Center for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd. 111-G, Los Angeles, CA 90064, USA.
J Gen Intern Med. 2012 May;27(5):513-9. doi: 10.1007/s11606-011-1930-3. Epub 2011 Nov 18.
Care for patients with advanced heart failure (HF) has traditionally focused on managing HF alone; however, little is known about the prevalence and contribution of comorbidity to mortality among this population. We compared the impact of comorbidity on mortality in older adults with HF with high mortality risk and those with lower mortality risk, as defined by presence or absence of a prior hospitalization for HF, respectively.
This was a retrospective cohort study (2002-2006) of 18,322 age-matched and gender-matched Medicare beneficiaries. We used the baseline year of 2002 to ascertain HF hospitalization history, in order to identify beneficiaries at either high or low risk of future HF mortality. We calculated the prevalence of 19 comorbidities and overall comorbidity burden, defined as a count of conditions, among both high and low risk beneficiaries, in 2002. Proportional hazards regressions were used to determine the effect of individual comorbidity and comorbidity burden on mortality between 2002 and 2006 among both groups.
Most comorbidities were significantly more prevalent among hospitalized versus non-hospitalized beneficiaries; myocardial infarction, atrial fibrillation, kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and hip fracture were more than twice as prevalent in the hospitalized group. Among hospitalized beneficiaries, myocardial infarction, diabetes, COPD, CKD, dementia, depression, hip fracture, stroke, colorectal cancer and lung cancer were each significantly associated with increased hazard of dying (hazard ratios [HRs]: 1.16-1.93), adjusting for age, gender and race. The mortality risk associated with most comorbidities was higher among non-hospitalized beneficiaries (HRs: 1.32-3.78).
Comorbidity confers a significantly increased mortality risk even among older adults with an overall high mortality risk due to HF. Clinicians who routinely care for this population should consider the impact of comorbidity on outcomes in their overall management of HF. Such information may also be useful when considering the risks and benefits of aggressive, high-intensity life-prolonging interventions.
传统上，对晚期心力衰竭（HF）患者的护理主要集中在单独管理 HF 上；然而，对于该人群中合并症对死亡率的影响知之甚少。我们比较了在 HF 死亡率高和死亡率低的老年人中，合并症对死亡率的影响，分别以是否存在 HF 住院史来定义。
这是一项回顾性队列研究（2002-2006 年），纳入了 18322 名年龄和性别匹配的 Medicare 受益人。我们使用 2002 年的基线年来确定 HF 住院史，以确定未来 HF 死亡率高或低风险的受益人。我们计算了在高风险和低风险受益人中，2002 年 19 种合并症的患病率和总体合并症负担，即疾病数量。比例风险回归用于确定两组人群中 2002 年至 2006 年期间，个体合并症和合并症负担对死亡率的影响。
大多数合并症在住院患者中明显比非住院患者更常见；心肌梗死、心房颤动、肾脏疾病（CKD）、慢性阻塞性肺疾病（COPD）和髋部骨折在住院组中患病率超过两倍。在住院患者中，心肌梗死、糖尿病、COPD、CKD、痴呆、抑郁、髋部骨折、中风、结直肠癌和肺癌与死亡风险增加显著相关（风险比[HR]：1.16-1.93），调整了年龄、性别和种族因素。在非住院患者中，大多数合并症的死亡率风险更高（HR：1.32-3.78）。
即使在 HF 死亡率总体较高的老年人中，合并症也会显著增加死亡率风险。常规护理该人群的临床医生应考虑合并症对其 HF 整体管理结果的影响。在考虑积极、高强度的延长生命干预措施的风险和益处时，此类信息也可能有用。
