Magnitude of change in quality of life 60 days after discharge identifies patients at very high risk of readmission or death following hospitalisation for heart failure
M McGinlay, M J E Visser, X Wang, E M Ketiar, D H Wessels, K K Witte, J Gierula, M T KearneyAbstract
Background
Chronic heart failure (HF) remains a major global health challenge and despite advances in therapy, high rates of rehospitalisation persist. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a patient-reported outcome measure used to evaluate symptoms, functional status, and quality of life in patients with HF where a ≥5-point increase reflects a small meaningful change. It has been demonstrated that the KCCQ has prognostic value in predicting risk of re-hospitalisation or death.
Purpose
To determine an association between the magnitude of change in KCCQ scores at 60 days post-discharge and the risk of subsequent readmission or death in patients with an unplanned HF admission.
Methods
A prospective cohort study of unselected patients admitted to secondary care with HF. KCCQ scores were obtained at baseline and 60 days post-discharge. KCCQ change score was analysed as an ordinal categorical variable (predefined 10-point groups) to evaluate its association with all-cause readmission, all-cause mortality, and a composite endpoint of readmission or death. Group differences were assessed using chi-square tests, and linear trends across ordered KCCQ categories were evaluated using the Cochran–Armitage trend test. For readmission and mortality individually, KCCQ change was additionally modelled as a continuous variable using restricted cubic splines in logistic regression. Overall associations were assessed using Type 3 Wald tests, and evidence of non-linearity evaluated by examining higher-order spline terms. Model discrimination was quantified using the c-statistic. A two-sided p-value < 0.05 was considered statistically significant.
Results
Among 338 patients, 144 (42.6%) experienced all-cause readmission, 54 (16.0%) died, and 161 (47.6%) experienced the composite outcome of readmission or death. For the composite outcome of readmission or mortality, event rates declined significantly across increasing ΔKCCQ categories, from 72.5% in the 0–9 group to 29.4% in the 90–100 group (p < 0.0001). Higher KCCQ improvement was associated with lower risk of all three outcomes. In categorical analyses, significant graded relationships were observed for readmission (χ² p = 0.0205), mortality (χ² p = 0.0042), and the composite endpoint (χ² p = 0.0056). Linear trend testing using the Cochran–Armitage trend test was significant for readmission (p < 0.0001), mortality (p = 0.0003), and the composite outcome (p < 0.0001). In restricted cubic spline logistic regression, KCCQ change was significantly associated with readmission (p = 0.0012) and mortality (p = 0.0166), with no evidence of non-linearity for either outcome. Model discrimination was modest (c-statistics 0.63 for readmission and 0.66 for mortality).
Conclusion
The risk of rehospitalisation and death is highest among patients who report only small or no improvement in their health status and quality of life 60 days following a HF hospitalisation.Figure 1Table 1