Survival after initial hospitalisation for heart failure: a multilevel analysis of patients in Swedish acute care hospitals

doi:10.1136/jech.55.5.323

Journal of Epidemiology and Community Health 2001;55:323-329; doi:10.1136/jech.55.5.323

J Epidemiol Community Health 2001;55:323-329 ( May )

Research report

Survival after initial hospitalisation for heart failure: a multilevel analysis of patients in Swedish acute care hospitals J Merlo^a ^b, P-O Östergren^a, K Broms^c, A Bjorck-Linné^a, H Liedholm^a

^a Department of Community Medicine, Malmö University Hospital, Lund University, Malmö, Sweden, ^b The NEPI Foundation, Medical Research Centre, Malmö, Sweden, ^c Department of Cardiology, Malmö University Hospital, Lund University, Malmö, Sweden

Correspondence to: Dr Merlo, Department of Community Medicine , Malmö University, Hospital, S-205 02 Malmö, Sweden (Juan.Merlo{at}smi.mas.lu.se)

Accepted for publication 4 December 2000

STUDY OBJECTIVE $---$ Although national variation in short-term prognosis (that is, 30 day mortality) after a patient's first hospitalisation forheart failure may depend on individual differences between patients,dissimilarities in hospital practices may also influence prognosis.This study, therefore, sought to disentangle patient determinantsfrom institutional factors that might explain suchvariation.
DESIGN $---$ A multilevel logistic regression modelling was performed with patients (1st level) nested in hospitals (2nd level). Institutionaleffects (that is, 2nd level variance and intra-hospital correlation)were calculated unadjusted and adjusted for specific patient (thatis, age and previous diseases) and institutional (that is, sizeof hospital) characteristics. Patients were followed up untildeath or 30 days from hospitaladmission.
SETTING $---$ Hospitals inSweden.
PATIENTS $---$ The study identified all the 20 420 men and 17 923 women (ages 65 to 85) admitted to the 90 acute care hospitals in Swedenduring the period 1992-1995 for their first hospitalisation attributableto heartfailure.
MAIN RESULTS $---$ Patient age and previous diseases (particularly senile dementia) were major determinants of impaired prognosis. Institutionalfactors explained only 1.6% and 2.3% of the total variation in30 day mortality in men and women, respectively. These modestinstitutional effects remained after adjusting for patient ageand previous diseases, but were in part explained by hospitalsize.
CONCLUSIONS $---$ National variation in short-term prognosis after an initial hospitalisation for heart failure was mainly explained by differencesbetween patients, with hospital factors playing a minor part.Of the latter, hospital size seemed to emerge as one determinant(that is, the greater the number of patients, the better the individualprognosis).

Keywords: heart failure; health care evaluation

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