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Characteristics and Outcomes of Patients With Advanced Chronic Systolic Heart Failure Receiving Care at the Veterans Affairs vs. Other Hospitals: Insights From the BEST Trial | Journal Scan
Study Questions:
What are the characteristics and outcomes of patients with advanced chronic systolic heart failure (HF) receiving care at Veterans Affairs (VA) versus non-VA hospitals?
Methods:
The study cohort was comprised of 2,707 chronic systolic HF patients enrolled in the BEST (Beta-Blocker Evaluation of Survival Trial) study, of whom 1,353 were randomized to bucindolol and 1,354 to placebo. The patients were enrolled in this study between 1995 and 1999. A total of 918 patients were from VA hospitals (98% men; n = 898) and 1,789 were from non-VA hospitals (68% men; n = 1,216), and the study authors limited their analyses to the 2,114 male patients.
Results:
The investigators found that VA patients were older, with higher symptom and comorbidity burdens. They found no significant difference between the two groups of patients in the unadjusted primary endpoint of 2-year all-cause mortality (35% VA vs. 32% non-VA; hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.94-1.26), and these data remained unchanged after adjusting for age and race (HR, 0.94; 95% CI, 0.80-1.10). They found no differences between groups with regard to cause-specific mortalities or hospitalizations. Significant predictors of mortality in both groups were chronic kidney disease, pulmonary edema, left ventricular ejection fraction <20%, and peripheral arterial disease. At non-VA hospitals, higher mortality was associated with African-American race, New York Heart Association class IV symptoms, atrial fibrillation, and right ventricular ejection fraction <20%; and these differences were not significantly different from VA hospitals.
Conclusions:
The authors concluded that systolic HF patients receiving care at VA hospitals were older and sicker; yet their risk of mortality and hospitalizations was similar to those younger and healthier receiving care at non-VA hospitals.
Perspective:
This important study with data from the past suggests that the outcomes in systolic HF patients belonging to New York Heart Association class III/IV in VA hospitals are comparable to the non-VA hospitals during the time period of 1995-1999. These data are from the time period when beta-blockers, aldosterone antagonists, hydralazine and nitrate combination, and implantable cardioverter-defibrillators and cardiac resynchronization therapy were not a part of mainstream management of HF. Ongoing studies are needed to examine whether changing demographics including the burden of atrial fibrillation, cardiorenal syndrome, sleep apnea, increasing right ventricular involvement, etc., and consequently changing natural history are having a differential impact of the management of systolic HF in VA and non-VA hospitals.
Keywords: Adrenergic beta-Antagonists, Atrial Fibrillation, Comorbidity, Cost of Illness, Heart Failure, Systolic, Hospitalization, Peripheral Arterial Disease, Propanolamines, Pulmonary Edema, Renal Insufficiency, Stroke Volume, Veterans
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