Predicting the Need for Hospice Care in Heart Failure
Predicting the Need for Hospice Care in Heart Failure
Abstract & Commentary
By Mary Elina Ferris, MD, Clinical Associate Professor, University of Southern California. Dr. Ferris reports no financial relationship to this field of study.
Synopsis: Using blood pressure, BUN, serum sodium, and presence of peripheral arterial disease as predictors of mortality in heart failure patients, 67% who had 3 or more factors died within 6 months and would qualify for the Medicare hospice benefit.
Source: Huynh BC, et al. Identification of older patients with heart failure who may be candidates for hospice care: Development of a simple four-item risk score. J Am Geriatr Soc 2008;56:1111-1115.
At the Barnes-Jewish Hospital in St. Louis, 282 patients aged 70 and older with heart failure were followed for up to 14 years to determine predictors of all-cause mortality at 6 months after hospital discharge; 43 (15%) died within 6 months of hospital discharge. The mean New York Heart Association functional class was 2.4 and average left ventricular ejection fraction was 42%. Mean age was 79 years, and most had other comorbid illnesses. A large number of clinical and laboratory variables were analyzed, including demographics, medical history, medications, and cognitive function.
Four independent predictors of 6-month mortality were found: serum urea nitrogen of 30 mg/dL or greater, systolic blood pressure less than 120 mmHg, serum sodium less than 135 mEq/L, and the presence of peripheral arterial disease. Age alone was not predictive of mortality. Using these factors, patients were stratified into risk groups with zero, one, two, or three or more risk factors. Six-month mortality occurred in 3.7%, 16.3%, 41.0%, and 66.7%, respectively.
Commentary
Heart failure in the elderly continues to have a fairly grim prognosis with only 50% surviving 1-5 years, and 1-year mortality rates of up to 75% for end-stage failure, yet predicting who would qualify for palliative and hospice care can be elusive. Physicians in one study predicted 6-month survival of more than 50% in seriously ill patients who later died within 3 days.1
Many patients and their families would benefit from end-of-life planning and the enhanced benefits from hospice referral, and they often express a desire for palliative care. However, Medicare eligibility criteria for hospice enrollment currently requires prediction of a 6-month mortality rate in excess of 50%, making it difficult to support hospice referrals in this heterogeneous population.
This study, although small and limited only to elderly patients with heart failure, does give tangible criteria using 4 readily available measures to add to the clinical impression of poor prognosis. Even with 2 risk factors, the 6-month mortality approached 50%, and with 3 or more factors the Medicare criteria were met. Unfortunately the data used were from 1990 to 1994, when different treatments were used for heart failure than today. But the information still adds to our ability to advise patients and make appropriate hospice referrals as they approach the end of their lives.
References
1. Fox E, et al. Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. JAMA 1999;282:1638-1645.
Using blood pressure, BUN, serum sodium, and presence of peripheral arterial disease as predictors of mortality in heart failure patients, 67% who had 3 or more factors died within 6 months and would qualify for the Medicare hospice benefit.Subscribe Now for Access
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