Symptom Burden Among Patients Who Were Hospitalized for Heart Failure

Heart failure (HF) is a leading cause of 30-day readmission.¹ Missing from our understanding of decompensated HF is the range and natural history of the symptoms that affect patients. Residual symptoms are known to be a powerful driver of health care use after hospitalization for HF.² Intensive symptom management, including palliative care, may represent a promising approach to improving patient outcomes after hospitalization for HF. Our objectives were to evaluate the spectrum of symptoms experienced by patients hospitalized for HF, the improvement in symptoms after discharge, and patients’ perceptions of palliative care.

This was a prospective study of patients who were hospitalized for HF at Yale–New Haven Hospital. The study was conducted from August 21, 2013, through December 31, 2014. Institutional review board approval was given by Yale–New Haven Hospital and written patient consent was obtained. Patients were enrolled within 2 days of hospital admission and queried about symptoms using the Edmonton Symptom Assessment Scale during hospitalization and a follow-up telephone interview 1 week after discharge. This scale ranges from 0 to 10, with higher scores denoting greater severity. Severity ratings were compared between the in-hospital and postdischarge assessments to assess improvement in symptoms. Patients were also queried about existing knowledge of palliative care and interest in receiving palliative care services while hospitalized.

Ninety-one patients were enrolled. The mean (SD) time for the baseline interview was 2.5 (1.6) days after hospital admission. The mean (SD) time for the follow-up interview was 9.9 (4.3) days after hospital discharge. The patients’ mean (SD) age was 71.5 (12.6) years, 47 (52%) were female, and 68 (75%) had an ejection fraction of less than 50%.

The Table shows the patients’ symptom severity at baseline and follow-up as well as the percentage of patients who reported no improvement. Severe symptoms during hospitalization included symptoms that are traditionally associated with decompensated HF (decreased well-being, fatigue, and dyspnea) as well as those that are not (anxiety and pain). A lack of symptom improvement shortly after hospital discharge was common. A total of 49 patients (58%) reported no improvement in fatigue, 36 (42%) reported no improvement in dyspnea, 35 (41%) reported no improvement in pain, and 35 (41%) reported no improvement in anxiety.

While only 19 patients (22%) reported familiarity with palliative care, after a standardized explanation, 58 (68%) were interested in receiving palliative care services. Of those who were already familiar with palliative care, the perceptions about the types of services provided are shown in the Box.

Our findings suggest that patients who are hospitalized for HF often present with symptoms that are not traditionally associated with HF and that current management approaches may fail to adequately address symptoms. There may be several reasons for this failure. The existence of multiple comorbid medical conditions is common in aging patients with HF, and these comorbidities may contribute to symptoms and complicate management. Physicians who care for patients with HF in the hospital setting may not be prepared to thoroughly assess and treat symptoms such as pain, anxiety, depression, and fatigue.³ Finally, there is pressure on health systems to reduce patients’ lengths of stay. Once patients no longer meet the clinical criteria for hospitalization (eg, hypoxia or hemodynamic instability), there is an impetus for discharge even if troublesome symptoms persist.

The progressive nature of HF, coupled with high mortality rates and poor quality of life, make it suited for the incorporation of palliative care. Given that symptoms frequently drive health care use, early integration of palliative care may reduce readmissions. There have been numerous calls to include palliative care as a component of HF management, but fewer than 10% of patients with HF receive palliative care.^4,5 To our knowledge, this is the only study that included a longitudinal assessment of symptom burden during hospitalizations for HF and shortly after discharge. Future studies should evaluate whether palliative care is effective in reducing symptom burden and readmission among patients who are hospitalized for HF.

Corresponding Author: Sarwat I. Chaudhry, MD, Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, Harkness Office Bldg, 367 Cedar St, Room 416, PO Box 208088, New Haven, CT 06520.

Published Online: August 17, 2015. doi:10.1001/jamainternmed.2015.3871.

Author Contributions: Drs Khan and Chaudhry had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Khan, Chaudhry.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Khan, Chaudhry.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Khan, Chaudhry.

Obtained funding: Khan.

Administrative, technical, or material support: Khan, Chaudhry.

Study supervision: Chaudhry.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by a pilot grant from the National Palliative Care Research Center (Drs Chaudhry and Goldstein).

Role of the Funder/Sponsor: The National Palliative Care Research Center had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.