Identification of Older Patients with Heart Failure Who May Be Candidates for Hospice Care: Development of a Simple Four‐Item Risk Score

Abstract

OBJECTIVES: To identify predictors of 6-month mortality in older patients with heart failure (HF) and to develop a risk score for identifying potential candidates for hospice care. DESIGN: Secondary data analysis of a previously conducted randomized, clinical trial. SETTING: Barnes-Jewish Hospital, St. Louis, Missouri. PARTICIPANTS: Two hundred eighty-two patients with HF aged 70 and older. INTERVENTION: Participants were randomized to conventional care or a multidisciplinary intervention designed to reduce rehospitalization. MEASUREMENTS: All-cause 6-month mortality. RESULTS: Patients were followed for up to 14 years; 43 (15.2%) died within 6 months of hospital discharge. Multivariate logistic regression analysis identified four independent predictors of 6-month mortality: serum urea nitrogen of 30 mg/dL or greater (odds ratio (OR)=5.78, 95% confidence interval (CI)=2.65-12.66), systolic blood pressure less than 120 mmHg (OR=4.81, 95% CI=1.94-11.91), peripheral arterial disease (OR=3.09, 95% CI=1.26-7.58), and serum sodium less than 135 mEq/L (OR=2.27, 95% CI=0.98-5.27). Patients were stratified into four risk groups based on the presence or absence of these four risk factors. Six-month mortality rates for patients with zero, one, two, or three or more risk factors were 3.7%, 16.3%, 41.0%, and 66.7%, respectively (P<.05). The presence of three or more risk factors was associated with a positive predictive value of 66.7% and a negative predictive value of 86.4%. CONCLUSION: Although additional studies are needed, these findings suggest that a simple four-item risk score can identify older patients with HF at high risk of dying within 6 months. This may enable clinicians to better advise patients about prognosis, adjust management accordingly, and if appropriate, facilitate referral for hospice care. Conversely, patients with a more-favorable prognosis may be suitable candidates for more-aggressive interventions.