Social network as a predictor of hospital readmission and mortality among older patients with heart failure

BackgroundThis study examines the relationship between social network and hospital readmission and mortality in older patients with heart failure.Methods and ResultsProspective study conducted with 371 patients, age 65 and older, admitted for heart failure–related emergencies at 4 Spanish hospitals. Social network was measured at baseline with a 4-item questionnaire that ascertained whether subjects were married, lived with another person(s), saw or had telephone contact with family members daily or almost daily, and were at home alone for less than 2 hours per day. Social network was deemed “high” where all 4 items were present, “moderate” where 3 were present, and “low” where 2 or fewer were present. Analyses were performed using Cox models, and adjusted for the main confounders. A total of 55% of patients had high or moderate social networks. During a median follow-up of 6.5 months, 135 (36.4%) patients underwent a first emergency rehospitalization and 68 (18.3%) died. Compared with patients with high social network, hospital readmission was more frequent among those who had moderate (hazard ratio [HR] 1.87; 95% confidence interval [CI] 1.06–3.29; P < .05) and low social networks (HR 1.98; 95% CI 1.07–3.68; P < .05). This relationship showed a positive dose-response (p for linear trend 0.042). The magnitude of this association was comparable to that of other important predictors of readmission, such as previous hospitalization. No relationship was observed between social network and death.ConclusionA very simple questionnaire measuring social network can identify patients with a higher short-term risk of hospital readmission.     

Health-related quality of life in patients with congestive heart failure

BACKGROUND: Despite abundant evidence attesting to poor physical, psychological and social functioning of congestive heart failure (CHF) patients, little is known about the impact of the disease itself on health-related quality of life (HRQL). Most previous work has focused on general quality of life issues rather than specifically on the impact of CHF on HRQL. AIM: To identify the significant demographic, clinical and psychosocial factors associated with HRQL in patients with CHF. METHODS: A total of 227 CHF patients were recruited from the medical unit of a general hospital in Hong Kong. Cross-sectional data on HRQL, functional status, psychological state, social support and health perception were obtained from each patient and clinical data were obtained from hospital records. RESULTS: In hierarchical regression analysis, psychological distress, poor health perception, higher NYHA grading and lower education level were identified as the significant factors associated with poorer HRQL. These correlates in total explained 52% of the variance for the HRQL scores. Among these correlates, psychological distress and NYHA grading demonstrated the greatest effect on HRQL scores. CONCLUSION: The findings highlight the significance of addressing the psychological and functional health of CHF patients. Assisting these patients to cultivate a positive attitude towards their own health status is also an important treatment goal.     

C-reactive protein as a predictor of improvement and readmission in heart failure

OBJECTIVES: Only recently, new risk factors to explain atherosclerotic disease have been identified. One of the most important clinical manifestations of atherosclerosis is heart failure. Our study was aimed at investigating C-reactive protein (CRP), a marker of systemic inflammation, in the context of heart failure, and to determine its usefulness in predicting the need for readmission in patients with heart failure and their degree of improvement. DESIGN: We studied patients admitted to our hospital due to heart failure, independent of the cause. CRP levels were measured with a sensitive standard assay on a Nephelometer analyser. Patients were classified on admission and discharge following New York Heart Association (NYHA) functional criteria; left ejection fraction was also determined by transthoracic echocardiography. Patients presenting clear sources of infection or inflammatory disease were excluded. Our control group consisted of patients admitted for syncope. Each patient was followed up through a computer system controlling admissions to and discharge from the hospital, for a period of 18 months after initial admission. End points considered were NYHA functional class on discharge, readmission and death. RESULTS: We studied prospectively 76 patients with a mean age of 73.5+/-11 [95% confidence interval (CI) 71.2-75.8]; 44 were male (58%) and 32 female (42%). The mean CRP level in patients with heart failure was 3.94+/-5.87 (95% CI, 1.26-7.60), while in 15 patients with syncope it was 0.84+/-1.95 (95% CI, 0.96-2.94) (P=0.0007). The principal causes of heart failure included dilated cardiomyopathy due to coronary arterial disease (30%), valvular disease (28%) and heart failure secondary to hypertension (25%). The mean left ejection fraction adequately measured in 72 (95%) patients was 50.41+/-9.88 (95% CI, 41.20-59.65). We observed a trend of higher CRP levels in relation to ejection fractions below 35%: 7.50+/-9.88 vs. 3.75+/-4.57, (P=0.09). Our results showed that on discharge CRP levels increased in relation to NYHA class: I: 0.74+/-0.69; II: 3.78+/-3.76; III: 7.4+/-8.65; IV: 12.2+/-15.27 (P<0.05). On follow-up of each patient for 18 months, 32 (43%) were readmitted due to deterioration of their heart condition. For patients who were readmitted, those presenting CRP levels >0.9 mg/dl were identified as candidates for earlier hospitalisation than those with levels below 0.9 mg/dl (P=0.02) RR=1.43. In logistic-regression analysis the only group of tested variables predicting readmission were levels of CRP, NYHA class and plasmatic K on discharge and left ventricle ejection fraction. Analysis of covariates yields CRP levels as being an independent predictor of readmission. CONCLUSIONS: An inflammatory response is present in deteriorating heart failure. We observed higher CRP levels in patients with higher NYHA functional class, perhaps signalling a poor therapeutic response. Higher CRP levels were also related to higher rates of readmission and mortality and it could be an independent marker of improvement and readmission in heart failure.     

Predictors of cause-specific hospital readmission in patients with heart failure

BACKGROUND: Repeated hospital readmissions are frequent and increasing over time in patients with heart failure (HF). The predictors for readmission in patients with HF are not completely understood. HYPOTHESIS: The study was undertaken to investigate the time course of readmission by specific cause in patients with HF, and to examine the independent effects of HF etiology and left ventricular (LV) function on cause-specific readmissions. METHODS: A retrospective cohort of 493 consecutive patients with HF was followed for readmission for 16.5 +/- 12.3 months. Ischemic etiology of HF was defined as history of myocardial infarction (MI), coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA), or > or = 70% coronary stenosis. Left ventricular function was assessed echocardiographically. Cause-specific readmissions were classified as HF, cardiovascular disease (CVD) other than HF, and other non-CVD. RESULTS: The annual readmission rate was 56.6%. Median time to readmission was 91 days, with 18.3% patients readmitted within 1 month after discharge. Ischemic etiology independently predicted all-cause readmission: Cox hazard ratio (95% confidence interval): 1.40 (1.11-1.79). This relationship was significant in women (1.83 [1.31-2.55]), but not in men (1.15 [0.82-1.62]), while readmissions were equally frequent in both genders. Similarly, ischemic etiology significantly predicted readmission for CVD in women (4.18 [2.14-8.19]), but not in men (1.49 [0.83-2.67]). However, LV dysfunction independently predicted readmission for recurrent HF (2.44 [1.46-4.08]), while ischemic etiology was not predictive in either gender. CONCLUSIONS: Readmissions for recurrent HF comprise only one-third of total hospital readmissions in patients with HF. Ischemic etiology is a significant predictor of readmission, and most of this effect is mediated through a four-fold increased risk of readmission for CVD other than HF in women. Readmission for recurrent HF is predicted by LV dysfunction but not by ischemic etiology. Patients with HF can be accurately risk stratified for cause-specific readmission with available clinical data.     

Health-related quality of life and sense of coherence among elderly patients with severe chronic heart failure in comparison with healthy controls

OBJECTIVE: To describe health-related quality of life (QoL) and sense of coherence (SOC) in a group of elderly people with moderate to severe chronic heart failure and to make comparisons with a healthy sex- and age-matched control group. METHODS: Patients (n = 94), with a mean age of 81 years, hospitalized for chronic heart failure with New York Heart Association functional classification III to IV were age- and sex-matched to a healthy control group. The instruments used were the 36-Item Short Form Health Survey (SF-36) and SOC. RESULTS: The patients had lower levels of health-related QoL scores (SF-36) but high and similar scores of SOC compared with the controls. There were, however, significant positive correlations between the SOC scores and the emotional dimensions in the SF-36 instrument. CONCLUSION: The findings from this study indicate that old age and severe chronic heart failure were associated with limited functional abilities and impaired health-related QoL but also with internal resources such as SOC.     

Usefulness of anemia as a predictor of death and rehospitalization in patients with decompensated heart failure

We investigated the prevalence of anemia and its relation to clinical events in patients with decompensated heart failure enrolled in the OPTIME-CHF study. Our data demonstrate that anemia is common in patients hospitalized with decompensated heart failure and is associated with a greater number of co-morbid conditions. Lower baseline hemoglobin is associated with risk of short-term adverse clinical outcomes in this population, even after controlling for other baseline differences.     

Systolic function as a predictor of mortality and quality of life in long-term survivors with heart failure

BACKGROUND: Patients with heart failure (HF) and preserved ejection fraction (EF) have been shown to have high mortality rates, comparable to those with reduced EF. Thus, long-term survivors of HF, regardless of ejection fraction, are a select group. Little is known about disease-related quality of life (QOL) and health status in these patients. HYPOTHESIS: Preserved EF in patients with heart failure independently predicts long-term survival, health related quality of life (QOL), or functional status. METHODS: The study followed a cohort of 413 patients consecutively hospitalized for HF between March 1996 and September 1998. In July 2005, information was collected about their mortality, health related QOL as defined by disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, and functional decline as defined by limitations in Activities of Daily Living (ADL) scores. RESULTS: The primary outcomes were mortality, QOL, and functional decline. At follow-up, 8.1 years after enrollment, overall mortality was 76% (314/413). Adjusted for age, gender, renal insufficiency, diabetes mellitus, hypertension, HF, and respiratory disease, those with decreased ejection fraction (EF < 40%) had higher mortality compared with those with preserved ejection fraction (hazard ratio [HR] 1.42; confidence interval [CI] = 1.13, 1.80, p = 0.003). The KCCQ scores, including Clinical Summary Scores and Symptom Limitation Scores, as well as ADL limitations, were not significantly different in the survivors with preserved or decreased EF. CONCLUSIONS: Heart failure patients with preserved EF have a modest survival advantage compared with those with decreased EF, but health related QOL scores and functional decline in survivors are similar regardless of systolic function.     

Symptom clusters and quality of life among patients with advanced heart failure

Objectives To identify symptom clusters among patients with advanced heart failure (HF) and the independent relationships with their quality of life (QoL). Methods This is the secondary data analysis of a cross-sectional study which interviewed 119 patients with advanced HF in the geriatric unit of a regional hospital in Hong Kong. The symptom profile and QoL were assessed by using the Edmonton Symptom Assessment Scale (ESAS) and the McGill QoL Questionnaire. Exploratory factor analysis was used to identify the symptom clusters. Hierarchical regression analysis was used to examine the independent relationships with their QoL, after adjusting the effects of age, gender, and comorbidities. Results The patients were at an advanced age (82.9 ± 6.5 years). Three distinct symptom clusters were identified: they were the distress cluster (including shortness of breath, anxiety, and depression), the decondition cluster (fatigue, drowsiness, nausea, and reduced appetite), and the discomfort cluster (pain, and sense of generalized discomfort). These three symptom clusters accounted for 63.25% of variance of the patients’ symptom experience. The small to moderate correlations between these symptom clusters indicated that they were rather independent of one another. After adjusting the age, gender and comorbidities, the distress (beta = ?0.635, P < 0.001), the decondition (beta = -0.148, P = 0.01), and the discomfort (beta = -0.258, P < 0.001) symptom clusters independently predicted their QoL. Conclusions This study identified the distinctive symptom clusters among patients with advanced HF. The results shed light on the need to develop palliative care interventions for optimizing the symptom control for this life-limiting disease.     

Health-related quality of life among patients with idiopathic pulmonary fibrosis

The hallmark of idiopathic pulmonary fibrosis (IPF) is relentless and progressive breathlessness culminating in respiratory failure and death. Clinicians and investigators are increasingly aware that many patients with chronic diseases, like IPF, value the quality of their lives as much or more than their length of survival. Despite this growing awareness, little research has focused on quality of life (QOL) in IPF patients. Nevertheless, the few studies that have been performed uniformly show the negative impacts of IPF on QOL, particularly in the areas of physical health, energy, and symptoms. To fill important knowledge gaps, more research is needed. For example, future studies in well-defined IPF patient populations should rigorously assess the psychometric properties of different measures of QOL. Currently, there is no disease-specific instrument for use in patients with IPF. A carefully developed, IPF-specific instrument that includes items most relevant to IPF patients should be more sensitive to change than existing generic or non-IPF respiratory disease-specific instruments. Longitudinal assessments are needed to map the trajectory of QOL in relation to disease progression and to reveal whether different aspects of QOL become impaired over time. Addressing these research opportunities will markedly improve our knowledge of this outcome, which is highly valued by patients. These endeavors will also help clinicians who care for patients with IPF to develop a better understanding of its profound negative impact, and it will help future IPF clinical investigators to select the most valid, reliable, and appropriate QOL instrument to fill the roles their studies require.     

Severe frequent ventricular ectopy after exercise as a predictor of death in patients with heart failure

OBJECTIVES: The study was done to determine the prognostic importance of frequent ventricular ectopy in recovery after exercise among patients with systolic heart failure (HF). BACKGROUND: Although ventricular ectopy during recovery after exercise predicts death in patients without HF, its prognostic importance in patients with significant ventricular dysfunction is unknown. METHODS: Systematic electrocardiographic data during rest, exercise, and recovery were gathered on 2,123 consecutive patients with left ventricular systolic ejection fraction 相似文献   

Health-related quality of life measurement in patients with chronic respiratory failure

The improvement of health-related quality of life (HRQL) is an important goal in managing patients with chronic respiratory failure (CRF) receiving long-term oxygen therapy (LTOT) and/or domiciliary noninvasive ventilation (NIV). Two condition-specific HRQL questionnaires have been developed to specifically assess these patients: the Maugeri Respiratory Failure Questionnaire (MRF) and the Severe Respiratory Insufficiency Questionnaire (SRI). The MRF is more advantageous in its ease of completion; conversely, the SRI measures diversified health impairments more multi-dimensionally and discriminatively with greater balance, especially in patients receiving NIV. The SRI is available in many different languages as a result of back-translation and validation processes, and is widely validated for various disorders such as chronic obstructive pulmonary disease, restrictive thoracic disorders, neuromuscular disorders, and obesity hypoventilation syndrome, among others. Dyspnea and psychological status were the main determinants for both questionnaires, while the MRF tended to place more emphasis on activity limitations than SRI. In comparison to existing generic questionnaires such as the Medical Outcomes Study 36-item short form (SF-36) and disease-specific questionnaires such as the St. George's Respiratory Questionnaire (SGRQ) and the Chronic Respiratory Disease Questionnaire (CRQ), both the MRF and the SRI have been shown to be valid and reliable, and have better discriminatory, evaluative, and predictive features than other questionnaires. Thus, in assessing the HRQL of patients with CRF using LTOT and/or NIV, we might consider avoiding the use of the SF-36 or even the SGRQ or CRQ alone and consider using the CRF-specific SRI and MRF in addition to existing generic and/or disease-specific questionnaires.     

Central sleep apnea is a predictor of cardiac readmission in hospitalized patients with systolic heart failure

BackgroundHospitalized heart failure patients have a high readmission rate. We sought to determine the independent risk due to central sleep apnea (CSA) of readmission in patients with systolic heart failure (SHF).Methods and ResultsThis was a prospective observational cohort study of hospitalized patients with SHF. Patients underwent sleep studies during their hospitalization and were followed for 6 months to determine their rate of cardiac readmissions; 784 consecutive patients were included; 165 patients had CSA and 139 had no sleep-disordered breathing (SDB); the remainder had obstructive sleep apnea (OSA). The rate ratio for 6 months' cardiac readmissions was 1.53 (95% confidence interval 1.1–2.2; P = .03) in CSA patients compared with no SDB. This rate ratio was adjusted for systolic function, type of cardiomyopathy, age, weight, sex, diabetes, coronary disease, length of stay, admission sodium, creatinine, hemoglobin, blood pressure, and discharge medications. Severe OSA was also an independent predictor of readmissions with an adjusted rate ratio of 1.49 (P = .04).ConclusionIn this first evaluation of the impact of SDB on cardiac readmissions in heart failure, CSA was an independent risk factor for 6 months' cardiac readmissions. The effect size of CSA exceeded that of all known predictors of heart failure readmissions.     

Transient variations of transthoracic impedance as a predictor of heart failure and death in patients with implanted defibrillators

Background

Transient variations in physiological parameters may forewarn of life-threatening cardiac events, but are difficult to identify clinically. Implantable cardioverter defibrillators (ICD) designed to measure transthoracic impedance provide a surrogate marker for pulmonary congestion.

Objective

The aim of this study is to determine if the frequency of changes in transthoracic impedance (TTI) is associated with congestive heart failure (CHF) exacerbation and predicts mortality.

Methods

We followed 109 consecutive patients (pts) with ICDs (n = 58) or CRT-ICDs (n = 51) for a mean of 21.3 (+ 10.2) months. Using 80 ohm-days as a reference, we correlated the frequency of TTI changes above this index to CHF hospitalizations or death.

Results

There was at least one TTI threshold crossing in 79 (72%) pts over 23.3 months follow-up, with a mean of 1.8 ± 3.4 per year. There were 18 pts with CHF hospitalizations who had a mean of 4.3 TTI threshold crossings/year (S.D. = ± 7.3; median = 2.8), compared to 1.3 (S.D. = ± 1.5; median = 0.8) among pts without CHF hospitalizations (p = 0.0006). Among 20 patients who died during follow-up, there were 4.2 (S.D. = ± 7.0; median = 2.9) TTI threshold crossings/year, compared with 1.3 (S.D. = ± 1.3; median = 0.9) threshold crossings/year among survivors (p = 0.0004). Using Cox Proportional Hazard modeling, after adjusting for age, baseline EF, and number of shocks, TTI threshold crossing was an independent predictor of death (HR 1.72, 95% CI 1.26–2.36, p = 0.001).

Conclusions

Increased frequency of TTI threshold crossings may be a useful predictor of transient risk for identifying a subgroup of ICD recipients at greater individual risk for death or CHF hospitalizations.