Summary
Background
Hospitalization for worsening/acute heart failure is increasing in France, and limited data are available on referral/discharge modalities.
Aim
To evaluate patients’ journeys before and after hospitalization for this condition.
Methods
On 1 day per week, between October 2014 and February 2015, this observational study enrolled 260 consecutive patients with acute/worsening heart failure in all 10 departments of cardiology and four of the departments of geriatrics in the Greater Paris University Hospitals.
Results
First medical contact was an emergency unit in 45% of cases, a general practitioner in 16% of cases, an emergency medical ambulance in 13% of cases and a cardiologist in 13% of cases; 78% of patients were admitted directly after first medical contact. In-hospital stay was 13.2 ± 11.3 days; intensive care unit stay (38% of the population) was 6.4 ± 5 days. In-hospital mortality was 2.7%. Overall, 63% of patients were discharged home, whereas 21% were transferred to rehabilitation units. A post-discharge outpatient visit was made by only 72% of patients within 3 months (after a mean of 45 ± 28 days). Only 53% of outpatient appointments were with a cardiologist.
Conclusion
Emergency departments, ambulances and general practitioners are the main points of entry before hospitalization for acute/worsening heart failure. Home discharge occurs in two of three cases. Time to first patient post-discharge visit is delayed. Therefore, actions to improve the patient journey should target primary care physicians and emergency structures, and efforts should be made to reduce the time to the first visit after discharge.
Résumé
Objectif
Le nombre d’hospitalisations pour un épisode d’insuffisance cardiaque aigu en France est en augmentation et les données concernant les modalités d’entrée/de sortie d’hospitalisation sont insuffisantes. L’objectif était de décrire les caractéristiques du parcours de soins de ces patients avant et après l’hospitalisation.
Méthodes et résultats
Cette étude observationnelle a inclut, un jour par semaine, 260 patients consécutifs en insuffisance cardiaque aiguë d’octobre 2014 à février 2015 dans tous les départements de cardiologie (10) et 4 départements de gériatrie de l’Assistance publique–Hôpitaux de Paris. Le premier contact médical était un service d’urgence (45 %), un médecin généraliste (16 %), le SAMU (13 %) ou un cardiologue dans 13 % des cas. Au total, 78 % des patients étaient admis directement après le premier contact médical. La durée de séjour était de 13,2 ± 11,3 jours et 6,4 ± 5 jours en soins intensifs (38 % de la cohorte). La mortalité hospitalière était de 2,7 %. Au total, 63 % des patients sont sortis directement à domicile, 21 % en centre de convalescence. Une consultation de suivi dans les trois mois a été réalisée dans seulement 72 % des cas (à 45 ± 28 jours). Au total, 53 % de ces consultations ont été réalisées par un cardiologue.
Conclusion
Les services d’urgence, le SAMU et les médecins généralistes sont les premiers intervenants des patients en insuffisance cardiaque aiguë avant leur hospitalisation. Le retour à domicile à la sortie est observé dans deux-tiers des cas. L’intervalle entre la sortie et la première consultation de suivi est tardif. Les actions envisagées devront cibler principalement les médecins généralistes et les structures d’urgences. L’initiation du suivi à la sortie doit être plus précoce.
Background
Heart failure (HF) is a highly prevalent condition associated with poor outcomes . Although mortality has decreased during the past 20 years because of the broad dissemination of evidence-based therapies in HF with depressed left ventricular function , hospitalizations for acute/worsening HF are lengthy and recurrent, and induce considerable costs for the healthcare systems .
Among the many factors put forward to explain the burden of HF (re)hospitalizations, inappropriate cooperation between professionals in/out of hospital has been discussed during the pre- and post-discharge periods, leading to a fragmented patient journey, with delays in referral and in the introduction/titration of life-saving medications . The French healthcare system is characterized by a huge number of private cardiologists and an absence of HF nurses, and data concerning the HF patient journey in France are scarce.
The aim of this study was to provide an analysis of the modalities of referral and discharge of patients hospitalized for acute/worsening acute HF in the Greater Paris University Hospitals.
Methods
Patients
Fourteen departments of the Assistance publique–Hôpitaux de Paris (all 10 departments of cardiology and four of the departments of geriatrics) participated in this prospective observational study from October 2014 to February 2015. Each center was asked to enroll 20 consecutive patients (on 1 day per week) aged > 18 years and hospitalized for de novo or worsening acute HF using the criteria of the European Society of Cardiology guidelines . Data on referral/discharge modalities, baseline demographic characteristics, therapies and procedures were collected. Each surviving patient was contacted by telephone 3 months after discharge to collect the time of the first post-discharge visit and the type of physician consulted. Outcomes, including all-cause rehospitalizations and all-cause deaths, were recorded.
Data collection
A structured paper case-report form was completed for each patient. For audit purposes, all case-report form data were compared with the discharge summary forms.
Written informed consent was obtained from all participating patients. This study is a substudy of the FRESH registry of the French Society of Cardiology, which was approved by the Institutional Committee on Human Research .
Statistical analysis
All quantitative data are expressed as means ± standard deviations; qualitative data are expressed as percentages. Comparisons between continuous data were made using the unpaired t -test. The χ 2 test or Fisher’s exact test were used to compare categorical data, as appropriate.
MedCalc Statistical Software, version 12.7.7 (MedCalc Software, Ostend, Belgium) was used for calculations. A P -value < 0.05 indicated statistical significance.
Results
From 1 October 2014 to 28 February 2015, 260 patients (cardiology, n = 197; geriatrics, n = 63) were enrolled.
Patient characteristics
The main patient characteristics before admission are presented in Table 1 . Mean age was 77 ± 15 years and 44% were women. Overall, 60% of the patients lived at home in a family environment, but a sizable proportion were isolated at home, and 5% lived in nursing homes. The proportions of female patients and patients isolated at home were higher in the geriatric subgroup. Main comorbidities were similar in geriatric and cardiology patients, except for cognitive disorders, which were more frequent in geriatric patients. A previous hospitalization for HF was common (58%). The most frequent causes of HF were ischemic heart disease (41%), hypertension (21%) and valvular disorders (20%), whereas non-ischemic cardiomyopathy was reported in 18%. The most common precipitating factors were supraventricular arrhythmias (38%), infections (28%) and treatment non-compliance (17%). Infection was much more frequent in patients from departments of geriatrics.
| Variable | Total | Geriatrics | Cardiology | P |
|---|---|---|---|---|
| Age (years) | 77 ± 15 | 89 ± 6 | 73 ± 15 | < 0.0001 |
| Women | 44 | 65 | 36 | 0.0006 |
| Home environment | ||||
| Living with family | 60 | 44 | 64 | 0.008 |
| Nursing home | 5 | 13 | 3 | 0.004 |
| Living alone with support | 19 | 30 | 16 | 0.02 |
| Living alone without support | 16 | 13 | 17 | 0.54 |
| Comorbidity | ||||
| Diabetes | 28 | 22 | 29 | 0.79 |
| COPD | 19 | 15 | 20 | 0.69 |
| Cognitive disorder | 19 | 48 | 9 | < 0.0001 |
| Cancer | 5 | 3 | 5 | 0.77 |
| Depression | 9 | 15 | 7 | 0.09 |
| Severe renal failure | 20 | 23 | 19 | 0.63 |
| Repeated falls (> 3/year) | 7 | 38 | 2 | < 0.0001 |
| Previous HF | 71 | 77 | 69 | 0.26 |
| Previous HF hospitalization | 58 | 61 | 57 | 0.56 |
| HF hospitalization < 6 months | 54 | 29 | 63 | 0.007 |
| Cause of HF | ||||
| Ischemic | 41 | 44 | 40 | 0.16 |
| Valvular | 20 | 24 | 18 | 0.4 |
| Hypertensive | 21 | 31 | 18 | 0.045 |
| Other | 18 | 2 | 24 | < 0.0001 |
| Precipitating factors | ||||
| Acute coronary syndrome | 13 | 9 | 14 | 0.51 |
| Supraventricular arrhythmia | 38 | 44 | 36 | 0.28 |
| Infection | 28 | 60 | 18 | < 0.0001 |
| Hypertension | 16 | 10 | 36 | 0.17 |
| Treatment non-compliance | 17 | 16 | 17 | 0.97 |
| Unknown | 16 | 8 | 19 | 0.07 |
In-hospital data are summarized in Table 2 . Mean left ventricular ejection fraction was 43%, and was higher in the geriatric subgroup. The majority of patients had a preserved ejection fraction, defined by a threshold of ≥ 45%, and the proportion of patients with a preserved ejection fraction was higher in the geriatrics subgroup. Use of intravenous nitrates, dobutamine and non-invasive ventilation was higher in patients hospitalized in cardiology departments.
| Variable | Total | Geriatrics | Cardiology | P |
|---|---|---|---|---|
| ICCU stay (days) | 6.4 ± 5 | 7 ± 1.6 | 6.4 ± 5.1 | 0.53 |
| Length of stay (days) | 13.2 ± 11.3 | 15.5 ± 9.3 | 12.5 ± 11.8 | 0.046 |
| Clinical data | ||||
| Systolic blood pressure (mmHg) | 131 ± 26 | 131 ± 21 | 131 ± 28 | 0.86 |
| Heart rate (beats/min) | 84 ± 22 | 80 ± 19 | 86 ± 22 | 0.06 |
| LVEF (%) | 43 ± 16 | 48 ± 13 | 41 ± 16 | 0.006 |
| LVEF ≥ 45% | 52 | 67 | 48 | 0.02 |
| Laboratory variables | ||||
| Hemoglobin (g/dL) | 12 ± 2 | 11.7 ± 2 | 12.2 ± 2 | 0.06 |
| NT-proBNP (ng/mL) | 8648 ± 11375 | 9750 ± 11762 | 8233 ± 11251 | 0.46 |
| BNP (ng/mL) | 1095 ± 1637 | 741 ± 281 | 1104 ± 1656 | 0.76 |
| Creatinine (μmol/L) | 120 ± 58 | 111 ± 47 | 123 ± 61 | 0.11 |
| Treatment | ||||
| Intravenous diuretic | 79 | 75 | 80 | 0.46 |
| Nitrate infusion | 15 | 3 | 18 | 0.003 |
| Dobutamine infusion | 13 | 2 | 16 | 0.008 |
| Non-invasive ventilation | 11 | 3 | 13 | 0.07 |
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