Changing preferences for survival after hospitalization with advanced heart failure.
OBJECTIVE
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.
Stevenson
Lynne W
LW
Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. LStevenson@partners.org
Hellkamp
Anne S
AS
Leier
Carl V
CV
Sopko
George
G
Koelling
Todd
T
Warnica
J Wayne
JW
Abraham
William T
WT
Kasper
Edward K
EK
Rogers
Joseph G
JG
Califf
Robert M
RM
Schramm
Elizabeth E
EE
O'Connor
Christopher M
CM
D000203:Activities of Daily Living; D000368:Aged; D001293:Attitude to Death; D002407:Catheterization, Swan-Ganz / Q000401:mortality; D015331:Cohort Studies; D003266:Continuity of Patient Care; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D017060:Patient Satisfaction; D011336:Probability; D011379:Prognosis; D011788:Quality of Life / Q000523:psychology*; D019057:Quality-Adjusted Life Years; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires; D013997:Time Factors