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J Am Coll Cardiol, 2008; 52:1702-1708, doi:10.1016/j.jacc.2008.08.028
© 2008 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: HEART FAILURE

Changing Preferences for Survival After Hospitalization With Advanced Heart Failure

Lynne W. Stevenson, MD, FACC*,*, Anne S. Hellkamp, MS{ddagger}, Carl V. Leier, MD, FACC§, George Sopko, MD, MPH||, Todd Koelling, MD, FACC, J. Wayne Warnica, MD, FACC#, William T. Abraham, MD, FACC§, Edward K. Kasper, MD, FACC**, Joseph G. Rogers, MD, FACC{dagger}, Robert M. Califf, MD, FACC{ddagger}, Elizabeth E. Schramm, BA{ddagger} and Christopher M. O'Connor, MD, FACC{dagger}

* Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
{dagger} Division of Cardiology, Duke University Medical Center, Durham, North Carolina
{ddagger} Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
§ Division of Cardiology, Ohio State University Medical Center, Columbus, Ohio
|| National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
Division of Cardiology, University of Michigan Cardiovascular Center, Ann Arbor, Michigan
# Division of Cardiology, University of Calgary, Alberta, Canada
** Division of Cardiology, Johns Hopkins, Baltimore, Maryland

Manuscript received March 28, 2008; revised manuscript received July 17, 2008, accepted August 4, 2008.

* Reprint requests and correspondence: Dr. Lynne W. Stevenson, Brigham and Women's Hospital, Cardiovascular Division, 75 Francis Street, Boston, Massachusetts 02115 (Email: LStevenson{at}partners.org).

Objectives: This study was designed to analyze how patient preferences for survival versus quality-of-life change after hospitalization with advanced heart failure (HF).

Background: Although patient-centered care is a priority, little is known about preferences to trade length of life for quality among hospitalized patients with advanced HF, and it is not known how those preferences change after hospitalization.

Methods: The time trade-off utility, symptom scores, and 6-min walk distance were measured in 287 patients in the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheter Effectiveness) trial at hospitalization and again during 6 months after therapy to relieve congestion.

Results: Willingness to trade was bimodal. At baseline, the median trade for better quality was 3 months' survival time, with a modest relation to symptom severity. Preference for survival time was stable for most patients, but increase after discharge occurred in 98 of 145 (68%) patients initially willing to trade survival time, and was more common with symptom improvement and after therapy guided by pulmonary artery catheters (p = 0.034). Adjusting days alive after hospital discharge for patients' survival preference reduced overall days by 24%, with the largest reduction among patients dying early after discharge (p = 0.0015).

Conclusions: Preferences remain in favor of survival for many patients despite advanced HF symptoms, but increase further after hospitalization. The bimodal distribution and the stability of patient preference limit utility as a trial end point, but support its relevance in design of care for an individual patient.

Key Words: heart failure • quality of life • health utilities • hospitalization • cardiomyopathy

Abbreviations and Acronyms
  CAD = coronary artery disease
  HF = heart failure
  MLHF = Minnesota Living with Heart Failure
  PAC = pulmonary artery catheter
  TTO = time trade-off


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