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OBJECTIVES: To determine the epidemiology of heart failure registered in primary healthcare clinical records in Catalunya, Spain, between 2010 and 2014, focusing on incidence, mortality, and resource utilization. DESIGN: Retrospective observational cohort study. SETTING: Study was carried out in primary care setting. PARTICIPANTS AND INTERVENTIONS: Patients registered as presenting a new heart failure diagnosis. The inclusion period ran from 1st January 2010 to 31st December 2013, but patients were followed until 31st December 2013 in order to analyze mortality. MAIN MEASURES: Information came from electronic medical records. RESULTS: A total of 64441 patients were registered with a new diagnosis of heart failure (2.76 new cases per 1000 persons-year). Among them, 85.8% were ≥65 years. The number of cases/1000 persons-year was higher in men in all age groups. Incidence ranged from 0.04 in women <45 years to 27.61 in the oldest group, and from 0.08 in men <45 years to 28.52 in the oldest group. Mortality occurred in 16305 (25.3%) patients. Primary healthcare resource utilization increased after the occurrence of heart failure, especially the number of visits made by nurses to the patients' homes. CONCLUSION: Heart failure incidence increases with age, is greater in men, and remains stable. Mortality continues to be high in newly diagnosed patients in spite of the current improvements in treatment. Home visits represent the greatest cost for the management of this disease in primary care setting.
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Insuficiência Cardíaca , Registros Eletrônicos de Saúde , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Masculino , Atenção Primária à Saúde , Estudos Retrospectivos , Espanha/epidemiologiaRESUMO
BACKGROUND: Several scores to identify patients at high risk of suffering atrial fibrillation have been developed. Their applicability in hypertensive diabetic patients, however, remains uncertain. Our aim is to develop and validate a diagnostic predictive model to calculate the risk of developing atrial fibrillation at five years in a hypertensive diabetic population. METHODS: The derivation cohort consisted of patients with both hypertension and diabetes attended in any of the 52 primary healthcare centres of Barcelona; the validation cohort came from the 11 primary healthcare centres of Terres de l'Ebre (Catalonia South) from January 2013 to December 2017. Multivariable Cox regression identified clinical risk factors associated with the development of atrial fibrillation. The overall performance, discrimination and calibration of the model were carried out. RESULTS: The derivation data set comprised 54 575 patients. The atrial fibrillation rate incidence was 15.3 per 1000 person/year. A 5-year predictive model included age, male gender, overweight, heart failure, valvular heart disease, peripheral vascular disease, chronic kidney disease, number of antihypertensive drugs, systolic and diastolic blood pressure, heart rate, thromboembolism, stroke and previous history of myocardial infarction. The discrimination of the model was good (c-index = 0.692; 95% confidence interval, 0.684-0.700), and calibration was adequate. In the validation cohort, the discrimination was lower (c-index = 0.670). CONCLUSIONS: The model accurately predicts future atrial fibrillation in a population with both diabetes and hypertension. Early detection allows the prevention of possible complications arising from this disease.
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Fibrilação Atrial/epidemiologia , Regras de Decisão Clínica , Diabetes Mellitus/epidemiologia , Hipertensão/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Feminino , Insuficiência Cardíaca/epidemiologia , Frequência Cardíaca , Doenças das Valvas Cardíacas/epidemiologia , Humanos , Hipertensão/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Doenças Vasculares Periféricas/epidemiologia , Modelos de Riscos Proporcionais , Fatores Sexuais , Acidente Vascular Cerebral/epidemiologiaRESUMO
BACKGROUND: Social and environmental factors in advanced heart failure (HF) patients may be crucial to cope with the end stages of the disease. This study analyzes health inequalities and mortality according to place of residence (rural vs urban) in HF patients at advanced stages of the disease. METHODS: Population-based cohort study including 1148 adult patients with HF attended in 279 primary care centers. Patients were followed for at least 1 year after reaching New York Heart Association IV functional class, between 2010 and 2014. Data came from primary care electronic medical records. Cox regression models were applied to determine the hazard ratios (HR) of mortality. RESULTS: Mean age was 81.6 (SD 8.9) years, and 62% were women. Patients in rural areas were older, particularly women aged > 74 years (p = 0.036), and presented lower comorbidity. Mortality percentages were 59 and 51% among rural and urban patients, respectively (p = 0.030). Urban patients living in the most socio-economically deprived neighborhoods presented the highest rate of health service utilization, particularly with primary care nurses (p-trend < 0.001). Multivariate analyses confirmed that men (HR 1.60, 95% confidence interval (CI) 1.34-1.90), older patients (HR 1.05, 95% CI 1.04-1.06), Charlson comorbidity index (HR 1.16, 95% CI 1.11-1.22), and residing in rural areas (HR 1.35, 95% CI 1.09 to 1.67) was associated with higher mortality risk. CONCLUSIONS: Living in rural areas determines an increased risk of mortality in patients at final stages of heart failure.
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Insuficiência Cardíaca , Idoso de 80 Anos ou mais , Estudos de Coortes , Registros Eletrônicos de Saúde , Feminino , Humanos , Masculino , Atenção Primária à Saúde , População RuralRESUMO
OBJECTIVE: To evaluate the precipitating factors for heart failure decompensation in primary care and associations with short-term prognosis. Design Prospective cohort study with a 30-d follow-up from an index consultation. Regression models to determine independent factors associated with hospitalisation or death. SETTING: Primary care in ten European countries. Patients Patients with diagnosis of heart failure attended in primary care for a heart failure decompensation (increase of dyspnoea, unexplained weight gain or peripheral oedema). MAIN OUTCOME MEASURES: Potential precipitating factors for decompensation of heart failure and their association with the event of hospitalisation or mortality 30 d after a decompensation. RESULTS: Of 692 patients 54% were women, mean age 81 (standard deviation [SD] 8.9) years; mean left ventricular ejection fraction (LVEF) 55% (SD 12%). Most frequently identified heart failure precipitation factors were respiratory infections in 194 patients (28%), non-compliance of dietary recommendations in 184 (27%) and non-compliance with pharmacological treatment in 157 (23%). The two strongest precipitating factors to predict 30 d hospitalisation or death were respiratory infections (odds ratio [OR] 2.8, 95% confidence interval [CI] (2.4-3.4)) and atrial fibrillation (AF) > 110 beats/min (OR 2.2, CI 1.5-3.2). Multivariate analysis confirmed the association between the following variables and hospitalisation/death: In relation to precipitating factors: respiratory infection (OR 1.19, 95% CI 1.14-1.25) and AF with heart rate > 110 beats/min (OR 1.22, 95% CI 1.10-1.35); and regarding patient characteristics: New York Heart Association (NYHA) III or IV (OR 1.22, 95% CI 1.15-1.29); previous hospitalisation (OR 1.15, 95% CI 1.11-1.19); and LVEF < 40% (OR 1.14, 95% CI 1.09-1.19). CONCLUSIONS: In primary care, respiratory infections and rapid AF are the most important precipitating factors for hospitalisation and death within 30 d following an episode of heart failure decompensation. Key points Hospitalisation due to heart failure decompensation represents the highest share of healthcare costs for this disease. So far, no primary care studies have analysed the relationship between precipitating factors and short term prognosis of heart failure decompensation episodes. We found that in 692 patients with heart failure decompensation in primary care, the respiratory infection and rapid atrial fibrillation (AF) increased the risk of short-term hospital admission or death. Patients with a hospital admission the previous year and a decompensation episode caused by respiratory infection were even more likely to be hospitalized or die within 30 d.
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Antagonistas de Receptores de Angiotensina , Insuficiência Cardíaca , Idoso de 80 Anos ou mais , Inibidores da Enzima Conversora de Angiotensina , Europa (Continente) , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Morbidade , Fatores Desencadeantes , Atenção Primária à Saúde , Prognóstico , Estudos Prospectivos , Volume Sistólico , Função Ventricular EsquerdaRESUMO
OBJECTIVES: This study is aimed at analyzing the impact of the main factors contributing to short and long-term mortality in patients at final stages of heart failure (HF). SETTING: Patients attended at any of the 279 primary health care centers belonging to the Institut Català de la Salut, in Catalonia (Spain). PARTICIPANTS: Patients with Advanced HF. DESIGN: Multicenter cohort study including 1148 HF patients followed for one-year after reaching New York Heart Association (NYHA) IV. MAIN MEASUREMENTS: The primary outcome was all-cause mortality. Multivariate logistic regression models were performed to assess the outcomes at 1, 3, 6, and 12 months. RESULTS: Mean age of patients was 82 (SD 9) years and women represented 61.7%. A total of 135 (11.8%) and 397 (34.6%) patients died three months and one year after inclusion, respectively. Male gender, age, and decreased body mass index were associated with higher mortality at three, six and twelve months. In addition, low systolic blood pressure levels, severe reduction in glomerular filtration, malignancy, and higher doses of loop diuretics were related to higher mortality from 6 to 12 months. The most important risk factor over the whole period was presenting a body mass index lower than 20kg/m2 (three months OR 3.06, 95% CI: 1.58-5.92; six months OR 4.42, 95% CI: 2.08-9.38; and 12 months OR 3.68, 95% CI: 1.76-7.69). CONCLUSIONS: We may conclude that male, age, and decreased body mass index determined higher short-term mortality in NYHA IV. In addition, low systolic blood pressure, reduced glomerular filtration, malignancy, and higher doses of loop diuretics contribute to increasing the risk of mortality at medium and long-term. Such variables are easily measurable and can help to decide the best way to face the most advances stages of the disease.
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Antagonistas de Receptores de Angiotensina , Insuficiência Cardíaca , Idoso , Idoso de 80 Anos ou mais , Inibidores da Enzima Conversora de Angiotensina , Estudos de Coortes , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Fatores de RiscoRESUMO
BACKGROUND: Heart failure (HF) is a chronic condition that usually leads to death a few years after diagnosis. Although several clinical factors have been found to be related to increased mortality, less is known about the impact of social context, especially at the end stage of the disease. Knowing about social context is important to properly classify risk and provide holistic management for patients with advanced HF. OBJECTIVE: The aim of this study was to determine the impact of social context on mortality in patients with advanced HF. METHODS: A retrospective cohort study was conducted using data from clinical records on community-dwelling patients with HF and with New York Heart Association IV functional class living in Catalonia in northeastern Spain. Clinical data, patient dependency for basic activities of daily living, and social assessments were collected between 2010 and 2013. The primary outcome was all-cause mortality. RESULTS: Data from 1148 New York Heart Association class IV patients were analyzed. Mean (SD) age was 82 (9.0) years, and 61.7% were women. The mean (SD) follow-up was 18.2 (11.9) months. Mortality occurred in 592 patients. Social risk was identified in 63.6% of the patients, and 9.3% acknowledged having social problems. In the adjusted multivariate model, being male (hazard ratio (HR), 1.82; 95% confidence interval [CI], 1.16-2.83), having high dependency on others for basic activities of daily living (HR, 2.16; 95% CI, 1.21-3.85), and presenting with a social problem (HR, 2.46; 95% CI, 1.22-4.97) were related to an increased risk of mortality. CONCLUSIONS: An unfavorable social profile is an independent risk factor for mortality in patients with advanced HF.
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Atividades Cotidianas , Insuficiência Cardíaca/mortalidade , Determinantes Sociais da Saúde/estatística & dados numéricos , Isolamento Social/psicologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Insuficiência Cardíaca/psicologia , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Rede Social , Fatores Socioeconômicos , Fatores de TempoRESUMO
PURPOSE: To describe the process of translation and cultural adaptation of the Patient empowerment in long-term condition to the Spanish language. DESIGN: Translation, cross-cultural adaptation, and pilot testing (cognitive debriefing) LOCATION: Primary and Hospital care. PARTICIPANTS: Ten patients admitted to a cardiology department of a University Hospital MAIN MEASUREMENTS: 1) Direct translation, 2) conciliation and synthesis of the versions by expert panel, 3) back- translation, 4) agreement on the back-translated version with the author of the original version, 5) analysis of comprehensibility through cognitive interviews. RESULTS: There were no differences between the direct-translated versions. The expert panel introduced changes in 23 out of the 47 items of the questionnaire. The author of the original version agreed with the version of the back-translation. In the cognitive interviews, patients reported high difficulty in one item and low difficulty in 4. CONCLUSIONS: The Spanish version of the Patient Empowerment in long-term conditions questionnaire is semantically and conceptually equivalent to the original tool. The assessment of the psychometric properties of the Spanish version of the questionnaire will be carried out at a later stage.
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Doença Crônica , Comparação Transcultural , Empoderamento , Idioma , Inquéritos e Questionários , Traduções , Compreensão , Humanos , Participação do PacienteRESUMO
BACKGROUND: The impact of atrial fibrillation (AF) on mortality of patients with heart failure (HF) has been established. Nevertheless, the effect of some factors in mortality, such as digoxin or diuretic use, remains controversial. This study aims at assessing mortality in community-dwelling patients with stable HF related to AF and determines the relation of these drugs with prognosis. MATERIALS AND METHODS: Community-based cohort study of HF patients diagnosed between January 2010 and December 2014 attended at any one of the 279 primary healthcare centres of the Catalan Institute of Health (Spain). Follow-up ended on December 31, 2015, and the main outcome was mortality for all causes. The effect of clinical and demographic characteristics on survival was assessed by Cox proportional hazards model. RESULTS: A total of 13 334 HF patients were included. Mean age was 78.7 years (SD 10.1), and 36.8% had AF. Mean follow-up was 26.9 months (SD 14.0). At the end of the study, 25.8% patients had died, and mortality was higher when AF was present (28.8% vs 24.1%, P < 0.001, respectively). Multivariate model confirmed the higher risk of death for AF patients (HR 1.10 95%, CI 1.02-1.19). Digoxin and diuretics were not associated with higher mortality in AF patients (HR 1.04 95% CI 0.92-1.18 and HR 1.04 95% CI 0.85-1.26, respectively). CONCLUSIONS: An excess of mortality in HF patients with AF was found in a large retrospective community-based cohort. Digoxin and diuretics did not affect mortality in HF patients with AF.
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Antiarrítmicos/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Digoxina/uso terapêutico , Diuréticos/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/mortalidade , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: It is common to find a high variability in the accuracy of heart failure (HF) diagnosis in electronic primary care medical records (EMR). Our aims were to ascertain (i) whether the prognosis of HF labelled patients whose ejection fraction (EF) was missing in their EMR differed from those that had it registered, and (ii) the causes contributing to the differences in the availability of EF in EMR. METHODS: Retrospective cohort analyses based on clinical records of HF and attended at 52 primary healthcare centres of Barcelona (Spain). Information of 8376 HF patients aged > 40 years followed during five years was analyzed. RESULTS: EF was available only in 8.5% of primary care medical records. Cumulate incidence for mortality and hospitalization from 1st January 2009 to 31th December 2012 was 37.6%. The highest rate was found in patients with missing EF (HR 1.84, 95% CI 1.68 -1.95) compared to those with preserved EF. Patients hospitalized the previous year and those requiring home healthcare (HR 1.81, 95% Confidence Interval 1.68-1.95 and HR 1.58, 95% CI 1.46-1.71, respectively) presented a higher risk of having an adverse outcome. Older patients, those more socio-economically disadvantaged, obese, requiring home healthcare, and taking loop diuretics were less likely to have an EF registered. CONCLUSIONS: EF is poorly recorded in primary care. HF patients with EF missing at medical records had the worst prognosis. They tended to be older, socio-economically disadvantaged, and more fragile.
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Documentação , Registros Eletrônicos de Saúde , Insuficiência Cardíaca/fisiopatologia , Serviços de Assistência Domiciliar/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Atenção Primária à Saúde , Volume Sistólico/fisiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Ecocardiografia , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Obesidade/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores Socioeconômicos , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico , EspanhaRESUMO
The soluble transferrin receptor (sTfR) is a marker of tissue iron status, which could indicate an increased iron demand at the tissue level. The impact of sTfR levels on functional capacity and quality of life (QoL) in non-anemic heart failure (HF) patients with otherwise normal systemic iron status has not been evaluated. We conducted an observational, prospective, cohort study of 1236 patients with chronic HF. We selected patients with normal hemoglobin levels and normal systemic iron status. Tissue iron deficiency (ID) was defined as levels of sTfR > 75th percentile (1.63 mg per L). The primary endpoints were the distance walked in the 6 min walking test (6MWT) and the overall summary score (OSS) of the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The final study cohort consisted of 215 patients. Overall QoL was significantly worse (51 ± 27 vs. 39 ± 20, p-value = 0.006, respectively), and the 6 MWT distance was significantly worse in patients with tissue ID when compared to patients without tissue ID (206 ± 179 m vs. 314 ± 155, p-value < 0.0001, respectively). Higher sTfR levels, indicating increased iron demand, were associated with a shorter distance in the 6 MWT (standardized ß = -0.249, p < 0.001) and a higher MLHFQ OSS (standardized ß = 0.183, p-value = 0.008). In this study, we show that in patients with normal systemic iron parameters, higher levels of sTfR are strongly associated with an impaired submaximal exercise capacity and with worse QoL.
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Background: Despite considerable evidence concerning heart failure (HF) risk factors, there is scarce information about the effect and degree of control regarding socioeconomic and gender inequalities. Methods: Cohort study including HF patients >40 years of age attended in 53 primary health care centers in Barcelona (Spain). Socioeconomic status (SES) was determined by an aggregated deprivation index (MEDEA) according to the neighborhood of residence. Logistic multivariable regression was performed to analyze differences in cardiovascular risk factor control, stratifying by SES and sex. Results: A total of 8235 HF patients were included. Mean age was 78.1 (standard deviation 10.2) years, and 56.0% were women. The most prevalent cardiovascular risk factors were hypertension, diabetes, and dyslipidemia. Blood pressure was the worst controlled factor in both genders with the lowest SES (odds ratio [OR] 0.56 95% confidence interval [CI] 0.56-0.71) and (OR 0.52, 0.46-0.71), respectively. In women, a social gradient was observed for glycemic and body mass index control, which were worse in the most unfavorable socioeconomic position (OR 0.54, 95% CI 0.38-0.77), and (OR 0.45, 95% CI 0.32-0.64), respectively. Men presented worse control of blood pressure (OR 0.55, 95% CI 0.42-0.71) and smoking habit (OR 0.67, 95% CI 0.47-0.90) in the most deprived socioeconomic bracket. Conclusion: Patients with HF in the most disadvantaged socioeconomic levels presented the worst degree of control for cardiovascular risk factors, and this negative effect was stronger in women.
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Doenças Cardiovasculares , Insuficiência Cardíaca , Idoso , Doenças Cardiovasculares/epidemiologia , Estudos de Coortes , Feminino , Fatores de Risco de Doenças Cardíacas , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Fatores de Risco , Classe Social , Fatores SocioeconômicosRESUMO
AIMS: Because evidence regarding risk stratification predicting prognosis of patients with heart failure (HF) decompensation attended in primary care is lacking, we developed and externally validated a model to forecast death/hospitalization during the first 30 days after an episode of decompensation. The predictive model is based on variables easily obtained in primary care settings. METHODS AND RESULTS: HEFESTOS is a multinational study consisting of a derivation cohort of HF patients recruited in 14 primary healthcare centres in Barcelona and a validation cohort from primary healthcare in 9 other European countries. The derivation and validation cohorts included 561 and 250 patients, respectively. Percentages of women in the derivation and validation cohorts were 56.3% and 47.6% (P = 0.026), respectively. Mean age was 82.2 years (SD 8.03) in the derivation cohort, and 79.3 years (SD 10.3) in the validation one (P = 0.001). HF with preserved ejection fraction represented 72.1% in the derivation cohort and 58.8% in the validation one (P = 0.004). Mortality/hospitalization during the first 30 days after a decompensation episode was 30.5% and 26% (P = 0.225) for the derivation and validation cohorts, respectively. Multivariable logistic regression models were performed to develop a score of risk. The identified predictors were worsening of dyspnoea [odds ratio (OR): 2.5; P = 0.001], orthopnoea (OR: 2.16; P = 0.01), paroxysmal nocturnal dyspnoea (OR: 2.25; P = 0.01), crackles (OR: 2.35; P = 0.01), New York Heart Association functional class III/IV (OR: 2.11; P = 0.001), oxygen saturation ≤ 90% (OR: 4.98; P < 0.001), heart rate > 100 b.p.m. (OR: 2.72; P = 0.002), and previous hospitalization due to HF (OR: 2.45; P < 0.001). The model showed an area under the curve (AUC) of 0.807, 95% confidence interval (CI): [0.770; 0.845] in the derivation cohort and AUC 0.73, 95% CI: [0.660; 0.808] in the validation one. No significant differences between both cohorts were observed (P = 0.08). Regarding probability of hospitalization/death, three risk groups were defined: low <5%, medium 5-20%, and high >20%. Outcome incidence was 2.7% for the low-risk group, 12.8% for medium risk, and 46.2% for high risk in the derivation cohort, and 9.1%, 12.9%, and 39.6% in the validation one. CONCLUSIONS: The HEFESTOS score, based on variables easily accessible in a community setting and validated in an external European cohort, properly predicted the risk of death/hospitalization during the first 30 days after an HF decompensation episode.
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Insuficiência Cardíaca , Idoso , Idoso de 80 Anos ou mais , Europa (Continente)/epidemiologia , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Modelos Cardiovasculares , Prognóstico , Características de Residência/estatística & dados numéricos , Medição de Risco/métodos , Índice de Gravidade de Doença , Volume Sistólico , Função Ventricular EsquerdaRESUMO
Background: Information regarding short-term vital prognosis in patients with heart failure at advanced stages of the disease is scarce. Objective: To develop a three-month mortality predictive model for patients with advanced heart failure. Methods: Prospective observational study carried out in primary care and a convalescence community facility. Heart failure patients either New York Heart Association (NYHA) III with at least two HF hospitalizations during the previous six months or NYHA IV with/without previous recent hospitalization were included in the study. Multivariable predictive models using Cox regression were performed. Results: Of 271 patients included, 55 (20.3%) died during the first three months of follow-up. Mean age was 84.2 years (SD 8.3) and 59.8% were women. Predictive model including NT-proBNP had a C-index of 0.78 (95% CI 0.71; 0.85) and identified male gender, low body mass index, high potassium and NT-proBNP levels, and moderate-to-severe dependence for daily living activities (Barthel index < 40) as risk factors of mortality. In the model without NT-proBNP, C index was 0.72 (95% CI 0.64; 0.79) and, in addition to gender, body mass index, low Barthel index, and severe reductions in glomerular filtration rate showed the highest predictive hazard ratios for short-term mortality. Conclusions: In addition to age, male gender, potassium levels, low body mass index, and low glomerular filtration, dependence for activities of daily living add strong power to predict mortality at three months in patients with advanced heart failure.
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BACKGROUND: The potential impact of telemedicine (TM) in the monitoring of patients with heart failure (HF) is still uncertain particularly in the frailest patients. The aim of this study was to define the efficacy of a TM-based managed care solution across different HF patient frailty phenotypes. METHODS: We performed a clustering analysis on the basis of 8 frailty-related dimensions to the HF-patients included in the 'insuficiència Cardíaca Optimització Remota' (iCOR) randomised study comparing TM vs. usual care (UC) in HF patients. The primary study endpoint was the incidence of a non-fatal HF event after 6 months of inclusion. The healthcare-related costs in each study group and cluster were also evaluated. The event rates of primary and secondary study endpoints were calculated for each cluster. Cox proportional-hazards regression models were used to evaluate the effect of cluster, treatment group and the interaction term cluster by treatment group on study endpoints. RESULTS: 5 different frailty phenotypes were identified. The positive effect of TM compared to UC strategy was consistent across all frailty phenotypes (p-value for interaction 0.711). The risk of experiencing a primary event was significantly lower in patients that underwent allocation to the TM arm compared to UC (p-value = 0.016). Ultimately, the healthcare costs were significantly reduced in patients allocated to the TM compared to UC in all 5 frailty phenotypes (all p-value < 0.05). CONCLUSIONS: Non-invasive TM-based follow-up tools are effective compared to UC follow-up in preventing HF events in the early post-discharge period, regardless of the 5 frailty phenotypes.
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Fragilidade , Insuficiência Cardíaca , Telemedicina , Assistência ao Convalescente , Fragilidade/epidemiologia , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Alta do Paciente , FenótipoRESUMO
BACKGROUND: The potential positive effect of electronic health (eHealth)-based heart failure (HF) monitoring remains uncertain mainly in the 'low literacy' or 'computer or digital illiterate' patients. The aim of this study was to determine the effectiveness of a telemedicine (TM)-based managed care solution across literacy levels and information and communications technology (ICT) skills. METHODS: We performed a sub-analysis on the basis of two literacy domains encompassed in the definition of 'eHealth literacy' to the HF-patients included in the 'insuficiència Cardíaca Optimització Remota' (iCOR) randomized study comparing TM vs. usual care (UC) in HF-patients. The primary study endpoint was the incidence of a non-fatal HF event after 6 months of inclusion. The event rates of primary and secondary study endpoints were calculated for each literacy domains and its combination. Cox proportional-hazards regression models were used to evaluate the effect of 'eHealth literacy' dimensions, treatment group and the interaction term 'eHealth literacy' domains by treatment group on study endpoints. RESULTS: The beneficial effect of TM compared to UC strategy was consistent across all literacy domains (p-value for interaction 0.207 and 0.117 respectively). The risk of experiencing a primary event was significantly lower in patients that underwent allocation to the TM arm compared to UC in both clustered in the 'lower literacy' (p-value=0.001) and those allocated to the 'lower ICT skills' (p-value=0.001) subgroup. CONCLUSIONS: Non-invasive eHealth-based HF monitoring tools are effective compared to UC in preventing HF events in the early post-discharge period, regardless of two 'eHealth literacy' domains ('traditional and computer literacy').
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Insuficiência Cardíaca , Monitorização Ambulatorial , Telemedicina , Letramento em Saúde , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do TratamentoRESUMO
AIMS: The assumption that improved self-care in the setting of heart failure (HF) care necessarily translates into improvements in long-term mortality and/or hospitalization is not well established. We aimed to study the association between self-care and long-term mortality and other major adverse HF events (MAHFE). METHODS AND RESULTS: We conducted an observational, prospective, cohort study of 1123 consecutive patients with chronic HF. The primary endpoint was all-cause mortality. We used the European Heart Failure Self-care Behaviour Scale 9-item version (EHFSCBS-9) to measure global self-care (overall score) and three specific dimensions of self-care including autonomy-based adherence, consulting behaviour and provider-based adherence. After a mean follow-up of 3.3 years, all-cause death occurred in 487 patients (43%). In adjusted analysis, higher EHFScBS-9 scores (better self-care) at baseline were associated with lower risk of all-cause death [hazard ratio (HR) 0.993, 95% confidence interval (CI) (0.988-0.997), P-value = 0.002], cardiovascular (CV) death [HR 0.989, 95% CI (0.981-0.996), P-value = 0.003], HF hospitalization [HR 0.993, 95% CI (0.988-0.998), P-value = 0.005], and the combination of MAHFE [HR 0.995, 95% CI (0.991-0.999), P-value = 0.018]. Similarly, impaired global self-care [HR 1.589, 95% CI (1.201-2.127), P-value = 0.001], impaired autonomy-based adherence [HR 1.464, 95% CI (1.114-1.923), P-value = 0.006], and impaired consulting behaviour dimensions [HR 1.510, 95% CI (1.140-1.923), P-value = 0.006] were all associated with higher risk of all-cause mortality. CONCLUSION: In this study, we have shown that worse self-care is an independent predictor of long-term mortality (both, all-cause and CV), HF hospitalization, and the combinations of these endpoints in patients with chronic HF. Important dimensions of self-care such as autonomy-based adherence and consulting behaviour also determine the risk of all these outcomes in the long term.
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Insuficiência Cardíaca , Autocuidado , Estudos de Coortes , Insuficiência Cardíaca/terapia , Hospitalização , Humanos , Assistência de Longa Duração , Estudos ProspectivosRESUMO
The HEFESTOS scale was developed in 14 Spanish primary care centres and validated in 9 primary care centres of other European countries. It showed good performance to predict death/hospitalisation during the first 30 days after an episode of acute heart failure (AHF), with c-statistics of 0.807/0.730 in the derivation/validation cohorts. We evaluated this scale in the emergency department (ED) setting, comparing it to the EHMRG and MEESSI scales in the ED and the EFFECT and GWTG scales in hospitalised patients, to predict 30-day outcomes, including death and hospitalisation. Consecutive AHF patients were enrolled in 34 Spanish EDs in January-February 2016, 2018, and 2019 with variables needed to calculate outcome scores. Thirty-day hospitalisation/death (together and separately) and post-discharge combined adverse event (ED revisit or hospitalisation for AHF or all-cause death) were determined for patients discharged home after ED care. Predictive capacity was assessed by c-statistic with 95% confidence intervals. Of 10,869 patients, 4,044 were included (median age: 83 years, 54% women). The performance of HEFESTOS was modest for 30-day hospitalisation/death, c-statistic=0.656 (0.637-0.675), hospitalisation, 0.650 (0.631-0.669), and death, 0.610 (0.576-0.644). Of 1,034 patients with scores for the 5 scales, HEFESTOS had the numerically highest c-statistic for hospitalisation/death at 30 days, 0.666 (0.627-0.704), vs. MEESSI= 0.650 (0.612-0.687, p=0.51), EFFECT=0.633 (0.595-0.672, p=0.21), GWTG=0.618 (0.578-0.657, p=0.06) and EHMRG=0.617 (0.577-0.704, p=0.07). Similar modest performances were observed for predicting hospitalisation [ranging from HEFESTOS=0.656 (0.618-0.695) to GWTG=0.603 (0.564-0.643)]. Conversely, prediction of 30-day death was good with the MEESSI=0.787 (0.728-845), EFFECT=0.754 (0.691-0.818) and GWTG=0.749 (0.689-0.809) scales, and modest with EHMRG=0.649 (0.581-0.717) and HEFESTOS=0.610 (0.538-0.683). Although the HEFESTOS scale was numerically better for predicting 30-day hospitalisation/death in ED AHF patients, its modest performance precludes routine use. Only 30-day mortality was adequately predicted by some scales, with the MEESSI achieving the best results.
Assuntos
Insuficiência Cardíaca , Alta do Paciente , Doença Aguda , Assistência ao Convalescente , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Feminino , Mortalidade Hospitalar , Humanos , MasculinoRESUMO
INTRODUCTION: Information about how patients with advanced heart failure (HF) live and cope with their disease remains scarce. The objective of this study was to explore, from phenomenological and holistic perspectives, the experiences of patients suffering from advanced HF, attended at home in the primary care setting in 2018. MATERIALS AND METHODS: Qualitative study conducted in 4 primary healthcare centers in Barcelona (Spain). Twelve in-depth interviews were conducted in advanced HF patients, aged over 65 and visited regularly at home. We developed a purposeful sampling, accounting for variability in gender, age, and socioeconomic level. Leventhal's framework was used to analyze the interviews. RESULTS: Participants received insufficient and contradictory information about HF. They talked about their cognitive representation and claimed a better communication with healthcare professionals. Due to their advanced age, subjects considered their daily living limitations to be normal rather than as a consequence of HF. Gender differences in emotional representation were clearly observed. Women considered themselves the keystone of correct family "functioning" and thought that they were not useful if they could not correspond to gendered societal expectations. Cognitive coping strategies included specific diets, taking medication, and registering weight and blood pressure. Nevertheless, they perceived the locus of control as external and felt unable to manage HF progression. Their emotional coping strategies included some activities at home such as watching television and reading. Social support was perceived crucial to the whole process. CONCLUSIONS: Locus of control in advanced HF was perceived as external. Healthcare professionals should adapt emotional health interventions in patients with advanced HF based on a gender perspective. Social support was found to be crucial in facing the disease. Patients reported poor communication with healthcare professionals.
Assuntos
Adaptação Psicológica , Insuficiência Cardíaca/psicologia , Qualidade de Vida , Idoso , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/reabilitação , Humanos , Masculino , Apoio Social , Espanha , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Information regarding the effect of social determinants of health on heart failure (HF) community-dwelling patients is scarce. We aimed to analyse the presence of socioeconomic inequalities, and their impact on hospitalisations and mortality, in patients with HF attended in a universal healthcare coverage system. METHODS: A retrospective cohort study carried out in patients with HF aged >40 and attended at the 53 primary healthcare centres of the Institut Català de la Salut in Barcelona (Spain). Socioeconomic status (SES) was determined by an aggregated deprivation index (MEDEA). Cox proportional hazard models and competing-risks regression based on Fine and Gray's proportional subhazards were performed to analyse hospitalisations due to of HF and total mortality that occurred between 1 January 2009 and 31 December 2012. RESULTS: Mean age was 78.1 years (SD 10.2) and 56% were women. Among the 8235 patients included, 19.4% died during the 4 years of follow-up and 27.1% were hospitalised due to HF. A gradient in the risk of hospitalisation was observed according to SES with the highest risk in the lowest socioeconomic group (sHR 1.46, 95% CI 1.27 to 1.68). Nevertheless, overall mortality did not differ among the socioeconomic groups. CONCLUSIONS: In spite of finding a gradient that linked socioeconomic deprivation to an increased risk of hospitalisation, there were no differences in mortality regarding SES in a universal healthcare coverage system.
Assuntos
Disparidades nos Níveis de Saúde , Insuficiência Cardíaca/mortalidade , Hospitalização , Cobertura Universal do Seguro de Saúde , Idoso , Idoso de 80 Anos ou mais , Humanos , Auditoria Médica , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Classe Social , Espanha/epidemiologiaRESUMO
BACKGROUND: Heart failure (HF) is frequent and its prevalence is increasing. We aimed to evaluate the epidemiologic features of HF patients, the 1-year follow-up outcomes and the independent predictors of those outcomes at a population level. METHODS AND RESULTS: Population-based longitudinal study including all prevalent HF cases in Catalonia (Spain) on December 31st, 2012. Patients were divided in 3 groups: patients without a previous HF hospitalization, patients with a remote (>1 year) HF hospitalization and patients with a recent (<1 year) HF admission. We analyzed 1year all-cause and HF hospitalizations, and all-cause mortality. Logistic regression was used to identify the independent predictors of each of those outcomes. A total of 88,195 patients were included. Mean age was 77 years, 55% were women. Comorbidities were frequent. Fourteen percent of patients had never been hospitalized, 71% had a remote HF hospitalization and 15% a recent hospitalization. At 1-year follow-up, all-cause and HF hospitalization were 53% and 8.8%, respectively. One-year all-cause mortality rate was 14%, and was higher in patients with a recent HF hospitalization (24%). The presence of diabetes mellitus, atrial fibrillation or chronic kidney disease was independently associated with all-cause and HF hospitalization and all-cause mortality. Hospital admissions and emergency department visits the previous year were also found to be independently associated with the three study outcomes. CONCLUSIONS: Outcomes are different depending on the HF population studied. Some comorbidity, an all-cause hospitalization or emergency department visit the previous year were associated with a worse outcome.