Community Based HF Patients in the Last Year of Life
Objective To assess the clinical utility of the Gold Standards Framework Prognostic Indicator Guide (GSF) and the Seattle Heart Failure Model (SHF) to identify patients with chronic heart failure (CHF) in the last year of life.
Design, setting and patients An observational cohort study of 138 community based ambulatory patients with New York Heart Association (NYHA) class III and IV CHF managed by a specialist heart failure nursing team.
Main outcome measures 12 month mortality, and sensitivity and specificity of GSF and SHF.
Results 138 CHF patients with NYHA class III and IV symptoms were identified from a population of 368 ambulatory CHF patients. 119 (86%) met GSF criteria for end of life care. The SHF model identified six (4.3%) patients with a predicted life expectancy of 1 year or less. At the 12 month follow-up, 43 (31%) patients had died. The sensitivity and specificity for GSF and SHF in predicting death were 83% and 22%, and 12% and 99%, respectively. Receiver operator characteristic analysis of SHF revealed a C index of 0.68±0.05 (95% CI 0.58 to 0.77). Chronic kidney disease (serum creatinine ≥140 μmol/l) was a strong univariate predictor of 12 month mortality, with a sensitivity of 56% and specificity of 72%.
Conclusions Neither the GSF nor the SHF accurately predicted which patients were in the last year of life. The poor prognostic ability of these models highlights one of the barriers to providing timely palliative care in CHF.
The epidemiology of heart failure is changing as we confront improved survival following myocardial infarction and advancing life expectancy. The highest incidence and prevalence is in people over 80 years of age. Complications arising from heart failure account for 4% of deaths in the UK each year, and following a new diagnosis of chronic heart failure (CHF), 40% of patients will survive less than 1 year. However, for the remaining 60%, progression of the illness can be variable, although is typically progressive with repeated episodes of decompensation, often requiring hospitalisation. Increased use of life prolonging medications and implantable devices over the past 10 years has increased the average life expectancy of CHF patients. Despite this, survival remains worse than many cancers (figure 1). However, unlike cancer patients, few CHF patients receive additional supportive or palliative care during the end stage of their disease.
(Enlarge Image)
Figure 1.
Organ failure trajectory (reprinted with permission from Murray et al.
In recognition of the current gap in end of life care, both UK and European initiatives have advocated the use of palliative care in CHF patients. The European Society of Cardiology set up a palliative care workshop to address the issues of palliative care in CHF and to increase awareness. In the recently published 'Clinical standards: for heart disease', it is recommended that "patients that remain symptomatic despite optimal treatment should have access to supportive and palliative care according to their needs". These standards also recommend the use of the Gold Standards Framework-Prognostic Indicator Guide (GSF) to help identify heart disease patients that are reaching end of life. The GSF published in 2006 in England recommended a series of simple criteria to help identify patients nearing end of life. For CHF, these guidelines set out four criteria, two of which the patient must meet in order to be considered for palliative care (see appendix 1). Although these criteria are being recommended for use in CHF patients, to date, there is no published evidence on their predictive accuracy in identifying patients in the last year of life.
In contrast, the Seattle Heart Failure Model (SHF) (available online http://depts.washington.edu/shfm/app.php) uses clinical data to statistically predict likelihood of survival in CHF patients. The model has been validated in over 10 000 patients with reasonable predictive value, and is now considered a 'gold standard' for clinical prognostication in ambulatory CHF patients. However, there have been criticisms of the SHF due to the fact that it was developed solely on data from patients taking part in randomised clinical trials. However, smaller subsequent studies have indicated it may be useful in community based heart failure patients when additional factors such as brain natriuretic peptide or renal function are added into the model.
The primary aim of this study, therefore, was to evaluate the GSF criteria for heart failure as a simple qualitative method of identifying patients in the last year of life and compare this to an established quantitative model based on detailed clinical and biochemical data, the SHF.
Abstract and Introduction
Abstract
Objective To assess the clinical utility of the Gold Standards Framework Prognostic Indicator Guide (GSF) and the Seattle Heart Failure Model (SHF) to identify patients with chronic heart failure (CHF) in the last year of life.
Design, setting and patients An observational cohort study of 138 community based ambulatory patients with New York Heart Association (NYHA) class III and IV CHF managed by a specialist heart failure nursing team.
Main outcome measures 12 month mortality, and sensitivity and specificity of GSF and SHF.
Results 138 CHF patients with NYHA class III and IV symptoms were identified from a population of 368 ambulatory CHF patients. 119 (86%) met GSF criteria for end of life care. The SHF model identified six (4.3%) patients with a predicted life expectancy of 1 year or less. At the 12 month follow-up, 43 (31%) patients had died. The sensitivity and specificity for GSF and SHF in predicting death were 83% and 22%, and 12% and 99%, respectively. Receiver operator characteristic analysis of SHF revealed a C index of 0.68±0.05 (95% CI 0.58 to 0.77). Chronic kidney disease (serum creatinine ≥140 μmol/l) was a strong univariate predictor of 12 month mortality, with a sensitivity of 56% and specificity of 72%.
Conclusions Neither the GSF nor the SHF accurately predicted which patients were in the last year of life. The poor prognostic ability of these models highlights one of the barriers to providing timely palliative care in CHF.
Introduction
The epidemiology of heart failure is changing as we confront improved survival following myocardial infarction and advancing life expectancy. The highest incidence and prevalence is in people over 80 years of age. Complications arising from heart failure account for 4% of deaths in the UK each year, and following a new diagnosis of chronic heart failure (CHF), 40% of patients will survive less than 1 year. However, for the remaining 60%, progression of the illness can be variable, although is typically progressive with repeated episodes of decompensation, often requiring hospitalisation. Increased use of life prolonging medications and implantable devices over the past 10 years has increased the average life expectancy of CHF patients. Despite this, survival remains worse than many cancers (figure 1). However, unlike cancer patients, few CHF patients receive additional supportive or palliative care during the end stage of their disease.
(Enlarge Image)
Figure 1.
Organ failure trajectory (reprinted with permission from Murray et al.
In recognition of the current gap in end of life care, both UK and European initiatives have advocated the use of palliative care in CHF patients. The European Society of Cardiology set up a palliative care workshop to address the issues of palliative care in CHF and to increase awareness. In the recently published 'Clinical standards: for heart disease', it is recommended that "patients that remain symptomatic despite optimal treatment should have access to supportive and palliative care according to their needs". These standards also recommend the use of the Gold Standards Framework-Prognostic Indicator Guide (GSF) to help identify heart disease patients that are reaching end of life. The GSF published in 2006 in England recommended a series of simple criteria to help identify patients nearing end of life. For CHF, these guidelines set out four criteria, two of which the patient must meet in order to be considered for palliative care (see appendix 1). Although these criteria are being recommended for use in CHF patients, to date, there is no published evidence on their predictive accuracy in identifying patients in the last year of life.
In contrast, the Seattle Heart Failure Model (SHF) (available online http://depts.washington.edu/shfm/app.php) uses clinical data to statistically predict likelihood of survival in CHF patients. The model has been validated in over 10 000 patients with reasonable predictive value, and is now considered a 'gold standard' for clinical prognostication in ambulatory CHF patients. However, there have been criticisms of the SHF due to the fact that it was developed solely on data from patients taking part in randomised clinical trials. However, smaller subsequent studies have indicated it may be useful in community based heart failure patients when additional factors such as brain natriuretic peptide or renal function are added into the model.
The primary aim of this study, therefore, was to evaluate the GSF criteria for heart failure as a simple qualitative method of identifying patients in the last year of life and compare this to an established quantitative model based on detailed clinical and biochemical data, the SHF.