Patient, hospital and country-level risk factors of all-cause mortality among patients with chronic heart failure: Prospective international cohort study.

Benedetta Pongiglione,Aldo P Maggioni,Aleksandra Torbica,Panos Vardas,Luigi Tavazzi,Chris P Gale,Pasquale Abete

doi:10.1371/journal.pone.0250931

Abstract

Although many studies have described patient-level risk factors for outcomes in heart failure (HF), health care structural determinants remain largely unexplored. This research reports patient-, hospital- and country-level characteristics associated with 1-year all-cause mortality among patients with chronic HF, and investigates geographic and hospital variation in mortality. We included 9,277 patients with chronic HF enrolled between May 2011 and November 2017 in the prospective cohort study European Society of Cardiology Heart Failure Long Term registry across 142 hospitals, located in 22 countries. Mean age of the selected outpatients was 65 years (sd 13.2) and 28% were female. The all-cause 1-year mortality rate per 100 person-years was 7.1 (95% confidence interval (CI) 6.6-7.7), and varied between countries (median 6.8, IQR 5.6-11.2) and hospitals (median 7.8, IQR 5.2-12.4). Mortality was associated with age (incidence rate ratio 1.03, 95% CI 1.02-1.04), diabetes mellitus (1.37, 1.15-1.63), peripheral artery disease (1.56, 1.27-1.92), New York Heart Association class III/IV (1.91, 1.60-2.30), treatment with angiotensin-converting enzyme inhibitor and angiotensin receptor antagonists (0.71, 0.57-0.87) and HF clinic (0.64, 0.46-0.89). No other hospital-level characteristics, and no country-level healthcare characteristics were associated with 1-year mortality, with case-mix standardised variance between countries being very low (1.83e-06) and higher for hospitals (0.372). All-cause mortality at 1 year among outpatients with chronic HF varies between countries and hospitals, and is associated with patient characteristics and the availability of hospital HF clinics. After full adjustment for clinical, hospital and country variables, between-country variance was negligible while between-hospital variance was evident.

Highlights

Heart failure (HF) is characterized by a high rate of hospital admissions and death, significant functional compromise, reduced quality of life, and increased caregiver burden [1,2]
All-cause mortality at 1 year among outpatients with chronic heart failure (HF) varies between countries and hospitals, and is associated with patient characteristics and the availability of hospital HF clinics
A unique contribution of this study is that it considered risk factors for HF outcomes acting at three levels simultaneously: clinical, hospital and country

Summary

Introduction

Heart failure (HF) is characterized by a high rate of hospital admissions and death, significant functional compromise, reduced quality of life, and increased caregiver burden [1,2]. A study using data from the European Society of Cardiology’s (ESC) Heart Failure Long-Term Registry (HF-LT-Registry, version 2013) found heterogeneity of treatments, most ineffective on hard endpoints, for patients with acute HF, while drug treatments for patients with chronic HF can be considered adherent to recommendations of current guidelines, even if dosing often appears too parsimonious [7]. Other studies found socioeconomic factors, such as low health literacy [12] and poor social support [13], are associated with higher all-cause mortality among patients with HF. Many studies have described patient-level risk factors for outcomes in heart failure (HF), health care structural determinants remain largely unexplored. This research reports patient-, hospital- and country-level characteristics associated with 1-year all-cause mortality among patients with chronic HF, and investigates geographic and hospital variation in mortality.

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Conclusion