Doubled death rates for HF patients in general wards

Patients with heart failure (HF) are twice as likely to die if admitted to general wards than those admitted to cardiology wards, according to a national HF audit published online in Heart.(1)

A survey was carried out of the first 10 patients hospitalised with a primary diagnosis of HF each month in 86 hospitals providing services for acute medical admissions in England and Wales, from April 2008 until March 2009. The main outcome measures were rates of investigations, treatments and specialist management, length of hospital stay and mortality.

general-ward-2 6,170 patients qualified overall, with a median age of 78 years. Patients admitted to general medicine rather than cardiology wards were more likely to die (HR=2.5, 95% CI 2.0 to 3.3, p<0.001) even after adjusting for differences (HR=1.9, 95% CI 1.5 to 2.5, p<0.001), the study found. Projected 1-year mortality below and above age 75 years was 26% and 56%, with higher rates if managed on general medicine rather than cardiology wards (HR=1.4, 95% CI 1.2 to 1.6, p<0.001).

The measurement of natriuretic peptides, which the authors say “provides a simple method of identifying patients who need investigation for heart failure”, is not yet widely used in the UK despite National Institute for Health and Clinical Excellence (NICE) recommendations (<2% of patients in the survey). The authors suggest this may result from existing financial structures that often deal poorly with problems such as HF, for which responsibility can be spread across multiple business units.

The authors assert that specialist care is associated with better outcomes, and that “intensified long-term management has a powerful effect on mortality”. Compared with those managed on general wards, those admitted to cardiology wards tended to be younger and were more likely to be men.

“Currently, hospital provision of care is suboptimal and the outcome of patents poor. The same rules that apply to suspected cancer should pertain to a disease with such a malign prognosis as heart failure,” conclude the authors. They emphasise that “easy access to the first diagnostic step (natriuretic peptides), speedy referral to an appropriate specialist, with inpatient and postdischarge management guided by appropriately trained specialist staff” are essential to improved outcomes.

References

Cleland JGF, McDonagh T, Rigby AS, Yassin A, Whittaker T, Dargie HJ. The national heart failure audit for England and Wales 2008-2009. Heart 2010; doi:10.1136/hrt.2010.209171
Available from: http://press.psprings.co.uk/heart/december/hrt209171.pdf