were run by a cardiologist and the study nurse. The study team at the HF unit was available for consultation during normal working hours and received calls from both patients and their general practitioners. At times of worsening symptoms, patients were advised to see their general practitioner in the first instance.
Endpoints
The primary endpoint was the HF-related readmission rate. Although there is no unanimous agreement on the endpoints to be used for HF trials, we consider readmission rate to be clinically relevant, related directly to the primary goal of the trial. The secondary endpoint was the all-cause in-hospital mortality rate of patients admitted for HF. Finally, average length of hospital stay was recorded from 1997 to 2007.
Statistical analysis
Continuous variables are expressed as mean ± standard deviation, and categorical data as numbers and percentages. Our main outcome was HF-related readmission rate. The HF-related readmission rate was measured as number of new patients readmitted for HF within the year after the first admission for HF, over the total of new patients admitted for HF in the same year. Our secondary outcome was all-cause in-hospital mortality rate, which was measured as the number of patients who died during hospitalization for HF, over the total number of patients admitted for HF. We also measured the length of hospital stay during the 10-year follow-up.
Comorbidity rates were compared using the Chi 2 test. HF-related readmission rate and all-cause in-hospital mortality rate were compared using the two-sided Cochran-Armitage test for trend. The mean age and length of hospital stay were compared using linear regression. A p < 0.05 was considered statistically significant. Statistical analyses were performed using SAS 9.1 software (SAS Institute Inc., Cary, NC, USA).
Results
Sample characteristics
From January 1997 to December 2007, the total number of new patients admitted for HF was 3200 (range per year: 179–377 patients). The population consisted of 1556 men (48.6%), with a mean age per year ranging from 68.5 ± 15.7 years to 74 ± 12.7 years; 53.7% of patients presented with systolic HF (LVEF < 45%), 15.4% had renal insufficiency and 20.2% had diabetes mellitus. Concerning these characteristics, no significant differences were found from 1997 to 2007, except for renal insufficiency: there was a significant increase after the creation of HF unit, from 10% ( n = 31) in 2002 to 22% ( n = 70) in 2007 ( p = 0.001) ( Table 1 ). Overall, 58% of patients had arterial hypertension and 62% had coronary artery disease.
