Changing preferences for survival after hospitalization with advanced heart failure

Abstract

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.

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, 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 four ranges for group description and analysis of major changes.

Figure 2. Changing Patient Preferences After Hospital Discharge

Bar graph indicates proportions of patients in each time trade-off group at different times after hospital discharge. The number of patients responding for each interval is shown below. The cumulative number of patients dying by the end of each interval is shown in the black bars. Definitions of intervals are as in previous tables and figures.

Figure 3. Stability of Survival Preference

Pie graph showing 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 1. Patients remaining in the highest survival preference are “stable high”, those remaining in the lowest survival preference are “stable low”. Patients remaining in one of the two other time-trade off groups are “stable mid-preference”. While the majority of patients demonstrated no change in preference, more patients described an increase than a decrease in preference for survival.

Figure 4. Patient-Preferred Survival

Days alive adjusted by time trade-off. The x–y plot compares for each patient the actual survival days during 6 months to the survival days adjusted for the survival preference described by the patient during each interval (see text). 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 more than 90% of their remaining days in order to feel better, compared to 6% of patients surviving all 180 days.