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

Bao C. Huynh, MD, PharmD, Aleksandr Rovner, MD, and Michael W. Rich, MD

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. J Am Geriatr Soc 2008;56(6):1111-1115.

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CLINICAL INVESTIGATIONS

Single-Point Assessment of Warfarin Use and Risk of Osteoporosis in Elderly Men

Claudine Woo, PhD, Linda L. Chang, PharmD, Susan K. Ewing, MS, and Douglas C. Bauer, MD, for the Osteoporotic Fractures in Men Study Group

OBJECTIVES: To determine whether warfarin use, assessed at a single point in time, is associated with bone mineral density (BMD), rates of bone loss, and fracture risk in older men.

DESIGN: Secondary analysis of data from a prospective cohort study.

SETTING: Six U.S. clinical centers.

PARTICIPANTS: Five thousand five hundred thirty-three community-dwelling, ambulatory men aged 65 and older with baseline warfarin use data.

MEASUREMENTS: Warfarin use was assessed as current use of warfarin at baseline using an electronic medication coding dictionary. BMD was measured at the hip and spine at baseline, and hip BMD was repeated at a follow-up visit 3.4 years later. Self-reported nonspine fractures were centrally adjudicated.

RESULTS: At baseline, the average age of the participants was 73.6 ± 5.9, and 321 (5.8%) were taking warfarin. Warfarin users had similar baseline BMD as nonusers (n=5,212) at the hip and spine (total hip 0.966 ± 0.008 vs 0.959 ± 0.002 g/cm2, P=.37; total spine 1.079 ± 0.010 vs 1.074 ± 0.003 g/cm2, P=.64). Of subjects with BMD at both visits, warfarin users (n=150) also had similar annualized bone loss at the total hip as nonusers (n=2,683) (−0.509 ± 0.082 vs −0.421 ± 0.019%/year, P=.29). During a mean follow-up of 5.1 years, the risk of nonspine fracture was similar in warfarin users and nonusers (adjusted hazard ratio=1.06, 95% confidence interval=0.68–1.65).

CONCLUSION: In this cohort of elderly men, current warfarin use was not associated with lower BMD, accelerated bone loss, or higher nonspine fracture risk. J Am Geriatr Soc 2008;56(7):1171-1176.