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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, 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, Robert M. Califf, MD, FACC, Elizabeth E. Schramm, BA and Christopher M. O'Connor, MD, FACC

^_* Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
Division of Cardiology, Duke University Medical Center, Durham, North Carolina
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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