Discussion
This retrospective study, which looked at heart failure activity in the elderly in a London university hospital, provides supportive evidence for the poor heart failure outcomes demonstrated by the NHF audit and specifically in the elderly population by the EHFS II.5
The patient demographics of this study population is similar to that of other heart failure studies where elderly patients have been studied5 and highlights that the presence of comorbidities including hypertension, atrial fibrillation and ischaemic heart disease are common in the elderly. Overall, our results also suggest that elderly patients with heart failure are likely to be vulnerable or frail, demonstrating the importance of a multidisciplinary approach to care.
Previously, underuse and underdosage of medications recommended for heart failure have been demonstrated in the elderly population by the EHFS II.5 Likewise, this study also shows that a large proportion of patients are not discharged on guidance-indicated treatments. In the NHF audit, age below 75 years was one of the strongest predictors of prescribing evidence-based treatments on discharge, and it is likely that the lower rates of prescribing observed in this study are partly reflective of the older age group studied. The possible reasons for this include a poorer awareness of the use of heart failure treatments in the elderly. Other reasons include the wider prevalence of comorbidities and frailty in the elderly, as demonstrated by the data, and increased side effects from medications, which can significantly limit the use of heart failure treatments in the elderly.
LOS was lower in our study compared with the NHF audit, and this was surprising, as increasing age has been associated with a prolonged LOS in patients with heart failure.3 ,8 The possible explanations for this include earlier discharge with high follow-up rates in the ambulatory care setting, by geriatricians, as demonstrated by the follow-up data.
An important finding—the high mortality from heart failure—as shown by other studies3 ,5 ,8–12 is also evident in this study. Inpatient mortality was recorded at 13%, which is higher than that reported by the NHF audit (9.4%) and EHFS II (10.7%). The long-term mortality in this study (median follow-up of 337 days) was also higher than that reported by the NHF audit (median follow-up of 222 days) and other studies.11 As increasing age and frailty have been shown to be predictors of mortality,7 the higher mortality rates in this study may represent the older, frailer population studied.
One of the most striking findings of this study is that readmission rates among the elderly appear to be markedly high with one-fifth of admissions occurring due to returning patients, mostly within 30 days of discharge. Encouragingly, there was better use of ARAs in the readmitters group compared to the single admitter group; however, this was not replicated for other treatments. This study has also shown that readmitters have less follow-up and increased long-term mortality compared to single admitters, highlighting the need for better community monitoring of heart failure in this group to prevent readmission and to improve outcomes. Interestingly, there were no significant differences in comorbidities or clinical frailty between single admitters and readmitters. LVEF, however, was significantly lower in the readmitters group, suggesting the use of LVEF in identifying patients who have a higher risk of readmission and carry a worse prognosis.
As with the NHF audit, this study has also identified key differences in heart failure management and patient outcomes between those managed on COE and cardiology wards. For example, like the NHF audit, a greater percentage of patients admitted to cardiology wards underwent inpatient echocardiography, suggesting poorer access to specialist investigations by COE teams. A lower percentage of patients on COE teams were also discharged on β blockers, as with the NHF data.3 This finding may partly be explained by the fact that chronic obstructive pulmonary disease was more common in the COE group, although this did not reach statistical significance. Another key finding was the significantly increased mortality in those managed on COE wards versus cardiology wards, and although our data have not been adjusted for age, sex, aetiology, symptoms, treatment and investigations, a similar outcome has also been identified in the NHF audit where such adjustments were made.
This study has a number of limitations. First, patient outcomes, such as treatment on discharge and echocardiography, may be under-represented through selection bias, as all patients without a discharge medication summary were excluded from the study, and only inpatient echocardiography, the data of which were available, was looked at. Mortality data in this study may also be under-represented due to the small population size. To improve the validity of our study and to look at the influence of social class/geographical differences on heart failure in the elderly, a larger multicentre study would need to be performed.
In summary, this study has shown that investigation and treatment for heart failure in the elderly can be improved, that readmission rates and mortality remain high and that access to specialist cardiology input is associated with better outcomes in terms of treatment and mortality. Clearly, this highlights the need for a change in the delivery of heart failure care in the elderly. This should start with the initial assessment, as the efficacy of rapid access heart failure clinics in providing a rapid assessment, diagnosis and early introduction of recommended treatments has been demonstrated previously.13 In the hospital setting, geriatricians and cardiologists should follow the lead taken by acute myocardial infarction to ensure that there are improvements in the access of older patients to recommended investigations and treatments, if tolerated. Following the success from acute stroke management, this could be implemented on a designated heart failure unit where geriatricians and cardiologists would work as part of a multidisciplinary team. Finally, much more needs to be done in the community setting to improve heart failure outcomes, including better integration of community and secondary care services. The role of community heart failure teams in reducing readmission and improving mortality has also been well documented in retrospective cohort studies14 and randomised controlled trials,15 ,16 and thus there should be greater involvement of specialist heart failure teams working alongside geriatricians in the outpatient setting.