Influence of the health-care pathway on the outcome of patients with infective endocarditis: Should all patients be treated in referral centers?

Abstract

Mortality in infective endocarditis (IE) remains high. Few studies have compared the prognosis and management of patients with IE according to their health-care pathway (HCP) To determine the prognosis of patients treated for IE according to their HCP. To assess how the ESC guidelines are implemented concerning the performance of transesophageal echocardiography, the use of antibiotic therapy, and the performance of valve surgery; and to compare the epidemiological profile of IE according to the type of centers in which patients are hospitalized. In a prospective multicentric study including 22 hospitals in the South-East of France, patients with a diagnosis of IE were classified in 3 groups according to their HCP: patients diagnosed and entirely managed in a reference center or hospital with cardiac surgery (group 1), patients initially taken care in a non-referral center, then referred in a center including cardiac surgery (group 2) and patients totally managed in non-referral centers (group 3). Primary endpoint was death from all cause at one-year follow-up. Between 2014 and 2017, 342 patients were consecutively included: 119 in group 1, 111 in group 2 and 112 in group 3. One-year mortality was 26% (88 deaths) and was not significantly different between groups 1 and 2 (20% vs. 21%, P = 0.83). Patients in group 3 had a higher mortality (37%) compared to patients in groups 1 and 2 ( P < 0.001). Belonging to group 3 was a predicitive factor of one-year mortality in multivariate analysis (HR 2.56; IC95% 1.44–4.55, P = 0.001). ESC guidelines were not implemented similarly depending on the HCP ( P = 0.04). Patients in group 3 were significantly older ( P < 0.001) and had more comorbidities ( P < 0.001) than patients treated in referral centers ( Fig. 1 ). Prognosis of patients with IE is influenced by their HCP. Patients treated in non-referral centers have a worse prognosis than patients treated in referral or surgical centers.