Quality of life in heart failure: screening alone is insufficient

This editorial refers to ‘Does heart-failure specific health status identify patients with bothersome symptoms, depression, anxiety, and/or poorer spiritual well-being?’ by K. Flint et al., doi:10.1093/ehjqcco/qcy061. In recent years, patient-reported outcomes, such as quality of life (QoL), have increasingly been recommended as critical components of cardiovascular research and care. Although cardiovascular research is incorporating patient-reported outcomes more readily, debate over the clinical utility of this information has delayed integration into care. This has been the case for assessment of QoL in patients with heart failure (HF), which is often severely impaired even when compared to patients with other chronic diseases.1,2 Patients with poor QoL may experience a range of symptoms, such as pain, sleep problems, depression, and anxiety; thereby limiting their engagement in activities.3 Ultimately, poor QoL in patients with HF is linked to negative clinical outcomes, including high rates of hospitalization and mortality.4,5 Therefore, screening for QoL deficits is of critical importance to HF care. Yet, given the complexity of HF care, limited time and resources, and the lack of clinical utility for HF-specific QoL measures, assessment of this domain in patients with HF is often neglected. Flint et al.6 sought to address several of these concerns in their study by exploring the association between responses on the short form of the Kansas City Cardiomyopathy Questionnaire (KCCQ) and QoL domain deficits (bothersome symptoms, depression, anxiety, and spiritual well-being), and examining the KCCQ as a screener for these deficits. Results showed that QoL domains were significantly associated with KCCQ score. Additionally, the authors found that a KCCQ threshold of ≤60 had high sensitivity for each QoL domain and was able to meaningfully identify patients who would benefit from additional QoL assessment. These findings suggest that the KCCQ can be used to screen for QoL deficits in HF. While this study by Flint et al. addresses some of the key criticisms about QoL assessment in the HF population, there remains important issues and practical implications that future research must address, including: (i) the clinical utility of the KCCQ as a screener for QoL deficits; (ii) the effects of treating QoL deficits on clinical outcomes; and (iii) resources needed to treat patients with QoL deficits.6 A common criticism related to patient-reported outcomes, such as QoL, is the clinical utility of measuring these outcomes. Clinician responses to elevated scores are of particular concern. The identification of a threshold score signalling the need for further assessment, as explored by Flint et al., in part addresses this concern. Yet, although the KCCQ threshold score of ≤60 was found to be highly sensitive, the authors noted the importance of tailoring the KCCQ threshold to different clinical settings and HF populations.6 This is especially important given that the population under investigation in the study was recruited because of low KCCQ scores, which limits generalization of results to other HF populations, a limitation acknowledged by the authors. Evidence indicates that QoL decreases across New York Heart Association (NYHA) classes, and therefore, it is likely that the threshold score on the KCCQ will vary depending on NYHA class and HF symptom severity.7 Future research is needed to examine the sensitivity and specificity of the KCCQ in detecting QoL deficits in a more representative HF population and to determine best practices for clinician responses to elevated scores. An additional issue that the study by Flint et al.6 was not designed to address, but that is critical for future research to examine is the effects of screening for and treating QoL deficits on clinical outcomes. Currently, there is limited evidence that improvements in QoL deficits may affect clinical outcomes, such as hospitalization and mortality rates. Despite the limited evidence, the assessment and management of QoL is recommended by several professional organizations.8–10 These recommendations are similar to guidelines supporting the screening and treatment of depression in patients with coronary heart disease (CHD).11 Although evidence suggests that treatment can improve depressive symptoms, there is limited evidence of improvements in clinical outcomes in CHD. Similarly, despite the effects of QoL deficits on clinical outcomes in HF, there is limited evidence that improvements in QoL domains, such as depression, are associated with better clinical outcomes in HF. Therefore, more research is needed to justify the screening and treatment of QoL deficits in HF. Furthermore, there are practical implications to consider when screening patients for QoL deficits. As the authors acknowledged, the threshold score on the KCCQ may need to be adjusted, in part, depending on the availability of resources in clinics.6 This is especially important to consider as patients with HF already report limited access to healthcare services. Given that patients with HF have limited access to healthcare services; it is unlikely that healthcare systems will be prepared to address these QoL deficits. Further, although the effects of treatment of QoL deficits on clinical outcomes is unknown, treatment is likely to improve patient-reported outcomes, including depression and anxiety. Healthcare systems will therefore need to mobilize resources to screen for and treat QoL deficits. In conclusion, the research by Flint et al.6 is encouraging as it shows that the KCCQ is a time-efficient method of screening for QoL deficits in patients with HF. Considering that the assessment of patient-reported outcomes, such as health status and QoL, is recommended by several professional organizations, it is critical to demonstrate the clinical utility of patient-reported outcomes to increase their integration into clinical care. Important questions concerning the generalizability of the KCCQ threshold score; the effects of screening for and treating QoL deficits, and the resources needed to treat these deficits remain. Conflict of interest: none declared. The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal – Quality of Care and Clinical Outcomes or of the European Society of Cardiology.