Assessing appropriateness of treatment: a case study of transplantation in older patients with congestive heart failure.
OBJECTIVE
To evaluate the appropriateness of transplantation therapy for older patients with congestive heart failure (CHF).


METHODS
Comparative review of contemporary survival and quality of life data of CHF patients treated medically versus by transplantation.


RESULTS
Approximately 300,000 Canadians have CHF and the incidence is increasing as the population ages; suitable donor allografts are found for about 300 CHF patients each year. Overall survival among cardiac allograft recipients, with a mean age of 48 years, is approximately 80% at two years. However, risk from all causes appears higher, and survival lower (range 40 to 78%), for transplant patients 55 years of age and older. Among medically treated patients, with mean age over 60 years, survival is inversely related to level of functional disability, averaging more than 90% at two years for patients with mild limitation and decreasing to 75% and 40% for patients with moderate and severe symptoms, respectively. Perceived quality of life is low in all CHF patients, but is significantly improved by intense out-patient care and education, irrespective of medical or transplant allocation.


CONCLUSIONS
Among adults with CHF, the greatest benefit of transplantation is enhanced survival in younger severely disabled patients. However, noncardiac risks are substantial, particularly for older recipients. The great discrepancy between donor and candidate availability prohibits transplantation from being a life expanding therapy for the whole CHF population. When physicians are, simultaneously, patients' and society's advocates a utilitarian decision model using the totality of efficacy data, including degree of efficacy and population effectiveness, may assist determination of the most appropriate therapy.
Montague
T
T
Department of Medicine, University of Alberta, Edmonton. TMJ@tachy.uah.ualberta.ca
Barnes
M
M
Taylor
L
L
Ignaszewski
A
A
Modry
D
D
Wensel
R
R
Humen
D
D
Teo
K
K
D000203:Activities of Daily Living; D000368:Aged; D002170:Canada / Q000453:epidemiology; D003661:Decision Support Techniques; D015577:Geriatric Assessment; D015276:Health Care Rationing; D006333:Heart Failure / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation; D006801:Humans; D015993:Life Tables; D008875:Middle Aged; D018579:Patient Selection; D011788:Quality of Life; D015996:Survival Rate; D016896:Treatment Outcome