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Survival after initial hospitalisation for heart failure: a multilevel analysis of patients in Swedish acute care hospitals
  1. J Merloa,b,
  2. P-O Östergrena,
  3. K Bromsc,
  4. A Bjorck-Linnéa,
  5. H Liedholma
  1. aDepartment of Community Medicine, Malmö University Hospital, Lund University, Malmö, Sweden, bThe NEPI Foundation, Medical Research Centre, Malmö, Sweden, cDepartment of Cardiology, Malmö University Hospital, Lund University, Malmö, Sweden
  1. Dr Merlo, Department of Community Medicine , Malmö University, Hospital, S-205 02 Malmö, Sweden (Juan.Merlo{at}


STUDY OBJECTIVE Although national variation in short-term prognosis (that is, 30 day mortality) after a patient's first hospitalisation for heart failure may depend on individual differences between patients, dissimilarities in hospital practices may also influence prognosis. This study, therefore, sought to disentangle patient determinants from institutional factors that might explain such variation.

DESIGN A multilevel logistic regression modelling was performed with patients (1st level) nested in hospitals (2nd level). Institutional effects (that is, 2nd level variance and intra-hospital correlation) were calculated unadjusted and adjusted for specific patient (that is, age and previous diseases) and institutional (that is, size of hospital) characteristics. Patients were followed up until death or 30 days from hospital admission.

SETTING Hospitals in Sweden.

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 Sweden during the period 1992–1995 for their first hospitalisation attributable to heart failure.

MAIN RESULTS Patient age and previous diseases (particularly senile dementia) were major determinants of impaired prognosis. Institutional factors explained only 1.6% and 2.3% of the total variation in 30 day mortality in men and women, respectively. These modest institutional effects remained after adjusting for patient age and previous diseases, but were in part explained by hospital size.

CONCLUSIONS National variation in short-term prognosis after an initial hospitalisation for heart failure was mainly explained by differences between 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 individual prognosis).

  • heart failure
  • health care evaluation

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  • Funding: this study was supported by the NEPI Foundation; an ALF-Government Grant (Dnr M: E 39 390/98, Dr. Juan Merlo), and by the National Institute for Public Health.

  • Conflicts of interest: none.