Heart failure survival among older adults in the United States: a poor prognosis for an emerging epidemic in the Medicare population.

OBJECTIVE: To describe the 6-year probability of survival for older adults after their first hospitalization for heart failure. SETTING: National Medicare hospital claims records for 1984 through 1986 and Medicare enrollment records from 1986 through 1992. DESIGN: We identified a national cohort of 170 239 (9% black patients) Medicare patients, 67 years or older, with no evidence of heart failure in 1984 or 1985, who were hospitalized and discharged for the first time in 1986 with a principal diagnosis of heart failure. For groups defined by race, sex, age, Medicaid eligibility, and comorbid conditions, we compared the probability of survival with Cox proportional hazards regression. RESULTS: Only 19% of black men, 16% of white men, 25% of black women, and 23% of white women survived 6 years. One third died within the first year. Men had lower median survival and 38% greater risk of mortality than did women (P<.05). White men had 10% greater risk of mortality than did black men (P<.05). Medicaid eligibility (white adults only) and diabetes were associated with increased mortality (P<.05). CONCLUSIONS: The prognosis for older adults with heart failure underscores the importance of prevention strategies and early detection and treatment modalities that can prevent, improve, or reverse myocardial dysfunction, particularly for the growing number of adults who are at increased risk for developing heart failure because of hypertension, diabetes, or myocardial infarction.

National trends in the initial hospitalization for heart failure.

OBJECTIVES: Heart failure is a major health care burden among older adults, but information on recent trends has not been available. We compare rates, sociodemographic characteristics, and discharge outcomes of the initial hospitalization for heart failure in the Medicare populations of 1986 and 1993. DESIGN: Information reported on the Medicare hospital claims record during initial hospitalization for heart failure was compared for patients aged 65 and older hospitalized in 1986 (N = 631,306) and those aged 65 and older hospitalized in 1993 (N = 803,506). RESULTS: Age-standardized hospitalization rates (per 1000 person-years) for any diagnosis of heart failure were higher in 1993 than in 1986 (white: 24.6 vs 22.4, black: 26.1 vs 22.4, respectively). Age-specific results suggested an earlier onset of heart failure in black adults. In 1993, compared with 1986, higher proportions of heart failure patients were discharged to another care facility (white: 23.9% vs 16.8%, black: 17.6% vs 10.5%, respectively) or to health service care at home (white: 11.3% vs 6.0%, black: 12.4% vs 6.5%, respectively). In contrast, in-hospital mortality was lower in 1993 than in 1986 (white: 10.4% vs 13.3%, black: 8.9% vs 11.1%, respectively). CONCLUSION: The increased numbers of hospitalizations for heart failure and the likelihood that these patients will require advanced nursing care after discharge have important implications for future national health care expenditures and resources.

The risk of acquiring hepatitis from sewage-contaminated water.

There is little information on the risk of acquiring hepatitis A from drinking sewage-contaminated water. In a large outbreak of gastrointestinal illness at Crater Lake National Park, Oregon, a US national park, in June-July, 1975, approximately 100,000 persons were exposed to sewage-contaminated water. State health departments reported three cases of Crater Lake-associated hepatitis A for a rate of 12/100,000 per year, comparable to the reported US incidence of non-B hepatitis 10/100,000 per year. Questionnaire survey of 3997 overnight park visitors revealed five cases of hepatitis A, occurring in 2206 persons who drank water but did not receive immune serum globulin (ISG) within two weeks of exposure, an attack rate of 0.23%. The association between drinking park water and subsequently developing hepatitis was not statistically significant. No cases of hepatitis occurred in 320 park staff and family members, repeatedly exposed to contaminated water. The authors do not recommend routine use of prophylactic ISG for similar outbreaks of gastroenteritis caused by sewage-contaminated water but suggest close surveillance of the exposed group, and careful consideration of risk factors and costs.

Acute water shortage and health problems in Haiti.

During a severe drought Port-au-Prince, Haiti, lost hydroelectric power for 10 weeks. This led to water shortages in areas of the city dependent on water supplied from electrically driven pumps. In a study of the impact of water restriction on disease, 400 families were randomly selected from two urban areas differentially affected by the water shortage. Disease in children was found to be related to quantity of water used, socioeconomic status, employment of head of household, and family size. The methods used in this study are recommended for the investigation of the relationship between water quantity and health.