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European Journal of Heart Failure 2001 3(5):611-617; doi:10.1016/S1388-9842(01)00142-8
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© 2001 European Society of Cardiology

Clinical profile and management of heart failure: rural community hospital vs. metropolitan heart center

G. Tauberta,*, C. Bergmeiera, H. Andresenb, J. Sengesa and J. Potratzb

a Herzzentrum Ludwigshafen, Department of Cardiology Bremserstraße 79, 67063 Ludwigshafen, Germany
b 1st Medical Department Diakoniekrankenhaus Rotenburg, Elise Averdieck Straße, 27356 Rotenburg, Germany

* Corresponding author. Herzzentrum Ludwigshafen, Medizinische Klinik B, Bremserstr. 79, 67063 Ludwigshafen, Germany. Tel.: +49-6215034000; fax: +49-6215034044. E-mail address: gtau1904{at}aol.com (G. Taubert)


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Background: Knowledge on clinical characteristics and prognosis of patients with heart failure originates from studies of selected populations in clinical trials or from epidemiological observations. Reports on the large numbers of patients with heart failure treated in community hospitals are sparse.

Objective: Are there differences in patient characteristics and heart failure management between a metropolitan heart center (HC) and a rural community hospital (RCH)?

Patients and methods: Retrospective analysis of medical charts from all patients admitted for heart failure (ICD 428.x, NYHA II–IV, EF < 45%) between May 1997 and April 1998 and discharged alive from a rural community hospital. A similar, but prospective registry was available at the HC. Follow-up information was obtained by request at registration authorities.

Results: Patient groups comprised 120 in RCH and 146 in HC. Mean age was 75 ± 11 and 66 ± 11 years, respectively (P < 0.001); 48% (RCH) vs. 74% (HC) of patients were male (P < 0.001). On admission the proportion of functional class IV was 69% (RCH) vs. 17% (HC) (P < 0.001). At discharge, the rate of ACE-inhibitors was 74% (RCH) vs. 98% (HC); 11% (RCH) vs. 43% (HC) of patients received β-blocker therapy. Ninety-six percent of patients in HC underwent and 22% in RCH had undergone invasive diagnostics. One-year mortality rate of patients discharged alive was 26% in RCH and 19% in HC (P = n.s. after adjustment for age and gender).

Conclusion: Heart failure management according to current guidelines, using β-blockers and ACE inhibitors, and invasive cardiac examination was significantly less performed in the rural community hospital than in the metropolitan heart center. Therefore, strategies to improve heart failure management according to guidelines are urgently needed.

Key Words: Clinical characteristics • Prognosis • Heart failure

Received December 30, 1999; Revised January 8, 2001; Accepted February 12, 2001


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Current information about presentation and prognosis of heart failure relies on large clinical trials, which are highly selective and are often based on university infrastructure [1–7] or on epidemiological field studies using non-invasive and thus rather inaccurate diagnostic criteria [8]. Although reports on non-selected patients with heart failure from general hospitals exist, comparisons between general hospitals and specialized centers are lacking [9–11]. A European survey addressing the quality of heart failure care in terms of diagnostics and therapy is currently ongoing [12].

The aim of the current study was to compare baseline characteristics and management of patients presenting with heart failure due to impaired left ventricular function in two hospitals with different levels of medical care: a rural general hospital vs. a metropolitan heart center.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 5. Conclusion
 References
 
2.1. Rural community hospital
Medical charts of all patients admitted between 1 May 1997 and 30 April 1998 were analyzed retrospectively. Selection criteria for our study were all patients discharged alive with a diagnosis of heart failure (ICD-9-code 428.X) and a left ventricular ejection fraction <45% by echocardiography. The community hospital is located in a sparsely populated rural area in north-west Germany and serves a population of 80 000 providing general medical and non-invasive cardiology procedures.

2.2. Cardiology department of a metropolitan heart center
Since January 1995 all patients presenting with an echocardiographically determined left ventricular ejection fraction <45% were prospectively enrolled in a registry. There were no exclusion criteria for enrollment in this registry. From this registry we collected data on all symptomatic patients (NYHA II–IV) admitted to the hospital between 1 May 1997 and 30 April 1998 who were subsequently discharged alive. The heart center is located in a densely populated area of south-west Germany and serves a population of 300 000 providing all non-invasive and invasive diagnostic and therapeutic cardiac procedures save heart transplantation.

Both hospitals were chosen for comparison because one of the authors (G.T.) worked with both institutions. Follow-up information on patients, concerning their live status, were obtained by request at local citizen registration authorities.

2.3. Statistics
Unless stated otherwise results are reported as arithmetic mean±1 S.D.

Frequencies of discrete parameters were compared using a {chi}2-test. Measures of central tendencies were examined applying the Mann–Whitney U-test. All statistical calculations were performed by the Statistica for Windows software, version 5.1 (StatSoft Inc, Tulsa, OK, USA). An error probability of less than 5% was deemed as significant.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusion
 References
 
3.1. Patients
During the study period 202 patients were admitted with a discharge diagnosis of heart failure (ICD-9-code 428.X) in the rural community hospital. One hundred and twenty patients remained for analysis. Reasons for exclusion of patients were: ejection fraction >45% (n=52), echocardiography not performed (n=12), death in hospital (n=10), NYHA class I (n=8). Mean age of enrolled patients were 75±11 years; 48% were male; 22 patients (20%) were younger than 65 years.

At the heart center 158 patients were enrolled in the LVD-registry during the study period. Out of those, 146 symptomatic patients (NYHA II–IV) were discharged alive and were chosen for comparison with the patients of the rural community hospital (12 patients have been classified as NYHA class I and were therefore excluded from this analysis). Mean age of enrolled patients was 66±11 years; 74% were male, 51 patients (37.7%) were younger than 65 years.

3.2. Symptoms and reasons for hospital admission
The patients of the rural hospital were admitted presenting with functional class 3.5±0.8 (median 4) while the patients of the heart center were admitted with functional class 2.8±0.7 (median 3).

The distribution of functional status is shown in Table 1. Reasons for admission are given in Table 2.


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  		Table 1 Demographical and clinical data of patients with heart failure: rural general hospital vs. heart center

 


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  		Table 2 Reasons for heart failure or admission: rural general hospital vs. heart center

 
The most frequent reason for hospital admission in both patient groups was deterioration of heart failure. Second were cardiac diagnostic in the heart center group and acute myocardial infarction in the rural hospital group.

On admission the patient group of the rural hospital presented twice as often with atrial fibrillation than the patients of the heart center.

Left ventricular ejection fraction was 31±10% in the patients of the rural community hospital and 30±8% in the patients of the heart center (n.s.).

The average length of stay in hospital was 9±10 days (median 8) at the heart center and 18±8 days (median 16.5) in the general hospital (P<0.0001).

3.3. Diagnostics
According to the inclusion criteria, all patients of the heart center cohort underwent echocardiography. Of the rural hospital group 12/202 patients (5.9%) did not receive an echocardiogram despite a discharge diagnosis of heart failure; 140/146 patients (96%) of the heart center cohort underwent invasive cardiac examination. No patient in the rural hospital group received invasive cardiac examination in association with the current hospital admission. However, invasive diagnostics had been performed in 30 patients (25%) at some time earlier.

Therefore, the invasively documented etiology of heart failure was unknown in 90 patients (75%) of the rural hospital group. Twenty-three patients were classified as coronary heart disease. All of them had undergone coronary bypass grafting; seven patients were classified as dilated cardiomyopathy.

In the heart center 98 patients (67%) were classified as coronary heart disease, 26 patients (27%) as dilated cardiomyopathy, 16 cases (16%) as other causes (hypertensive heart disease, valvular heart disease). In six patients (4%) the etiology was indeterminate.

3.4. Comorbidities
In the rural hospital group every second patient presented with a comorbid condition related to hypertension, diabetes or a cardiovascular, chronic pulmonary obstructive, or malignant disease while in the heart center cohort any patient presented with one of these comorbid conditions (P<0.001; see Table 3).


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  		Table 3 Comorbidity in heart failure patients: rural hospital vs. heart center

 
3.5. Drug therapy
ACE-inhibitors and β-blockers, both medications with a documented impact on long time survival, were prescribed more often in the heart center (Table 4). In contrast symptomatic therapy with diuretics and digitalis was more often prescribed in the rural community hospital. Furthermore, only three patients were discharged on a fourfold drug combination (ACE inhibitors, β-blockers, diuretics, and digitalis) while in the heart center the number of patients discharged on a fourfold combination was 18. The various combinations of one to four heart failure drugs in both patient groups are shown in Fig. 1. These combinations are significantly different between both patient groups ({chi}2=11.3; P=0.01).


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  		Table 4 Heart failure drug therapy at discharge: rural general hospital vs. heart center

 


Figure 1
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  		Fig. 1 Combinations of one to four of the following heart failure therapeutics: ACE-inhibitors, β-blocking agents, diuretics, digitalis. Rural general hospital vs. heart center.

 
3.6. Follow-up
Follow-up information was obtained by request at local authorities. Follow-up information was available for 110 of 120 patients (92%) of the rural hospital and of 136 of the 146 patients (93%) of the heart center. The median follow-up period was 397 days for the rural hospital group and 455 days for the heart center. The 1-year all-cause mortality rate was 29/110 (26%) for the rural hospital group and 26/136 (19%) for the heart center group ({chi}2=1.84; P=n.s.; adjusted for age and gender).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusion
 References
 
The present study sought to examine differences between a rural general hospital and a heart center in terms of clinical presentation, diagnostics, and therapy in heart failure patients.

4.1. Patient characteristics
The differences in patient characteristics between patients admitted for heart failure at a rural hospital vs. a heart center could be explained by the fact that the vast majority of patients admitted at general hospitals are admitted for acute illness, while in specialized centers there is a substantial proportion of patients admitted for elective diagnostics. This is underlined by two of our findings: (1) none of the rural hospital patients underwent an invasive cardiac examination while in the heart center group 96% of the patients underwent invasive diagnostics; and (2) 69% of the rural hospital cohort were admitted with class IV dyspnea vs. 17% class IV dyspnea in the heart center cohort.

The proportion of women admitted for heart failure and impaired left ventricular function was 52% in the rural hospital as opposed to 26% in the heart center. Thus, the proportion of women in the rural hospital is similar to the proportion of women in epidemiological cohorts as in the Framingham study [8]. Selection bias might be the cause for a difference in gender distribution according to Schulman and coworkers [13]. Heer and coworkers demonstrated in a large observational study of patients admitted for acute myocardial infarction that invasive diagnostics and prognostic therapy with a proven prognostic benefit were used less often in women [14]. Recently, Mejhert found in a retrospective analysis of two Swedish hospitals a more pronounced underuse of diagnostic tests and medical treatment in women [15]. However, the reason for this difference remains unclear.

The patients of the rural community hospital were on average 9 years older than the patients of the heart center. Published findings are consistent with our data: in a London general hospital, only 21% of the patients admitted for heart failure were younger than 65 years [10]. The mean age of patients admitted for heart failure was 70 years in a Portuguese general hospital [11]. In a published comparison from the United States, patients treated for heart failure by general practitioners were older and more often female than patients treated by cardiologists, as seen in our observation [16].

4.2. Symptoms
As stated above, while only 17% of patients admitted for heart failure in the heart center were in functional class IV, the rate of class IV was 69% in the rural hospital. This difference could be explained in part by the proportion of patients admitted at the heart center for diagnostics (17.8%). An inverse relation was seen in the American study reported above: 51% of the patients treated by specialists were in class IV, while 17% of patients treated by general practitioners were in class IV [16]. The lower rate of class IV patients in comparison to that study might be attributed to the lacking heart transplantation service in our heart center. In a London general hospital, 61% of heart failure patients presented at admission with lung edema [10], which is in concordance with the proportion of class IV in our rural hospital group.

4.3. Reasons for hospital admission
The main reason for hospital admission in both patient groups was deterioration of heart failure.

The second frequent reason was cardiac examination in the heart center group and myocardial infarction in the rural hospital group. Surprisingly, non-compliance with drug therapy as a reason for hospital admission was quoted in neither patient group. However, according to the literature, non-compliance is a problem particularly common in elderly heart failure patients [17,18] and might be a frequent reason for hospital admission in patients with heart failure accounting for a proportion of up to 50% [19,20].

4.4. Comorbidity
Comorbidity in patients with heart failure may deteriorate prognosis [21,22] and physicians could suggest withholding prognostic therapy, as shown for renal transplantation [23].

However, in our study the rural hospital group received less often prognostic pharmacotherapy and less often invasive cardiac examination than the heart center group, despite the lower comorbidity.

4.5. Diagnostics
Echocardiography should be used routinely for the optimal diagnosis of heart failure [24]. In particular, in comparison to published frequencies of echocardiography in suspected heart failure patients in a community hospital setting or a primary care setting of 30% [25,26], an echocardiography rate of 94% echocardiography in our rural hospital group was exceptional. While invasive examination is not required to establish the diagnosis of heart failure, coronary angiography is mandatory if revascularization is considered as the treatment option in coronary heart disease as an underlying cause of heart failure [24]. Not performing invasive examination precludes the option for revascularization a priori. Invasive diagnostic has been significantly less often performed in patients of the rural hospital than in patients of the heart center despite a substantial proportion of patients younger than 65 years and a significantly lower comorbidity.

This might be due to the fact that patients had to be transferred to another hospital for invasive examination. However, the charts of these patients did not contain information regarding transfer for invasive examination.

4.6. Therapy
The intensity of therapy in terms of proportion of patients on ACE-inhibitor therapy, ACE-inhibitor dosage, and proportion of patients on β-blocker therapy, shifted towards drugs with a prognostic benefit in the heart center, while in the rural hospital symptomatic therapy (diuretics, digitalis) prevails. This was confirmed by others who found that cardiologists used ACE-inhibitors more often and prescribed higher ACE-inhibitor doses than primary care physicians [27] or internal medicine specialists [28]. Philbin et al. reported on a lower rate of ACE-inhibitor application in elderly patients in two community hospitals [29].

The study results indicating favorable effects of heart failure therapy using β-blockers in functional class IV were published very recently [30] while the favorable effects of β-blockade in heart failure in general have been published in 1989 and thereafter [31]. However, the proportion of functional class IV with the rural hospital patient group was as high as 69%, which might at least partially explain the lower β-blocker use in that particular patient group. Additionally, the fear of deleterious side effects in a rural hospital setting with a significantly older patient cohort could suggest to physicians that they be cautious with a prognostic therapy [32].

Non-pharmological therapy such as dietary or rehabilitative advice [28] has not been documented in either patient group.

4.7. One-year mortality
The 1-year-mortality in the rural hospital group was 26% in comparison to 19% in the heart center cohort. After adjusting for age and gender, this difference was not statistically significant. However, this study was not designed to demonstrate any difference in mortality.

The 1-year mortality for heart failure in a London general hospital was 44% [10]. The American comparison between general practitioners and cardiologists showed the same mortality, but a 1.7-fold higher readmission rate in the general practitioners group [16]. We did not investigate the frequency of readmission in our patient groups.

4.8. Limitations of this study
The present study compares a cohort of heart failure patients collected prospectively and consecutively with another patient group selected retrospectively using the same diagnostic criteria. However, this methodology may lead to a selection bias.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
References
 
Patients with congestive heart failure due to impaired left ventricular function are less intensively cared for in a rural community hospital than in a metropolitan heart center with regard to prognostic pharmacological therapy and invasive cardiac examination. These differences in heart failure management could not be explained solely by differences in age, gender, and comorbidity.

Therefore, strategies to improve adherence to heart failure guidelines in the community hospital setting in terms of diagnostic and therapeutic heart failure management are urgently needed.

Efforts to address problems of patient non-compliance should be initiated in either hospital.

The potential of non-pharmacological therapy, such as dietary and rehabilitative patient counseling, seems to be not fully exhausted in both hospitals.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 

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