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European Journal of Heart Failure 2002 4(3):353-359; doi:10.1016/S1388-9842(02)00013-2
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© 2002 European Society of Cardiology

Effect of a heart failure clinic on survival and hospital readmission in patients discharged from acute hospital care

Ana Azevedoa,b,c,*, Joana Pimentaa, Paula Diasa, Paulo Bettencourta,b, António Ferreiraa,b and Mário Cerqueira-Gomesb

a Heart Failure Clinic, Department of Internal Medicine Hospital de S. João, Porto, Portugal
b Unidade de Investigação e Desenvolvimento Cardiovascular Porto, Portugal
c Serviço de Higiene e Epidemiologia, Faculdade de Medicina da Universidade do Porto Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal

* Corresponding author. Tel. +351-22-5507597; fax: +351-22-5095618. E-mail address: anazev{at}med.up.pt


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Ambulatory care by physicians especially devoted to the management of heart failure (HF) has been reported to have beneficial effects. The aim of this work was to assess the effect of outpatient management at a HF clinic, as compared with care by the usual assistant physician, on prognosis of HF patients. In this non-randomised study, we prospectively followed 339 patients after a hospitalisation index for HF, in order to compare prognosis between two groups of HF patients according to the ambulatory assistance setting: either a specific outpatient clinic (n=157) or the usual assistant physician (n=182). The outcomes assessed were all-cause death or cardiac-cause rehospitalisation during the first month after discharge and survival over the longer term. The risk of dying or being readmitted during the first month after discharge was significantly lower in patients followed at the HF clinic (adjusted odds ratio 0.23; 95% CI 0.12–0.46). Patients followed in the HF clinic also had an independent significantly lower hazard of dying during a longer-term follow up of average length 373 days (adjusted hazard ratio 0.52; 95% CI 0.34–0.81). The results support the fact that a multidisciplinary and permanently available medical staff might be of relevance in improving outcomes in HF patients.

Key Words: Heart failure • Outpatient management • Prognosis • Survival • Outcomes

Received March 30, 2001; Revised August 8, 2001; Accepted October 23, 2001


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Despite the availability of drug therapies that have been proved to increase survival, heart failure (HF) remains a clinical entity with very poor prognosis. Although drugs that were shown to have beneficial effects in large-scale randomised clinical trials have been included in American and European therapeutic guidelines for HF [1–3], the level of care provided to many patients with HF remains disappointing [4,5]. In fact, many primary care physicians, internists and cardiologists have been reluctant to use some of those agents, or use them in suboptimal doses [5–10].

Recently published data provided evidence for the superiority and cost-effectiveness of specialised HF centres [6]. Ramahi et al. [11] suggested that these results are probably due not only to an increase in the utilisation of known beneficial drugs, significant increase in the dose of angiotensin-converting enzyme (ACE) inhibitors and intensification of diuretic regimen, but also to the comprehensive preventive nature of care, based on frequent evaluation and close interaction with experienced staff.

However, most of the studies on the outcome of patients attending HF clinics have been conducted in a particular setting, which is that of patients referred for transplantation [12]. These patients are a small proportion, clearly not representative of the enormous group of HF patients, since they are younger and have fewer comorbidity problems, as well as a better chance of compliance. Rich et al. [13] have demonstrated a reduction in readmission rates of elderly patients with HF under a specific multidisciplinary, nurse-oriented program. However, that study included only patients at high risk of being readmitted, who are more likely to benefit from such a program. The challenge now is to extend those data and define the impact that HF centres might have on the larger population with HF. Furthermore, the outcomes assessed in both observational and experimental studies on diverse interventions have not included survival, an analysis of considerable interest that remains to be carried out [10].

The aim of this study was to compare survival and risk of rehospitalisation after discharge from a hospitalisation index between two groups of HF patients according to the ambulatory assistance setting: either a HF-specific outpatient clinic, or the usual assistant physician.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
In this study we assessed 339 patients with HF, defined according to guidelines for diagnosis of the European Society of Cardiology [14], who were discharged from a medical ward of a community hospital, where they had been consecutively admitted because of decompensated HF between January 1995 and December 1996. On admission, patients were allocated to 10 different wards (five for each gender) in regular succession. Upon discharge, those patients who had been in a ward under the responsibility of physicians working at the HF outpatient clinic of the same hospital were sent to that ambulatory clinic, unless they were already assisted elsewhere by an internist or cardiologist. The patients who had been admitted to other wards in our Internal Medicine Department were sent to their usual assistant physician (in the vast majority of cases, the primary care physician). The sample included 339 patients non-randomly distributed into two subgroups: 157 patients followed at the HF clinic and 182 patients sent to their assistant physician.

The outpatient clinic medical staff is constituted of internists and cardiologists specially devoted to investigation and management of HF. This clinic also has trained nutritionists and nursing staff. The hospital has a diagnostic catheterization laboratory and cardiac surgery department. The HF clinic has free access to the echocardiography laboratory and to all the other facilities. Patients followed up at the HF clinic had their regular appointments and unscheduled visits or phone consultations whenever needed. Intervention at our HF clinic consisted of systematic diagnostic assessment [14] and therapeutic strategies based on several large randomised trials conducted over the last 15 years, tailoring therapy according to individual patient characteristics: 95.5% of patients were receiving furosemide (mean dose 82.1±36.3 mg/day), 93% were receiving an ACE inhibitor (mean lisinopril-equivalent dose 23.1±10.0 mg/day) and 37.1% of patients with systolic dysfunction were treated with beta-blockers.

All patients were followed up in order to register the occurrence of the outcome of interest (death or hospital readmission). Data for the first group were prospectively collected and registered on the medical records of our clinic. Follow-up of the latter patients was carried out both by mail and telephone contact, either with the patient or a close relative at 1 and 6 months after discharge, and every 6 months thereafter. Information on survival status and date of death was collected until the end of follow-up for all patients; in addition, data on death or readmission to hospital due to a cardiac cause were collected during the first month after discharge. For readmitted patients, medical records were reviewed in order to validate the self-reported information. Due to the difficulty in obtaining accurate data on the cause of death, all-cause mortality was chosen as the primary end-point.

The outcomes were crudely compared between the two groups and taking into account several demographic, clinical, analytical, echocardiographic and electrocardiographic baseline variables, which had been assessed during the in-hospital stay. Echocardiographic variables were assessed by M-mode and bidimensional echocardiography and included left atrium and diastolic left ventricle dimensions (adjusted for body surface area), and left-ventricle ejection fraction measured using the biplane disc-summation method (Simpson rule) or the Bullet single and biplane ellipse method. Serum biochemical analyses were all performed at the hospital laboratory using standard methods.

Data storage and analysis were performed using SPSS (SPSS Inc, Chicago, IL). Continuous variables were compared with a Mann–Whitney test and categorical ones with the likelihood-ratio {chi}2 test. Cumulative survival curves were estimated by the Kaplan–Meier method and compared by the log-rank test. Cox proportional hazards regression models were used for multivariable survival analysis. Logistic regression was further used to calculate odds ratios (OR) for comparison of the occurrence of the combined event in the first month. The final models were built using a forward stepwise method, including all variables that were significantly different between groups of type of care and associated with the outcome of interest in univariate analysis. All P values were two-tailed and a significance level of 5% was used.

The investigation conformed with the principles outlined in the Declaration of Helsinki. The study was approved by the local Ethics Committee and patients gave informed consent.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
The baseline characteristics of patients according to type of care are described in Table 1. Patients referred to the HF clinic were found to be significantly older, more often of male gender and significantly more likely to have ejection fraction lower than 40%. Patients sent to their assistant physician were more likely to have atrial fibrillation and had a higher mean heart rate. There were no significant differences between the two groups in the frequency of ischemic etiology of HF, diabetes mellitus, New York Heart Association (NYHA) class on entrance, blood pressure and length of index hospitalisation (11.6±6.6 vs. 12.3±8.3 days, respectively, in the HF clinic and the assistant physician group, P=0.42).


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  		Table 1 Description and comparison of baseline characteristics of patients

 
As shown in Table 2, the risk of dying (all causes) or being readmitted to hospital (cardiac cause) during the first month after discharge was significantly higher in patients followed by their assistant physician (25.8% vs. 8.3% in HF clinic patients). These data are based on all patients, since there were no patients missing or lost to follow up. A higher risk was also significantly associated with higher NYHA class on entrance, lower ejection fraction, lower systolic arterial pressure, higher left atrium and diastolic LV dimensions, and higher serum levels of creatinine and uric acid. In order to assess the association between the outcome and type of care independently of covariates that might explain at least part of the difference observed, we performed a logistic regression multivariable model, which is shown in Table 3. It is evident that the adjusted effect of being followed in the HF clinic remains significantly protective. Since there was a significantly higher prevalence of atrial fibrillation in the group of patients sent to their assistant physician, we evaluated the association between type of care and occurrence of the combined event separately in the subgroups with atrial fibrillation and sinus rhythm. In this stratified analysis, we observed that the OR for developing the combined event showed a significantly lower risk in HF clinic patients, both in the 211 patients with sinus rhythm (OR=0.32, P=0.005) and the 128 with atrial fibrillation (OR=0.17, P=0.006).


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  		Table 2 Crude odds ratios (OR) and hazard ratios (HR) for evaluation of the association between baseline variables and death or rehospitalisation during the first month after discharge and survival, respectively

 


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  		Table 3 Adjusteda odds ratios (OR) for the occurrence of death or hospital readmission during the first month after discharge

 
The patients were further followed up to assess survival status. The maximum follow-up time was 21 months (630 days) and the mean (±standard deviation) was 373±196 days. At the end of follow-up, 39 deaths (24.8%) had occurred in the HF clinic patients, while in the patients sent to their assistant physician, 63 deaths (34.6%) were registered. Fig. 1 presents Kaplan–Meier estimates of survival in the two groups: the cumulative survival was significantly higher in the HF clinic patients. In order to assess this relation independently of relevant covariates, we first identified among them those that were also associated with the outcome. The results of this analysis are shown in Table 2. We included those that might be confounding the association of interest in a multivariable Cox proportional-hazards model. The final model is presented in Table 4. Patients followed in the HF clinic had an independent significantly lower hazard of dying. This effect was stronger for patients with sinus rhythm (HR=0.41, P<0.002), while for patients with atrial fibrillation, although the HR was still smaller than 1 (HR=0.79), the association did not reach statistical significance (P=0.49).


Figure 1
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  		Fig. 1 Kaplan–Meier estimates of survival according to type of ambulatory care.

 


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  		Table 4 Finala Cox proportional hazards model for assessment of the independent effect of type of care on survival

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
This study shows a significantly reduced risk of hospital readmission and death, both in the short and long term, among patients discharged from a hospitalisation index to a HF clinic, as compared with those who were discharged to the outpatient care of their usual assistant physician. This difference could not be explained by factors usually reported to influence prognosis in HF for which data were available. However, we cannot exclude other prognostic factors, namely neuro-humoral parameters such as B-type natriuretic peptide [15], which might have accounted for part of the heterogeneity in outcomes.

It is self-evident that during a time when healthcare costs must be contained, physicians must ensure that less expensive care does not mean suboptimal care, and that specialised, updated care does not necessarily mean higher costs. An increasing number of reports have shown that organised speciality centres provide more efficacious treatment to patients with complex chronic diseases such as HF [6,11–13,16–19]. Physicians especially devoted to the care of those patients are not only more likely to be up-to-date with the necessary knowledge, but are also in a better position to build an integrated delivery system, thus being able to link research output with medical practice more efficaciously. The reported differences in outcomes have been attributed both to therapeutic optimisation, mainly related to use of higher doses of ACE inhibitors and more aggressive diuretic therapy, and to better compliance with medication and diet [13], as well as the comprehensive preventive nature of care. While it is obvious that such centres cannot possibly take care of all HF patients, they may at least play increasingly important roles in delivering model care [5].

The approach followed in our HF clinic (see Section 2) is not likely to be systematically applied in other settings, namely in primary healthcare, and this could explain, at least in part, the better outcome of patients from our HF clinic. We believe that daily availability of physicians from the clinic to perform non-scheduled appointments due to clinical decompensation or medication doubts, and the strong encouragement of patients to use this resource instead of emergency department visits, were largely responsible for the reduction in rehospitalisation of our patients.

Although the data reported in this study cannot be reduced to the probability of survival at some point in the follow-up time, that is the more direct way to compare our results with those of other reports, thus allowing assessment of the consistency of findings across populations. In our study, the 1-year survival among patients sent to their usual physician was 66.1%. This is comparable to the 61.5% reported for patients under regular care discharged from acute hospital care for exacerbation of HF [20] and the 62% reported by Cowie et al. [21] among incident cases of HF, who were cared for by general practitioners in consultation with a hospital physician. On the other hand, in spite of the differences between the clinical characteristics of patients, the 1-year survival among patients referred to our HF clinic was 82%, while Hanumanthu et al. [22] reported 1-year survival of 87% in the setting of a Heart Failure and Heart Transplantation Program and Ramahi et al. [11] reported 90% probability of survival at 1 year under a Heart Failure and Transplant Cardiology Program. Nevertheless, our study was performed in a community hospital setting with non-selected HF patients, which could partially explain the difference in survival, as the meticulous selection of the patient population enrolled in other studies might have increased the likelihood of showing a beneficial effect of the study's intervention.

The main limitation of our study is the absence of random allocation of patients to the intervention groups. However, we have no reason to believe that there was an important systematic difference between groups, because patients admitted from the emergency department were consecutively distributed by wards (and so by physician) in regular succession. In this way, the distribution does not even depend on any particular trend of individual physicians to reduce hospital stay of patients (thus being more likely to have free beds) or, on the contrary, to prolong it. In any case, the sample size was large enough to allow us to perform multivariable analyses and to assess how the baseline variables that were unevenly distributed might have affected the difference observed. Clearly, no other method of dealing with confounders comes so close to randomisation as to render it unnecessary or not useful. In particular, random assignment of intervention is able to avoid bias due to unknown cofounders, while in data analysis, the confounding effect of identified variables can be dealt with at best. On the other hand, even in randomised studies, uneven distributions can happen by chance alone (according to the definition of random), and that could also have occurred in our study.

We cannot exclude that there was some influence of care during in-hospital stay on the outcomes. However, if all of the differences observed were attributable to differences in care during hospitalisation, we would expect the relative hazard of dying to become closer to 1 over time, and that was not the case. In-hospital care could have played a role in the difference in readmissions in the first month after discharge, but since patients subsequently sent to the HF clinic were already treated by physicians from that clinic during hospitalisation, this would still reflect management by physicians specially devoted to HF.

The subgroup sent to the HF clinic turned out to be older, but that could have explained a lower survival in this group and not the other way around. Supporting this argument, the effect of being assisted at the HF clinic remained the same when we analysed the data separately for patients with age below or above the median of the distribution of the whole sample (data not shown). In addition to being older, a higher proportion of HF clinic patients had an ejection fraction lower than 40%, which itself is associated with decreased survival.

As far as atrial fibrillation (AF) is concerned, in stratified analysis, both outcomes assessed were more favourable in patients sent to the HF clinic, whether they had AF or sinus rhythm. Furthermore, we could not document an overall significant difference in survival between patients with AF or sinus rhythm; therefore, it is not likely that the higher prevalence of AF in patients sent to the usual assistant physician explains the difference in survival by type of care. Some reports suggest that atrial fibrillation may no longer be an important predictor of prognosis, at least in advanced HF, possibly due to wider use of anticoagulants or amiodarone and/or reduced use of class I anti-arrhythmic drugs [23]. It is likely that part of the benefit of the HF clinic observed among patients with AF is explained by more appropriate management of AF.

In spite of being significantly associated with both the outcome and type of care, creatinine was not included in the final models because it is highly correlated with uric acid, and thus might introduce collinearity. When creatinine was substituted for uric acid in those models, the effect of being assisted at our HF clinic remained practically the same (data not shown), confirming that adjusting for uric acid also adjusts for creatinine.

In summary, these results support the relevance of a multidisciplinary and permanently available assistant staff in improving outcomes in HF patients. Our study is encouraging in two aspects. First, it points to the beneficial effects of such management in the community setting, with a larger and non-selected HF population and by feasible and patient-tailored means, in concordance with other reports [24]. These results differ from previous studies that were performed on more selected populations, sometimes under strict guidance and rigid protocols, hardly applicable to everyday clinical practice. Second, it shows a positive effect on long-term survival of that strategy, an outcome as yet largely unexplored. Nevertheless, as an observational study, it requires support from randomised trials.

The reduction in rehospitalisation suggests that our intervention was cost-effective. However, an analysis of cost implications would be very interesting and could reinforce the utility and importance of HF clinics.


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

  1. The Task Force of the Working Group on Heart Failure of the European Society of Cardiology. The treatment of heart failure. Eur Heart J (1997) 18:736–753.[Free Full Text]
  2. Heart Failure Society of America. HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction — pharmacological approaches. J Cardiac Fail (1999) 5:357–382.[CrossRef][Web of Science][Medline]
  3. Membership of the Advisory Council to Improve Outcomes Nationwide in Heart Failure. Consensus recommendations for the management of chronic heart failure. Am J Cardiol (1999) 83:2A–38A.
  4. Torp-Pedersen C., Kober L. Prolongation of life with angiotensin-converting enzyme inhibitor therapy. Eur Heart J (2000) 21:597–598.[Free Full Text]
  5. Pitt B., Nicklas J.M. Specialized heart failure centers — a success or an indicator of the failure of our healthcare delivery system. Clin Cardiol (2000) 23:881–882.[Web of Science][Medline]
  6. Abraham W.T., Bristow M.R. Specialized centers for heart failure management. Circulation (1997) 96:2755–2757. Editorial.[Free Full Text]
  7. Rajfer S.I. Perspective of the pharmaceutical industry on the development of new drugs for heart failure. J Am Coll Cardiol (1993) 22(Suppl_A):198–200.
  8. Philbin E.F., Andreou C., Rocco T., Lunch L.J., Baker S.L. Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol (1996) 77:832–838.[CrossRef][Web of Science][Medline]
  9. Smith N.L., Psaty B.M., Pitt B., Garg R., Gottdiener J.S., Heckbert S.R. Temporal patterns in the medical treatment of congestive heart failure with angiotensin-converting enzyme inhibitors in older adults, 1989 through 1995. Arch Intern Med (1998) 158:1074–1080.[Abstract/Free Full Text]
  10. Rich M.W. Heart failure disease management: a critical review. J Cardiac Fail (1999) 5:64–75.[Web of Science][Medline]
  11. Ramahi T.M., Longo M.D., Rohlfs K., Sheynberg N. Effect of heart failure program on cardiovascular drug utilization and dosage in patients with chronic heart failure. Clin Cardiol (2000) 23:909–914.[Web of Science][Medline]
  12. Fonarow G.C., Stevenson L.W., Walden J.A., et al. Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol (1997) 30:725–732.[Abstract]
  13. Rich M.W., Beckham V., Wittenberg C., Leven C.L., Freedland K.E., Carney R.M. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med (1995) 333:1190–1195.[Abstract/Free Full Text]
  14. The Task Force on Heart Failure of the European Society of Cardiology. Guidelines for the diagnosis of heart failure. Eur Heart J (1995) 16:741–751.[Free Full Text]
  15. Bettencourt P., Ferreira A., Dias P., et al. Predictors of prognosis in patients with stable mild to moderate heart failure. J Cardiac Fail (2000) 6:306–313.[CrossRef][Web of Science][Medline]
  16. Bucknall C.E., Robertson C., Moran F., Stevenson R.D. Differences in hospital asthma management. Lancet (1988) 1:748–750.[Web of Science][Medline]
  17. Mayo P.H., Richman J., Harris H.W. Results of a program to reduce admissions for adult asthma. Ann Intern Med (1990) 112:801–802.[Abstract/Free Full Text]
  18. Ward M.M., Leigh J.P., Fries J.F. Progression of functional disability in patients with rheumatoid arthritis. Associations with rheumatology subspecialty care. Arch Intern Med (1993) 153:2229–2237.[Abstract/Free Full Text]
  19. Smith L.E., Fabbri A.S., Pai R., Ferry D., Heywood T. Symptomatic improvement and reduced hospitalization for patients attending a cardiomyopathy clinic. Clin Cardiol (1997) 20:949–954.[Web of Science][Medline]
  20. Jaagosild P., Dawson N.V., Thomas C., et al. Outcomes of acute exacerbation of severe congestive heart failure. Arch Intern Med (1998) 158:1081–1089.[Abstract/Free Full Text]
  21. Cowie M.R., Wood D.A., Coats A.J.S., et al. Survival of patients with a new diagnosis of heart failure: a population-based study. Heart (2000) 83:505–510.[Abstract/Free Full Text]
  22. Hanumanthu S., Butler J., Chomsky D., Davis S., Wilson J.R. Effect of a heart failure program on hospitalization frequency and exercise tolerance. Circulation (1997) 96:2842–2848.[Abstract/Free Full Text]
  23. Cowburn P.J., Cleland J.G.F., Coats A.J.S., Komajda M. Risk stratification in chronic heart failure. Eur Heart J (1998) 19:696–710.[Free Full Text]
  24. Cline C.M., Israelsson B.Y., Willenheimer R.B., Broms K., Erhardt L.R. Cost-effective management programme for heart failure reduces hospitalisation. Heart (1998) 80:442–446.[Abstract/Free Full Text]

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