DenHeart: Differences in physical and mental health across cardiac diagnoses at hospital discharge

https://doi.org/10.1016/j.jpsychores.2017.01.003Get rights and content

Highlights

  • This is the first study to explore patient-reported outcomes in all diagnostic groups within cardiology.

  • Approximately one third of all cardiac patients experience symptoms of anxiety.

  • Significant differences exist in patient-reported outcomes across diagnostic groups at discharge.

  • The strongest predictors of poor patient-reported outcomes were female sex and high co-morbidity.

Abstract

Objective

To describe: (i) differences in patient reported physical and mental health outcomes at hospital discharge between a) cardiac diagnostic groups and b) cardiac patients and a national representative reference population and to describe (ii) in-hospital predicting factors for patient reported outcomes.

Methods

A national cross-sectional survey combined with national register data. From April 2013 to April 2014 all patients (n = 34,564) discharged or transferred from one of five Danish Heart Centres were invited to participate. 16,712 patients (51%) responded; 67% male and mean age 64 years. All diagnostic groups were represented similar to real life proportions. Patient reported outcome measures included: SF-12, Hospital Anxiety and Depression Scale, EQ-5D, Brief Illness Perception Questionnaire, HeartQoL and Edmonton Symptom Assessment Scale.

Results

Statistically significant differences were found in all patient reported outcomes across diagnostic groups. Listed from worst to best outcomes were heart failure, heart valve disease, ischemic heart disease, infectious heart disease, arrhythmia, congenital heart disease and heart transplant. Also “observation for cardiac disease” scored poorly on some aspects such as anxiety and treatment control. Compared to the reference population, cardiac patients had lower physical and mental health scores. Predicting factors for worse outcomes across diagnoses were female sex, older age, being unmarried, planned admission, longer hospital stay, and higher co-morbidity score.

Conclusions

This large nationwide study finds significant differences in patient reported outcomes across cardiac diagnostic groups, however the differences were small and did not reach minimal important difference. The total population of cardiac patients had significant and clinically relevant poorer scores on mental and physical health than the reference population. Predicting factors for poor outcomes were identified. It is the first study comparing all diagnostic groups within cardiology and it provides important benchmarks between diagnostic groups and future comparisons. This knowledge may help clinicians make better decisions about post-hospital care and prevention.

Introduction

The risk of poor health outcomes after the onset of cardiac disease is influenced by numerous clinical factors modifiable by disease monitoring, lifestyle changes and medication. However, diagnostic profile and patient reported outcomes seem to play an equally important role in secondary prevention [1].

The central goals of health care are to help people live longer and live better. In cardiovascular health science the primary focus tends to be on health behaviour (e.g. smoking and diet) and clinical health factors (e.g. blood pressure) as metrics of cardiovascular health [1]. These factors are of high importance; however, patient reported health status reflects the impact of disease and treatment on e.g. patients' symptom burden, functional status and quality of life (QoL), as perceived by the patient and is an important measure of health.

Previous studies have found associations between heart disease, self-reported health and morbidity and mortality, and that patient reported outcome measures can predict prolonged hospital stay, labour market affiliation, morbidity and mortality in cardiac patients [2], [3], [4], [5]. QoL and anxiety scores seem to provide important prognostic information, independent of traditional clinical data. High QoL scores and low anxiety scores have been associated with longer survival in patients with e.g. ventricular arrhythmias and coronary artery disease [6], [7], [8]. Furthermore, psychosocial factors account for 39% of the risk of myocardial infarction, and an overwhelming 67% in women alone, whereas smoking accounts for 29%, hypertension 21% and lipids 45% [9]. However, no studies have investigated patient reported outcomes in all diagnostic groups within cardiology and comparisons are not possible due to different times of measurement, different instruments and lack of power. Furthermore, additional research is needed to better understand the determinants and the predicting factors of patients' health status [1].

The overall aim of the DenHeart survey was to gain knowledge about patient reported outcomes regarding health among cardiac patients at hospital discharge [10]. The study results will provide important benchmark for between-diagnostic comparison. Knowledge about patients' own perception of their health status and predicting factors can guide in-hospital and out-patient practice as well as general practitioners and local secondary prevention teams to make better decisions about post-hospital care to prevent mortality, disease progression and readmission and to make evidence based decisions about priorities in the use of resources. Comparing outcomes with a national representative reference population are useful benchmarks for realistic goal setting in health care and trial design.

The objectives of this paper were to describe: (i) differences in patient reported outcomes at hospital discharge between a) cardiac diagnostic groups and b) cardiac patients and a national representative reference population and to describe (ii) in-hospital predicting factors for patient reported outcomes.

Section snippets

Study design

The DenHeart study was designed as a cross-sectional survey combined with national registry data. The methods and publication plan were thoroughly described in the published study protocol [10].

Setting and participants

Over one year (April 15th 2013 to April 15th 2014) all patients (34,564) discharged or transferred from the five Danish Heart Centres were asked to fill out a questionnaire at hospital discharge to evaluate patient reported outcomes across cardiac diagnostic groups.

Results

A total of 34,564 patients were discharged from April 15th 2013 to April 15th 2014. Most, 33,060 were eligible and 16,712 patients completed the questionnaire, Fig. 1. The response rate was 51%.

Discussion

In summary, statistically significant differences were found in all patient reported outcomes across diagnostic groups. Listed from worst to best patient reported outcomes were heart failure, heart valve disease, ischemic heart disease, infectious heart disease, arrhythmia, congenital heart disease and heart transplant. The differences were very small and cannot be considered clinically relevant. Most diagnoses have similar scores with proportions of depression and anxiety around 20–30%.

Contributors

SKB conceived the idea for the study. All designed the study. KJ, OE and AVC performed the statistical analyses. SKB and AVC wrote the first draft of the manuscript. All revised the manuscript critically. All have given their final approval of the version to be published.

Acknowledgements

We would like to express our gratitude to the patients who took the time to participate in the survey. We would also like to thank the 800 cardiac nurses involved in the data collection and the Heart Centres: Rigshospitalet, Gentofte Hospital, Odense University Hospital, Aarhus University Hospital and Aalborg University Hospital for prioritizing this study in a busy clinic. Furthermore, we would like to acknowledge the DenHeart research expert committee for its guidance. The study was funded by

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    Conflicts of interest and sources of funding: The study was funded by the Danish Heart Centres and the Novo Nordisk Foundation (NNF13OC0007229). The research presented was investigator initiated. The study funders played no role in the study. The authors report no conflicts of interest.

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