Kraai IH, Vermeulen KM, Luttik ML et al.
Eur J Heart Fail. 2013 May 5.

Background

Only few studies addressing patient preferences have been performed in the field of cardiology. Although cardiovascular trials are often set up to measure endpoints such as mortality and re-hospitalisation, the treatment of heart failure (HF) is aimed at the relief of symptoms and improvement of health-related quality of life (HR-QoL).
HR-QoL is reduced in HF patients as compared to a normative population in the community [1], or to patients suffering from other chronic diseases [2]. Moreover, reduced HR-QoL predicts adverse prognosis in patients with chronic HF [3].
It is not well known which factors contribute to HF patients’ preferences on quality of life and longevity. The utility approach is a patient-centered method to determine patient preferences. The utility approach combines mortality, morbidity and treatment regimen into a single score. QoL or longevity preferences of outpatients were assessed with the TTO approach [4], which offers patients 2 alternatives, namely 1) current health state for time t or 2) perfect health for time x<t. In a verbal interview, x is varied until the patient shows indifference for either of the two alternatives. A score for utility is given based on the extent to which an outcome is preferable. 100 Dutch HF patients with mean age 70 years were included.

Main results

• 61% of patients were willing to trade time for QoL, with a large variability in the traded amount of time. 9% and 14% of patients were willing to trade 6 and 12 months respectively for perfect health , thus preferred quality of life. 23% wanted to trade at least 2.5 years for perfect health.
• Patients willing to trade time had significantly higher NT-proBNP-levels (1540 vs. 923 µg/L, P=0.042) and reported more dyspnoea during exertion (64% vs 44%, P=0.046).
• Patients with a low utility score more often showed symptoms such as dyspnoea during rest or exertion, and tiredness, as compared to patients with a higher utility score. Patients with a low utility score also had lower disease-specific HR-QoL and lower generic HR-QoL.
• Life expectancy as estimated by the patients was not different between those willing to trade time and those unwilling to trade time, nor between the groups with different utility scores.

Conclusion

This is the first European study that investigates patient preferences in routine care. A majority of patients (61%) indicated that they find quality of life more important than longevity, which confirms the belief that HF patients are willing to trade time for in improvement in health status. Although certain clinical symptoms were associated with more willingness to trade time, it cannot be assumed that patients with several symptoms always prefer QoL over longevity, thus no specific profile can be delineated that identifies patients willing to trade time.
In order to be able to deliver optimal care to HF patients, it is vital to know the patient’s preferences with respect to QoL or longevity. Preferences may change over time, thus adequate and regular assessment of the subject is required. 

References

1. Lesman-Leegte I, Jaarsma T, Coyne JC, et al. Quality of life and depressive symptoms in the elderly: a comparison between patients with heart failure and age- and gender-matched community controls.
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2. Juenger J, Schellberg D, Kraemer S, et al. Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables. Heart 2002;
87:235–241.
3. Mommersteeg PM, Denollet J, Spertus JA, Pedersen SS. Health status as a risk factor in cardiovascular disease: a systematic review of current evidence. Am Heart J 2009; 157:208–218.
4. Torrance GW. Utility approach to measuring health-related quality of life. J Chronic Dis 1987;40:593–603.

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