A study of the contemporary profile, clinical outcomes and economic burden of acute heart failure in Abeokuta, Nigeria

Abstract

Background Heart failure has become a global public health issue because of the rising global burden, high cost of care, frequent rehospitalisation and poor prognosis. Compared to other regions of the world, there are limited data on contemporary clinical profile, outcome, and economic cost of heart failure in Sub-Saharan Africa in general and Nigeria (Africa’s most populous country) in particular. We examined these in patients admitted with acute heart failure to a tertiary hospital in Nigeria. Methods This was a hospital based, prospective, observational study conducted at the Federal Medical Centre, Idi-Aba, Abeokuta, Nigeria. Detailed clinical documentation on cases of acute heart failure was carried out. The following data were obtained: demographic data, pre-admission history (previous heart failure related admissions). Others include NYHA functional class, symptoms, signs, self-reported cardiovascular risk factors, aetiology of heart failure, precipitating factors, co-morbidities, blood investigations, 12-lead ECG, echocardiography, medications and intra-hospital and 6-month outcomes. The study cohort was prospectively followed up for 6 months post initial hospitalisation. The subjects were contacted through clinic visits or telephone calls at one and six months. Information obtained during follow-up included their wellbeing, prescribed pharmacotherapy, history of re-hospitalization and deaths (from next of kin if they died at home). In addition to patient or relation’s telephone interviews, where necessary referring physicians were contacted for additional information. The following health outcomes were documented - 1) length of initial hospital stay (LoS) in days, 2) survival status on discharge (dead or alive), 3) short-term case-fatality (30 days), 4) medium-term case-fatality (180 days), and 5) re-hospitalization status (180 days) Heath economic data were extracted from the registry. Outpatient and inpatient costs were computed from the cohort of HF cases admitted in 2010 including personnel, diagnostic and treatment resources used for their management over a 12-month period. Indirect costs were also calculated. The annual cost per person was then calculated. Results The mean age of the subjects was 56.6±15.3 years (57.3±13.4 for men, 55.7±17.1 for women) and 204 (45.1%) were women. Overall, 415 (91.8%) subjects presented with de novo acute heart failure. The most common risk factor for HF was hypertension (pre-existing in 64.3% of cases). Type 2 diabetes mellitus was present in 41(10.0%). Hypertensive HF was the commonest aetiological cause of heart failure being responsible for 78.5% of cases. Dilated cardiomyopathy (7.5%), cor-pulmonale (4.4%), pericardial disease (3.3%), rheumatic heart disease (2.4%) and ischemic heart disease were less common (0.4%) causes. The majority (71.2%) of subjects presented with left ventricular dysfunction (mean left ventricular ejection fraction 43.9 ± 9.0%) and valvular dysfunction and abnormal left ventricular geometry were frequently documented. Mean duration of hospital stay was 11.4± 9.1 days and intra-hospital mortality was 3.8%. Case fatality at 30-days was 4.2% (95%CI, 2.4-7.3%) for the cohort of newly presenting acute HF subjects that were followed up [3.9% (95%CI, 1.7-8.5%) in men and 4.5% (95%CI 2.1-9.3%) in women]. At 180-days, case-fatality was 7.3% (95%CI, 4.7-11.2%) [7.1% (95%CI, 3.8-12.7%) in men and 7.5% (95%CI 3.9-14.0%) for women] Patients with pericardial diseases had the highest early mortality. Mortality was related to some socio-demographic and clinical characteristics. Thirty two denovo HF subjects (12.2%) were rehospitalised at least once. There were 21 men (65.6%) and 11(34.4%) women. Worsening heart failure was the commonest reason for readmission. Among others, factors associated with rehospitalization include presence of mitral regurgitation (OR, 2.37; 95%CI, 1.26-4.46), age greater than 60 years (OR, 2.04; 95%CI, 0.96-3.29), presence of tricuspid regurgitation (OR, 1.77; 95% CI, 0.86-3.61), and presence of atrial fibrillation (OR, 1.34; 95%CI, 0.59-3.03). The total computed cost of care of HF in Abeokuta was 76, 288,845 Naira (US$508, 595) translating to 319,200 Naira (US$2,128 US Dollars) per patient per year. Inpatient and outpatient care contributed 46% and 54% of total cost respectively. The high cost of outpatient care was largely due to cost of transportation for monthly follow up visits. Payments were mostly made through out-of-pocket spending. Conclusions Compared to high income countries, individuals presenting with AHF in Abeokuta, Nigeria are relatively younger and still of a working age. It is also commoner in men and associated with severe symptoms because of late presentation. Intra-hospital mortality is similar to other parts of the world. Rehospitalization after admission for HF is relatively common within 6-months. The economic burden of heart failure in the study setting is high considering the minimum wage of 18,000 Naira (120 US dollars) per month in the country. This calls for financing reforms for the control of the disease, which may include a reduction or waiver of user fees in government hospitals, scaling up of financial risk protection pre-payment mechanisms such as health insurance and use of primary healthcare centres for follow-up visits for mild cases. The development and adequate funding of community HF care programmes in the country is also a possible panacea.