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
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Figure 1 Bimodal Distribution of Patient Preferences
Histogram showing distribution of time trade-off values at baseline. The x-axis is expressed in terms of months traded, such that 24 months indicates that the patient awards no value to survival at the current state of health, and 0 months traded indicates full value. These month-values can be changed into a utility from 0 to 1 by subtracting from 24 months and then expressing as a fraction of 24. The values have been divided symmetrically into 4 ranges for group description and analysis of major changes.
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Figure 2 Changing Patient Preferences After Hospital Discharge
The proportions of patients in each time trade-off group at different times after hospital discharge are shown. The number of patients responding for each interval is shown below the figure. Purple bars = willing to trade almost all (22 to 24 months); red bars = willing to trade one-half or more (12 to 21 months); blue bars = willing to trade less than one-half (3 to 11 months); green bars = willing to trade almost none (0 to 2 months); black bars = cumulative number of patients dying by the end of each interval. Definitions of intervals are as in Table 2. *Patients in each willingness-to-trade category at each interval are shown as percent of patients with data at that interval; cumulative deaths are shown as percent of 404 patients with baseline data.
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Figure 3 Stability of Survival Preference
The pie graph shows the proportions of 287 patients with stable or changing preferences in the 6 months after hospital discharge. Change was defined as movement between the 4 preference levels described in Table 2. Patients remaining in the highest survival preference are "stable high"; those remaining in the lowest survival preference are "stable low." Patients remaining in 1 of the 2 other time-trade off groups are "stable mid-preference." Although the majority of patients demonstrated no change in preference, more patients described an increase than a decrease in preference for survival.
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Figure 4 Patient-Preferred Survival
Days alive adjusted by time trade-off. For each patient, the x-y plot compares the actual survival days during 6 months to the survival days adjusted for the survival preference described by the patient during each interval (see Methods). Overall, the majority of patients had <10% devalued days. Patients dying before 105 days had the highest proportion of days devalued by low preference for survival (p = 0.0015), with 31% of patients indicating that they would trade >90% of their remaining days to feel better, compared with 6% of patients surviving all 180 days.
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