Comparison of Days Alive Out of Hospital With Initial Invasive vs Conservative Management

Professor Harvey White, cardiologist and Director of the Cardiovascular Research Unit at Auckland City Hospital has just published in JAMA Cardiology simultaneously with presentation at the virtual American College of cardiology Meeting in Atlanta. The manuscript is from the NIH funded ISCHEMIA trial for which Professor White was on the steering committee and in which New Zealand randomized 28 patients.

The trial compared two strategies in 5179 patients with moderate to severe angina randomised to stenting or bypass surgery compared with medical therapy. At 4 years there was no difference in mortality rates but angina was decreased in the stenting or bypass surgery group.

In this study Professor White and colleagues measured a new patient focused outcome of Days Alive Out of Hospital. Days Alive Out of Hospital is valued enormously by patients. What is important to patients is spending more time at home with family and friends, in recreation, or at work. Patients don’t really want to spend time in hospitals with loss of independence and autonomy, perhaps the food may not be what the patient is used to having and now the risk of perhaps getting covid. For example, in a study where frail older patients were asked “what is most important to you?” what emerged was that they valued most “time spent at home” (Sayer C. Time Spent at Home” — A Patient-Defined Outcome.)

In this analysis all hospital and rest home stays and the number of days spent were counted which are reflective of the severity of a patient’s illness. The results show that patients having stenting or bypass surgery spent an extra six days in hospital or rest homes in the first 2 years. At 4 years there was a difference of 2.8 days favoring the medical group but that difference was not statistically significant. The incidence of heart attacks was reduced in the stenting and bypass surgery group equating to one fewer event per 45 patients at 4 years.

There is thus a tradeoff between more Days Alive Out of Hospital if patients are treated with medical therapy compared with fewer heart attacks if patients have stenting or bypass surgery. Individual patients may want different things. These findings should be incorporated into patient discussions and shared decision making as well as in future trials. Days Alive Out of Hospital could also be used in assessing quality of care for other diseases in New Zealand.

Article: Comparison of Days Alive Out of Hospital With Initial Invasive vs Conservative Management
Publication Date: 05-03-2021