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European Journal of Heart Failure 2002 4(1):99-104; doi:10.1016/S1388-9842(01)00204-5
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© 2002 European Society of Cardiology

Hospitalization for congestive heart failure: is it still a cardiology business?

Francesco Grigionia, Valeria Carincia, Luca Faverob, Letizia Bacchi Reggiania, Gaia Magnania, Luciano Potenaa, Alessandra Barbieria, Carlo Magellia,*, Angelo Branzia and Bruno Magnania

a Cardiology Institute of the University Hospital S. Orsola-Malpighi Via Massarenti n. 9, 40100 Bologna, Italy
b Medical Management Staff of the University Hospital S. Orsola-Malpighi Bologna, Italy

* Corresponding author. Tel.: +39-051-6364-526; fax: +39-051-3448-59. E-mail address: bibcard{at}almadns.unibo.it


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Background: Hospital management of CHF and predictors of hospital mortality remain unclear.

Methods: To address these issues, we analyzed the hospital admissions for CHF during 1996 in a large university hospital. Patients discharged with the principal diagnosis of CHF were considered eligible for the study.

Results: Among the 1511 patients (3% of all discharges) who satisfied the inclusion criteria, 75% were treated in general medicine departments (GMD) and 22% in cardiology units (CU). Patients admitted to GMD were older than those treated in CU (79±10 vs. 68±15 years, P<0.001), included a higher proportion of females (56% vs. 37%, P<0.001), and presented a higher rate of hospital mortality (13% vs. 4%, P<0.001). The overall mean length of stay was 11±9 days. At multivariate analysis, length of stay was not associated with the department (i.e. GMD/CU) (P=0.273).

Conclusions: CHF is a common lethal condition often requiring treatment in GMD. Length of stay appears to depend more on patients' characteristics than on differences in practice between GMD and CU. Patients admitted to GMD present higher rates of comorbidity and hospital mortality. Strategies are urgently needed to improve hospital management of CHF.

Key Words: CAD, coronary artery disease • CCU, coronary care units • CHF, congestive heart failure • CU, cardiology units • ED, emergency departments • GMD, general medicine departments • ICU, intensive care units

Received December 15, 2000; Revised June 7, 2001; Accepted September 7, 2001


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
It has been estimated that congestive heart failure (CHF) affects approximately 2.3 million people in the United States alone, with 400 000 new cases being reported each year [1]. In Italy, up to 190 000 patients with suspected or known CHF are examined every year by cardiology units (CU) [2–4]. Of these, approximately 30% require hospital admission [2]. Despite new therapeutic strategies designed to reduce the number of cases of CHF [5–8], recent data demonstrate that the incidence has remained largely unchanged [9]. This finding can probably be explained by the reduced fatality rate from acute cardiovascular events, resulting in an increased number of patients at risk of developing CHF [10–12]. Moreover, even if the incidence remains stable, the prevalence of CHF is expected to increase due to the aging of the general population, and the impact of this condition on healthcare will probably grow [9,13].

CHF is a lethal syndrome, with a mortality comparable with the more aggressive forms of cancers [9,14–16]. Since CHF is a serious condition and its prevalence is increasing, it is scarcely surprising that the number of hospital admissions for CHF has been growing over the years [3,4,17,18]. The trend is so steep that in the USA CHF now represents the most common cause of hospitalization in patients over 65 years of age [19,20].

CHF is a major burden not only for CU [2], but also for general medicine departments (GMD), which are often involved in the care of CHF patients [3]. Because medical and surgical resources for the management of CHF are allocated in accordance with the specific mission of the various departments, correct selection of patients is mandatory in order to deliver appropriate therapeutic strategies. Furthermore, because intervention always has to be directed to the improvement of prognosis and the reduction of costs, identification of predictors of length of hospital stay and of hospital mortality could provide important information. However, the available studies on the hospital management of CHF [2–4,17,18,21–23] have only partially addressed these issues. In particular, to our knowledge no analysis focusing on the overall CHF hospital management and predictors of length of stay and hospital mortality is currently available.

We analyzed the admissions to hospital for CHF at the Bologna University Hospital of S. Orsola-Malpighi in order to (1) determine the impact of CHF on daily hospital practice; (2) characterize hospital management of CHF; and (3) identify predictors of length of stay and hospital mortality.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusions
 References
 
All patients discharged from S. Orsola-Malpighi hospital between 1 January and 31 December 1996 with the principal diagnosis of CHF were considered eligible for the study. All patients were considered, irrespective of whether they were dead or alive at discharge. Principal diagnosis at discharge was recorded on the basis of the code reported in the patients case records, according to the Ninth Revision of the WHO International Classification of Disease (ICD), as previously described [3,4,17,18,22,24]. Presence of concomitant illnesses was similarly assessed. Patients treated by any of the two coronary care units (CCU) or the two intensive care units (ICU) of the hospital were considered together in the analysis. Patients treated by the two CU were also considered together, as were the patients treated in any of the 11 GMD. Data were used unaltered from the original records by means of electronic transfer. Continuous variables are expressed as mean±S.D. and categorical variables as percentages. Group comparisons were performed with the standard t test or {chi}2 test, as appropriate. Event rates were estimated by the Kaplan–Meier method. Identification of baseline predictors of events was accomplished initially by performing univariate Cox proportional hazards analysis. To confirm independent predictive values, the variables with P<0.10 were then tested in a multivariate model. P<0.05 was considered significant.

The investigation conforms with the principles outlined in the Declaration of Helsinki.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusions
 References
 
3.1. Patient population
During 1996, 51 239 patients were discharged from S. Orsola-Malpighi hospital. For 1511 (3%) of these patients, CHF was the principal diagnosis at the time of discharge. The proportion of these CHF patients in each ICD 9 code was as follows: 428.0 (‘congestive heart failure’), 39%; 428.1 (‘left heart failure’), 31%; 428.9 (‘heart failure, unspecified’), 30%. The mean age of the CHF patients at time of discharge was 77±12 years; 51% were female. Coronary artery disease was diagnosed in 595 (33%) of the CHF patients. Age- and sex-specific discharge rates are reported in Fig. 1. In 1245 (82%) cases, the patient was initially admitted to emergency departments (ED); from there, 1213/1245 (97%) patients were ultimately transferred to the various ward settings on the basis of their status, the preferences of ED physicians, and the availability of beds. The remaining 266 (18%) patients who did not pass through an ED were admitted directly to CU or GMD on an elective basis in order to complete diagnostic work up or to undergo specific therapeutic protocols. Mean duration of in-patient stay was 11±9 days (range 1–90 days). The total in-hospital fatality rate was 12.4% (n=187 deaths).


Figure 1
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  		Fig. 1 Age distribution by gender (left male; right female) of patients dismissed with the principal diagnosis of congestive heart failure.

 
3.2. CHF hospital treatment
Among the 1511 CHF patients, 32 (2%) were discharged from the ED, 18 (1%) from the intensive or coronary care units (ICU/CCU), 326 (22%) from the CU, and 1135 (75%) from the GMD. Table 1 reports the mean age, gender, prevalence of CAD, hypertension, diabetes and renal insufficiency with respect to the discharging department. Among the various groups, the mean age, gender and prevalence of CAD and renal insufficiency varied significantly (all P<0.003). In particular, mean age was significantly higher in patients from the GMD than in patients from the CU (79±10 years vs. 68±15 years, P<0.001). Prevalence of males was higher in the CU than in the GMD (63% vs. 44%, P<0.001), as was prevalence of CAD (41% vs. 31%, P<0.001).


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  		Table 1 Patient population characteristics according to the type of treating departments

 
3.3. Duration and predictors of length of stay
Overall, the mean length of stay at S. Orsola-Malpighi hospital of the 1511 CHF patients was 11±9 days. As can be seen from Table 1, the mean length of in-hospital stay varied significantly with respect to the departments from which the patients were discharged (P<0.001 overall). At univariate analysis, predictors of length of stay were age (P<0.001), treatment in CU (P<0.001) and presence of hypertension (P=0.008). No other variable, including presence of CAD or of diabetes, was associated with length of stay. Moreover, no association was observed between length of stay and hospital mortality (P=0.52). At multivariate analysis, only age [B (95% C.I.)–0.076 (–0.034–0.112) P<0.001] and presence of hypertension [B (95% C.I.)–1.39 (–0.27–2.51] P=0.015] were independently associated with length of stay, whereas treatment in CU was not (P=0.273).

3.4. Hospital mortality from CHF
Mortality rates in the GMD, CU, ICU/CCU and ED were 13, 4, 19 and 78%, respectively (P<0.001 overall; P<0.001 GMD vs. CU). Using the proportional hazard model, at univariate analysis predictors of in-hospital mortality were age (P<0.001), presence of systemic hypertension (P=0.001) and presence of renal insufficiency (P<0.001). Moreover, discharge of patients directly from the ED was associated with an increased risk of hospital mortality (P<0.001). At multivariate analysis, all of these variables remained independently associated with the risk of hospital mortality [adjusted RR (95% C.I.): per year of age 1.04 (1.03–1.06), P<0.001; per presence of renal insufficiency 1.90 (1.27–2.86), P=0.002; per presence of systemic hypertension 0.46 (0.29–0.73), P=0.001; per treatment in ED 5.49 (3.10–9.71), P<0.001]. When the analysis was restricted to patients admitted to the GMD and CU, the former presented a higher risk of hospital mortality [adjusted RR (95% C.I.) 1.41 (1.23–1.62), P<0.001].


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusions
 References
 
The present study investigated patterns of hospital admissions for CHF in a major university hospital. We found that as many as 75% of the patients were treated in a GMD. However, length of in-hospital stay appeared to be more related to the patients’ characteristics rather than to differences in practice between GMD and CU. We also found that the GMD tended to treat patients with particularly high comorbidity and hospital mortality.

4.1. Admissions for CHF
In our hospital, CHF (as first diagnosis) accounted for 3% of all discharges. These findings are in agreement with previous studies highlighting the growing number of hospital admissions for CHF observed in recent years [3,22]. In accordance with the age-related prevalence of this condition [9,13,15,25], the vast majority of admissions regarded elderly patients. Overall, gender was evenly distributed (51% females), and the increase in hospital admission rate with age was apparent in both males and females (Fig. 1). However, whereas in men the trend was clearly apparent as early as the sixth decade of life, in women it was largely delayed until the seventh or eighth decade.

When the discharging department was considered, the vast majority of patients turned out to have been treated by a GMD rather than a CU (75% vs. 22%). Patients treated in the GMD were significantly older than those in the CU, and showed a higher prevalence of serious diseases associated with CHF. Conversely, CU more often provided care to patients with CHF potentially due to CAD.

As regards length of stay, on average patients were kept significantly longer in the CU than in the GMD. This finding is not in keeping with other studies [3] and therefore requires some explanation. Since the CU of the S. Orsola-Malpighi hospital is the referring center for the local heart transplant program, many critical young CHF patients are admitted for evaluation, stabilization or transplant work up. Moreover, because of the presence of a catheterization laboratory and the availability of conventional heart surgery, patients with CHF due to CAD tend to be referred to the CU from peripheral centers for time-consuming evaluations and treatments. These explanations were confirmed by the results of our multivariate analysis: after adjusting for patients’ baseline characteristics, treatment in CU no longer turned out to be associated with length of stay.

4.2. Hospital mortality for CHF
A hospital mortality rate of 12% was recorded (187 deaths among the 1511 admissions). At multivariate analysis, age, hypertension, and renal insufficiency were the only variables independently associated with hospital mortality. The negative contributing role of age and renal insufficiency on the prognosis of CHF patients comes as no surprise: these factors have already been highlighted in population based studies, as has the independent positive predictive value of hypertension, which, however, is rather more difficult to explain [9]. In our study, the favorable influence of hypertension might be interpreted as follows. Left ventricular diastolic function is responsible for the clinical pictures of approximately 30% of patients with a definitive diagnosis of CHF [26–28], and diastolic heart failure bears a better prognosis than systolic heart failure. It is therefore quite possible that the patients in the present study who had systemic hypertension may have presented a higher prevalence of diastolic heart failure than the other patients, and thus were affected by a lower hospital mortality.

Hospital mortality among our CHF patients was significantly higher in GMD as compared with CU. Since data on the medical treatment administered during the hospitalization period were not available for study, no comments can be made regarding either its appropriateness or any differences in non-medical strategies adopted by the CU with respect to the GMD. However, we do know that the clinical characteristics of the patients admitted to the CU were vastly different from those treated in the GMD. In fact the latter were significantly older and presented higher rates of comorbidity. Among the possible medical strategies for CHF patients, the benefits of angiotensin-converting enzyme (ACE) inhibitors have been conclusively demonstrated in randomized trials [5–8,29]. However, in practice ACE inhibitors are still underused, especially in the elderly [2]. The situation is even worse for beta-blockers, which are almost never administered to elderly patients [2]. The age-related penalization of CHF treatment does not only regard drugs. Heart transplantation is an effective therapeutic option, but is reserved for patients under 65 years of age, and is contraindicated in cases of high comorbidity. Furthermore, even for traditional cardiac surgery, advanced age and high comorbidity mean a poor prognosis. Therefore, the discrepancies in outcome between the GMD and CU could be easily enough explained by the major differences in the clinical characteristics of the patients admitted, irrespective of any differences in therapeutic approach. In any case, the aim of the present study was not to compare the quality of care provided by internists and cardiologists, but rather to correctly identify the characteristics and outcomes of CHF patients admitted to the hospital in order to maximize the diagnostic and therapeutic resources of the single departments. Such information could be particularly relevant for ED physicians, who have the responsibility of allotting the specific ward settings where the patients are to be treated for the rest of their stay in hospital. Furthermore, close cooperation between cardiologists and internists is required to personalize the therapeutic strategies according to the specific characteristics of the available wards [30–33].

4.3. Limitations of the study
The CHF patients included in the present study were identified on the basis of their principal diagnosis at discharge, and therefore classification errors and underestimation of the overall number of CHF hospital admissions cannot be excluded. However, the diagnosis of CHF is intrinsically difficult in any case [34]. We followed the criteria of the Ninth Revision of the International Classification of Disease, which has proved reliable in previous studies on CHF [3,4,17,18,22]. Furthermore, in order to limit discrepancies in recording practices [3], we restricted our analysis to CHF in the first diagnostic position (corresponding to 1511 cases among the 2292 recorded in any diagnostic position). Moreover, since the code 428 associates well with the diagnosis of CHF made according to the Framingham criteria, this code was exclusively used for the selection of our study population [18,35].


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
References
 
CHF is a common and lethal condition which often calls for long-term in-hospital treatment. In our hospital, length of stay appears to be related to the patients’ clinical characteristics more then to the characteristic practices of the GMD or CU. The majority of CHF patients were admitted to GMD. GMD had to provide care to elderly CHF patients with significant comorbidity, paucity of therapeutic options, and high mortality. Strategies are urgently needed to reduce mortality, and also to cut the costs associated with hospital management of CHF patients.


   Acknowledgements
 
We thank nurses Gianna Canu, Paola Marchesini and Sandra Sassi for their exceptional work in the heart failure clinic. We are grateful to Robin M.T. Cooke for editing.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 

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