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Discordance Between Patient-Predicted and Model-Predicted Life Expectancy Among Ambulatory Patients With Heart Failure
Larry A. Allen, MD, MHS;
Jonathan E. Yager, MD;
Michele Jonsson Funk, PhD;
Wayne C. Levy, MD;
James A. Tulsky, MD;
Margaret T. Bowers, RN, MSN;
Gwen C. Dodson, RN, MSN;
Christopher M. O’Connor, MD;
G. Michael Felker, MD, MHS
JAMA. 2008;299(21):2533-2542.
Context Patients with chronic heart failure have impaired long-term survival, but their own expectations regarding prognosis have not been well studied.
Objectives To quantify expectations for survival in patients with heart failure, to compare patient expectations to model predictions, and to identify factors associated with discrepancies between patient-predicted and model-predicted prognosis.
Design, Setting, and Participants Prospective face-to-face survey of patients from the single-center Duke Heart Failure Disease Management Program between July and December 2004, with follow-up through February 2008. Patient-predicted life expectancy was obtained using a visual analog scale. Model-predicted life expectancy was calculated using the Seattle Heart Failure Model. Actuarial-predicted life expectancy, based on age and sex alone, was calculated using life tables. Observed survival was determined from review of medical records and search of the Social Security Death Index.
Main Outcome Measure Life expectancy ratio (LER), defined as the ratio of patient-predicted to model-predicted life expectancy.
Results The cohort consisted of 122 patients (mean age, 62 years; 47% African American, 42% New York Heart Association [NYHA] class III or IV). On average, patients overestimated their life expectancy relative to model-predicted life expectancy (median patient-predicted life expectancy, 13.0 years; model-predicted expectancy, 10.0 years). Median LER was 1.4 (interquartile range, 0.8-2.5). Younger age, increased NYHA class, lower ejection fraction, and less depression were the most significant predictors of higher LER. During a median follow-up of 3.1 years, 29% of the original cohort died. There was no association between higher LER and improved survival (adjusted hazard ratio for overestimated compared with concordant LER, 1.05; 95% confidence interval, 0.46-2.42).
Conclusions Ambulatory patients with heart failure tended to substantially overestimate their life expectancy compared with model-based predictions for survival. Because differences in perceived survival could affect decision making regarding advanced therapies and end-of-life planning, the causes of these discordant predictions warrant further study.
Author Affiliations: Duke Clinical Research Institute and Division of Cardiology (Drs Allen, O’Connor, and Felker and Mss Bowers and Dodson) and Center for Palliative Care and Division of General Internal Medicine (Dr Tulsky), Duke University Medical Center, Durham, North Carolina; Cardiac Care Associates, Fairfax, Virginia (Dr Yager); Department of Epidemiology, University of North Carolina, Chapel Hill (Dr Jonsson Funk); and Division of Cardiology, University of Washington, Seattle (Dr Levy).
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