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European Journal of Heart Failure 2003 5(4):557-567; doi:10.1016/S1388-9842(02)00298-2
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© 2003 European Society of Cardiology

Differences in psychosocial and behavioral profiles between heart failure patients admitted to cardiology and geriatric wards

Sabina De Geesta,b, Lieve Scheurweghsa, Isabelle Reyndersa, Walter Pelemansd, Walter Droognéc, Johan Van Cleemputc, Marcia Leventhalb and Johan Vanhaeckec,*

a Center for Health Services and Nursing Research Catholic University of Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
b Institute of Nursing Science University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
c Department of Cardiology University Hospitals of Leuven, Herestraat 49, B-3000 Leuven, Belgium
d Department of Geriatrics University Hospitals of Leuven, Herestraat 49, B-3000 Leuven, Belgium

* Corresponding author. Tel.: +32-16-344251; fax: +32-16-344240 E-mail address: johan.vanhaecke{at}uz.kuleuven.ac.be


   Abstract
Top
 Abstract
1. Introduction
 2. Methodology
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
Background: Heart failure represents a growing epidemic, primarily in the elderly. Development and implementation of management programs designed for use in daily clinical practice remains a major challenge.

Aims: This study aimed at profiling a hospitalized heart failure population in view of medical, behavioral, educational, psychosocial and health resources utilization parameters stratified by admission to cardiology and geriatric wards.

Methods and results: Using a descriptive comparative design, 109 European heart failure patients admitted to cardiology (42%) and geriatric wards (58%) were included. Significant differences (all P<0.0001) were identified between the two groups. Patients admitted to cardiology had a mean age of 68.5, 33% were women, and the mean ejection fraction was 38%. Patients admitted to geriatrics had a mean age of 85, 68% were women, and the mean ejection fraction was 56%. Sixty-six percent were admitted for cardiac reasons. Medical, educational, behavioral, psychosocial and health resources utilization data were retrieved from medical files as well as by patient and family interviews. Results showed significant differences between groups. Patients admitted to geriatric wards received significantly less ACE inhibition and β-blockers. Moreover, these patients were significantly less knowledgeable, showed poorer self-management, poorer hearing, more cognitive impairment, a higher degree of depressive symptomatology, more problems with ADL and IADL, and used significantly more home health care services compared to patients admitted to cardiology wards.

Conclusion: The characteristics of the heart failure population at large are quite different from those of populations included in large-scale therapeutic trials. Findings from this study provide options for tailored management strategies for both profiled subgroups.

Key Words: Heart failure • Elderly • Compliance • Patient education • Psychosocial

Received December 17, 2001; Revised October 1, 2002; Accepted December 12, 2002


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methodology
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
There is increasing research activity devoted to optimizing the management of heart failure patients in order to improve outcomes in this growing and costly patient group. Despite the proven effectiveness of interdisciplinary and comprehensive heart failure programs [1], development and implementation of these programs in daily clinical practice in a particular setting remains a major challenge for the future [2].

Psychosocial and behavioral deficits are recognized as major factors in the management of heart failure as these factors have been shown to be associated with poor outcomes. Depressive symptomatology, lack of knowledge and/or self-management skills, lack of social support, and non-adherence with the therapeutic regimen, put patients at risk for complications and subsequent readmissions [3–7] which is the most important cost driver in heart failure management [8].

Since heart failure represents a growing epidemic, primarily in the elderly [9], adequate services for this patient group must be developed. Successful implementation of heart failure programs necessitates a thorough understanding of the characteristics of both the heart failure population as well as the health care system in the setting in which the program will be developed. Little is known, however, concerning the characteristics of the actual heart failure population, a population quite different from patients included in large-scale therapeutic trials where an over-proportion of younger patients and males is observed [10–13]. In general, the heart failure patient seems to be an elderly person with co-morbidities in need of more complex and specialized care [14–22]. In order to deliver care targeted to the needs of this fragile population, in depth information on their educational, psychosocial and behavioral needs is required [2].

The aim of this study was to determine the prevalence of educational, psychosocial and behavioral issues in the management of heart failure patients, and to compare the characteristics of patients admitted to cardiology and geriatric wards. This descriptive study examined the actual heart failure management of patients with a primary or secondary diagnosis of heart failure admitted to either a cardiology or a geriatric ward in a university hospital in Belgium. Since not all patients with heart failure are admitted to cardiology wards, the study was designed to identify whether differences exist between hospitalized patients treated by cardiologists or by internists, which may signify different approaches in providing optimal services to either group of patients.


   2. Methodology
Top
 Abstract
 1. Introduction
 2. Methodology
3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
2.1. Design, sample and setting
This study used a descriptive comparative design. The convenience sample included 109 patients admitted either to a cardiology ward (42%) or to a geriatric ward (58%) of a Belgian University hospital during a 3-month period. Patients were included in the study if their medical chart indicated a primary or secondary diagnosis of heart failure and if they gave their informed consent for participation in the study. As the study focused on the treatment of the patient's heart failure prior to admission, patients were excluded if the diagnosis of heart failure was made during the current admission. Since questionnaires were administered to the subjects in an interview format, and these questionnaires were in Dutch, patients were excluded if they were not Dutch speaking or if they could not communicate adequately.

The sample consisted of 53% females with a median age of 80 years (Q1=70.5; Q3=86). Sixty-six percent were admitted for cardiac reasons. Forty-three percent of the patients were NYHA III or IV. The median ejection fraction was 45.5% (Q1=33; Q3=64.25) and patients had a median of three comorbidities. Of the 198 patients admitted to the hospital with heart failure, 147 patients were determined to be eligible for this study, 78 in geriatrics and 69 in cardiology. Of those ineligible to be in the study, 46 were newly diagnosed with heart failure, and the majority of these patients were male. Of those eligible to be in the study from the cardiology ward, 38 (26%) were not included in the data collection due to (78.1%) refusal to give informed consent, (3%) aphasia, (9.4%) condition too unstable to be interviewed, (9.4%) early discharge, (3%) included in the geriatric population and for 3% there was no information available. Of the eligible geriatric patients, one refused to give informed consent, three had a low mental status, and two were discharged early.

The setting where this study was conducted has a compulsory health insurance system. Medical services are provided on a fee for service basis. Whereas hospital care is organized and financed at the federal level, primary care is organized and financed at the regional level, thereby hindering optimal cooperation between hospital and home care. Since there is no mechanism for restricting access to hospital based services, non-urgent cases have access without referral by a primary care physician or specialist. There were no programs in place, at the time of data collection, whereby patients with heart failure could be managed and followed continuously, beginning with hospitalization and continuing through the discharge period and into the home setting.

2.2. Variables and measurement
Selected demographic, clinical, behavioral, educational, psychosocial, and functional status variables as well as resource utilization data for the previous year were collected from medical files and by patient and family interviews. In addition to using established methods, a screening questionnaire specifically developed for this study was used. Five experts evaluated the content and face validity of the developed questionnaire. The use and measurement of variables included in this report will be discussed in more detail in the following section.

Treatment regimen before admission, vaccination status, characteristics of the follow-up care (i.e. type of health care provider, frequency of follow-up visits) and self-management of heart failure (i.e. daily weight measurements with subsequent adjustment of diuretics, and behavior in view of symptom deterioration) were retrieved from medical files and obtained through structured interviews with the patients and their families. The process, provider and content of patient education and knowledge concerning heart failure management, including knowledge about symptoms associated with deterioration of heart failure, were tested using a structured format and a 10-item multiple choice questionnaire.

Non-adherence with medication, diet, fluid restrictions and smoking guidelines in the week before admission was assessed by self-report using a five-point scale ranging from always to never adhering. Patients were classified as non-compliant if they indicated that they had not always adhered to the prescribed regimen in the previous week. Adherence with the different aspects of the treatment regimen was only assessed in patients who reported to have received the specific health recommendation (e.g. fluid restriction).

Depressive symptomatology was assessed using the 15-item Flemish version of the Yesavage Geriatric Depression Scale (GDS). The GDS does not include questions pertaining to somatic complaints, and thereby differentiates symptoms of depression from symptoms of heart failure [23]. Total score varies between 0 and 15 and a score >5 indicates a depressive state. Reliability as assessed by Cronbach alpha is 0.80. Sensitivity and specificity of the short version GDS is 91% and 72%, respectively, using a structured clinical interview by a psychiatrist as the gold standard [24].

Cognitive impairment was assessed by the Mini Mental State Exam (MMSE) [25], which is an 11-item questionnaire. The MMSE takes approximately 10 min to administer, and has been shown to screen for abnormalities in cognition irrespective of age and education [26]. An MMSE score ≤23–18 indicates mild cognitive impairment and a score of 0–17 indicates severe cognitive impairment. Internal consistency is appropriate with Cronbach alphas ranging from 0.54 to 0.96 among different studies [25]. The MMSE is often used as the standard against which other mental status tests are measured [23].

Functional status was assessed based on activities of daily living (ADL) and instrumental activities of daily living (IADL). The Belgian version of the Katz ADL scale assesses the following six physical care needs: washing, dressing, mobility, toilet visits, eating and continence. The total ADL score ranges from 6 to 24 and is calculated by summing six items [27]. The IADL was measured using the Lawton & Brody IADL scale [28] scoring the patient's capabilities concerning using the telephone, shopping, household activities, medication management, cooking, laundry, transportation and finances. Inter-rater reliability of this scale is 1.00 and test–retest reliability is 0.88 [29].

Resource utilization parameters during the previous year were also collected through patient interviews. More specifically, the number of hospitalizations, the duration of the admissions for heart failure in the previous year, the length of time since the last hospital admission for heart failure, and the use of community nursing and elderly or family help were assessed. Due to the retrospective nature of this data collection and possible recall bias, no discrepancy between planned and unplanned hospital admissions could be made.

2.3. Data collection
Data collection took place over a 3-month period in 1999. Once the patient's condition was stabilized and prior to discharge, the researchers (L.S. & I.R.) approached all eligible patients. Following oral informed consent, data collection was commenced using an interview format. Depending on the patient's status, data could be obtained in more than one session. Family members were approached to provide additional information if this proved to be helpful in completing the data collection. The research protocol was reviewed and approved by the local ethics committee. The study conforms with the principles outlined in the Declaration of Helsinki.

2.4. Data analysis
Descriptive statistics, after checking data for normality, included mean values, standard deviations, median, interquartile range, and frequencies as appropriate. The T-test, Wilcoxon two-sample test and the chi-square or Fisher's Exact test were used as appropriate to compare groups using SPSS 9.0. The level of statistical significance was set at P<0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methodology
 3. Results
4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
3.1. Demographic, clinical and follow-up characteristics
Comparison of demographic characteristics of the patients admitted to the geriatric ward with those admitted to the cardiology ward revealed that the patients admitted to the geriatric ward were older, and comprised a higher proportion of females (Table 1). The significantly higher ejection fraction in geriatric patients indicates that a larger proportion of these patients have a preserved left ventricular function indicating diastolic dysfunction. The higher age of geriatric patients is also reflected in an increased tendency towards a higher number of comorbidities.


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  		Table 1 Demographic, clinical and follow-up parameters of the total group and patients admitted to cardiology and geriatrics wards, respectively

 
Of the patients with documented left ventricular dysfunction, 80% and 6.4% took ACE inhibitors or angiotensin II receptor antagonists, respectively. Seventy-seven percent of the patients on the geriatric ward with documented left ventricular dysfunction received ACE inhibition compared to 100% on the cardiology ward (P=0.03). The dose of ACE inhibitor, however, was equal between groups. Forty percent of the patients were taking β-blockers, and β-blockers were significantly more often prescribed in patients admitted to cardiology wards. Digitalis was prescribed in 60% of the patients, a rate comparable between groups. Diuretics were prescribed in 86.2% of the patients, with a significantly higher rate of diuretic prescription for the geriatric patients. Changes in medication regimen during the previous year occurred in 42% of the patients, a rate which was comparable between groups.

Seventy-eight patients were vaccinated against influenza and 31% were vaccinated against pneumococcus infection. Follow-up care for geriatric patients was primarily given by primary care physicians (98%) with 54% of the patients receiving home visits at least twice a month. The majority of patients admitted to cardiology wards received followed-up care by both a cardiologist and a primary care physician. In the year preceding the current admission, the majority of the patients (61%) had contact with a physician at least every 2 weeks either in the physician's office or during a home visit.

3.2. Patient education and knowledge status
In spite of the frequent contact with their respective physicians, 18% of the patients reported not having received information concerning their heart failure condition, and one-quarter of the patients indicated that they would have liked to have received more information about their heart condition (Table 2). If information was given, it was primarily provided by the cardiologist and/or the family physician. Ten percent of the patients indicated having received conflicting information concerning their heart failure management, which was especially evident in those patients who received follow-up care by both a cardiologist and a family physician. A lack of knowledge concerning the nature of heart failure (45.9%), medication regimen (42.2%), diet prescriptions (42.2%), and symptoms indicating deterioration of health status (82.2%) was observed, with cardiology patients being more knowledgeable compared with geriatric patients, yet still showing important knowledge deficits.


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  		Table 2 Educational, behavioral and psychosocial parameters of the total group and patients admitted to cardiology and geriatrics wards, respectively

 
3.3. Behavioral and psychosocial factors
Non-adherence with medication, diet and fluid restrictions occurred in 20.2%, 60% and 57.2% of the patients, respectively (Table 2). Eleven percent of the patients smoked, with a significantly higher proportion of those patients who smoke being admitted to a cardiology ward. Only 12.8% of patients adjusted their diuretics according to weight gain/loss, 25% vs. 5% of patients admitted to cardiology and geriatric wards, respectively. One-third of all of the patients were advised to weigh themselves daily and non-adherence with this guideline in informed patients was 13.5%. Hospital admissions were significantly more often initiated by the patient or a family member for patients admitted to a cardiology ward as compared with a geriatric ward.

The following findings may have been hindrances to adequate self-management (Table 2). Vision and hearing were compromised even with the help of glasses or hearing aids in 31% and 41% of the patients, respectively. Geriatric patients showed significantly more hearing problems. Fifty percent of the patients were shown to have at least moderate cognitive impairment (MMSE <23). Nearly 80% of geriatric patients compared with 11% of the cardiology patients had an MMSE score ≤24. Forty-three percent of the sample showed symptoms indicative of depression (GDS>5), with a higher proportion of geriatric patients having a GDS score ≥5. The patients admitted to the geriatric ward were also significantly more dependent for all ADL- and IADL-parameters (Table 3). Sixty percent needed assistance with medication taking, with cognitively impaired patients needing more assistance (P<0.01). Twenty-seven percent of the patients reported adaptations in their home (e.g. bed on ground floor) due to their heart failure condition.


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  		Table 3 Functional parameters of the total group and patients admitted to cardiology and geriatrics wards, respectively

 
3.4. Resource utilization
The median number of hospital admissions for heart failure during the previous year was comparable between the two groups, however, the total length of stay was longer in patients admitted to the geriatric ward (Table 4). Duration of time since the last heart failure related admission, in patients admitted for heart failure problems at the time of the data collection, was 14 weeks in geriatric patients and 6.5 weeks in cardiology patients. Nearly 40% of the patients used additional services such as home nursing, elderly or family help, physical therapy, and/or meals on wheels. Geriatric patients received significantly less physical therapy despite having a significantly poorer functional status based on ADL and IADL scores compared with cardiology patients. Congruent with geriatric patients’ poorer ADL and IADL scores, they received a significantly greater frequency of nursing, family or elderly care.


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  		Table 4 Health care and resource utilization parameters of the total group and patients admitted to cardiology and geriatrics wards, respectively

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methodology
 3. Results
 4. Discussion
5. Study limitations
 6. Conclusion
 References
 
Although recent publications have focused on the characteristics of the actual heart failure population and have identified a different profile from those patients who have been included in the large scale clinical trials [10,16,19,22], this study provides a more detailed description which is more representative of the heart failure population. More specifically, this study describes heart failure patients in terms of medical characteristics as well as psychosocial, educational, behavioral and health care utilization factors. These factors are then stratified by admission status to the cardiology or geriatric ward of a university hospital. The findings show major room for improvement in heart failure management in both groups and confirm the clinical observation that heart failure patients admitted to geriatric wards are a distinct population from heart failure patients admitted to cardiology wards. This information will allow the development of heart failure programs, which are tailored to the needs and characteristics of both groups.

4.1. Characteristics representative of a heart failure population
The present study focused on hospitalized heart failure patients, which admittedly results in an overall poorer clinical profile compared with the heart failure population at large. The sample studied clearly differs from the predominantly male and overall younger patients included in clinical trials. The pharmacological treatment of the studied sample was comparable with recently reported European data showing that between 63% and 84% of heart failure patients were treated with angiotensin-converting-enzyme (ACE) inhibitors [12,30–32]. This is a higher rate than a study of Medicare patients, which showed 55% to be receiving ACE-inhibitors [33]. The rate of 40% of the patients who are prescribed beta-blockers is comparable with European data [30,34]. The high rate of flu vaccination (78%) may in part result from an intensive yearly public health campaign targeting both patients and physicians in Belgium. This rate is significantly higher than that reported by Bratzler et al., where only 31.9% of 40 488 hospitalized Medicare patients had received a flu vaccination prior to admission [35].

Forty-two percent and 89% of the patients received follow-up care by a cardiologist and a general practitioner, respectively. These proportions are comparable with recently published data from Spain and Ireland [16,31] and somewhat higher than the proportions reported in a recent study in New York of all patients discharged in 1995 after hospitalizations for heart failure [36]. Frequency of health care provider/patient contact is high, a picture that is also congruent with data reported in a study in Oregon by Ni [37].

A major concern is that patients expressed a need for more information concerning their heart failure condition. Moreover, patients showed major knowledge deficits in their heart failure management, despite frequent contact with their physicians. Nurses did not seem to play a significant role in the patient education of this patient group at the time of data collection. Lack of knowledge and need for information is an issue also addressed in other recent studies [31,38–41].

Self-management behaviors could be improved in terms of daily weighing with adjustment of diuretics, symptom management, and early recognition of warning symptoms indicating a deterioration in their health and subsequent contacting the health care worker. These factors are typically targeted for interventions as they are known to be effective strategies in improving outcomes in this patient population [2,32,42].

Non-compliance has been reported as the precursor of events leading to 64% of hospitalizations in the heart failure population [2–4,7,43,44]. Among patients admitted to the cardiology ward and those admitted to the geriatrics ward, non-compliance with various aspects of the heart failure regimen has been identified as a substantial problem. Based on self-reports in the present study, non-compliance with medication regimen was 20% in the week preceding admission. Non-compliance with the medication regimen is the aspect of the therapeutic regimen being most studied in the literature, with prevalence ranging from 7% to 90% depending on the measurement method and operational definition used [2,3,7,13,41,43,45–47]. Non-compliance with dietary guidelines and fluid restrictions was even more substantial ranging between 57% and 67% in the present study. Non-compliance with cardiovascular risk-reduction dietary plans has been reported to range from 24% to 86% [48], and, non-compliance rates with sodium restrictions range from 22% to 70% [3,44,45,47,49]. Despite their heart condition, a proportion of the patients in this study continued to smoke. Ten percent of the patients were current smokers, a rate similar to that reported in the literature [37]. While this rate is lower than the rate of 28.5% of the general population in Belgium who smoke [50], it is still substantial given the detrimental impact of smoking on health.

It is possible that a major factor jeopardizing adequate patient education, self-management and compliance in the present study is that 50% of the patients were assessed to be cognitively impaired. Cognitive impairment is a well-recognized problem in heart failure patients [51]. It has been reported that chronic heart failure increases the odds for cognitive impairment two-fold after controlling for other known risk-factors [51].

Depressive symptomatology was especially a problem in the heart failure patients admitted to the geriatric wards in the present study. In addition, the overall rate of depressive symptomatology of 43.3% was higher than the 35.3% reported in a recent study which included an overall younger patient group. Depressive symptomatology is not only an independent risk factor for poor medical outcome in heart failure patients [52–54], but is also a major risk factor for non-adherence in chronic patient populations as highlighted by a recent meta analysis by DiMatteo et al. [55].

A substantial proportion of the geriatric patients showed problems with ADL/IADL. This explains the higher rate of health care and community services which are needed by this patient group. Dependency for ADL and IADL has been found to be a risk factor for rehospitalization in the elderly as well as in heart failure patients [56–58] and needs careful consideration in the care and management of heart failure patients as well as their primary caregivers.

4.2. Suggestions for tailored interventions in patients admitted to cardiology and geriatric wards
The AHA consensus paper indicates the need and challenge to translate tested care delivery models for heart failure patients into practice. Models should include the following components: (1) comprehensive and intensive patient education and counseling; (2) interventions targeting adherence; and (3) frequent follow-up and increased access to the health care provider [2]. Based on our findings indicating distinct differences in the patient profiles of patients admitted to cardiology wards and patients admitted to geriatric wards, suggestions for tailored approaches could be given. We found that patients admitted to geriatric wards were not only older and presented with more comorbidities, but also showed an overall higher risk-profile for poor outcomes. Primary care physicians tended to provide care for patients in the home setting. Specially tailored services for this high-risk population, focusing on interventions in the home setting in collaboration with the primary care providers, seems to be strongly indicated for this subgroup. This is congruent with findings of Ekman et al. (1998) who tested an outpatient HF clinic model for elderly, and concluded that patients’ psychosocial and clinical conditions prevented them from attending the outpatient clinics for their follow-up care [34]. Home monitoring for the elderly patient was suggested to be a more appropriate approach and has previously been successfully tested in the heart failure population [59–67].

Patients admitted to cardiology wards seemed to be more active and independent partners in the treatment process (e.g. a higher proportion adjusted their diuretics according to results of daily weight, decided independently to use hospital-based services, and/or contacted a health care worker in case of deterioration in the health status). Although significant knowledge deficits were evident, compared with the patients admitted to the geriatric ward, the cardiology patients were better informed and more knowledgeable about their disease. In addition, they were less dependent on others for their heart failure management including transportation to doctor or clinic appointments. Nevertheless, an overall increase in educational and behavioral intervention strategies is indicated to overcome knowledge deficits, self-management problems and non-compliance. Services provided within a specialty setting seem to be feasible for this subgroup [64–75]. Although the emphasis on heart failure management seems to be more hospital based for patients admitted to cardiology wards and more community based for patients admitted to geriatric wards, an integrated and co-operative approach between these settings is of utmost importance to guarantee continuity of high quality services. Basic approaches in educational, psychosocial and behavioral management will be similar, yet it is evident that adaptations need to be made depending on the specific risk-factors prevailing in each of the subgroups. For example, education will be a challenge in a cognitively impaired and depressed patient with vision and hearing problems who is dependent on his medication management from a family member or outside service agency.

In Belgium, a major problem will be to overcome the barriers that exist between hospital care and primary care because these two systems are structured and financed independently of one another. This will make the implementation of programs bridging care from hospital-to-home difficult, as previous experience with a case management model for high-risk frail elderly with a variety of conditions has demonstrated [58]. Even the use of telematics to streamline information processes will not guarantee that a constructive collaboration can be realized.


   5. Study limitations
Top
 Abstract
 1. Introduction
 2. Methodology
 3. Results
 4. Discussion
 5. Study limitations
6. Conclusion
 References
 
Some limitations of this study merit attention. The nature of the cross-sectional design, which incorporated a retrospective approach relying on self-reporting to assess resource utilization, could have jeopardized the reliability of the results. Self-reporting can introduce a recall bias. However, we limited the self-reported non-compliance to 1 week prior to admission thereby reducing, but admittedly not eliminating, the risk for recall bias. In future studies, it would be advisable to measure non-compliance using a prospective design incorporating the use of triangulation, for example combining electronic event monitoring, self-report and reports from a care-giver [76]. Regarding sampling methods, the fact that all patients were from the University hospital may restrict the generalizability of the results as often the sicker patients are admitted to a university hospital. In future studies, it would be advisable to include a larger sample of subjects who are recruited both from university hospitals as well as community hospitals. The case finding methods in this study relying on primary or secondary diagnosis for heart failure as noted in the medical charts could have introduced a sampling bias. It is possible that some asymptomatic heart failure patients were not identified, or symptomatic patients may have been misclassified as heart failure patients in the absence of further diagnostic tests such a echocardiography, BNP or heart catheterization. The study design did not permit controlling for attrition bias as incomplete information was gathered from the patients who were excluded from participating in the study. The hospital where the study was conducted has separate geriatric wards and internal medicine wards in contrast to other hospitals where these wards are integrated. However, as our primary focus was on heart failure management prior to admission, findings can be generalized to patients being treated for their heart failure by cardiologists or primary care physicians. In order to assess how specific medical, psychosocial and behavioral factors influence outcomes, it would be worthwhile to include a prospective follow-up in this study.


   6. Conclusion
Top
 Abstract
 1. Introduction
 2. Methodology
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
References
 
This study focused on identifying characteristics representative of a heart failure population and compared two relevant subgroups stratified by admission status to geriatric wards and cardiology wards. Major differences in the educational, behavioral and psychosocial profile between the two groups were identified. Knowledge of these differences will enable an evidence based heart failure program to be specifically tailored to, rather than superimposed upon, a local setting by taking into account the strengths and weaknesses of the subgroups, the current heart failure management, and the local health care system.


   Acknowledgements
 
Johan Vanhaecke is holder of the Michael Ondetti chair in Cardiology at the Katholieke Universiteit Leuven. The study was conducted at the University Hospitals of Leuven, Leuven, Belgium.


   References
Top
 Abstract
 1. Introduction
 2. Methodology
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 

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