The science of quality-of-life-directed care!

A spirations have no limit, barring reality. The obstacles imposed by reality to temper aspirations can be divided into 3 categories. First are those obstacles that are not negotiable (eg, 24 hours in a day, we all must die). Second are those that are negotiable, easily or with difficulty, but come at an acceptable opportunity cost. Such obstacles often are the foundation of aspirations and inspirations alike; examples of achievements in medicine and elsewhere overcoming them are too numerous to illustrate. Third are those that are negotiable but come only at a high opportunity cost. Here, the devil really does lie in the details, because the definition of opportunity cost is not absolute; hence, the debate. Let us examine the article by Allen et al 1 in the current issue of Circulation: Cardiovascular Quality and Outcomes in this framework. The primary concern of healthcare providers is to deliver the best treatment to all patients, with an aim to extend longevity and improve quality of life. This concern is even more important for patients with chronic diseases. During the past 2 decades, several drugs and devices have been shown to improve mortality risk from heart failure with depressed ejection fraction. 2– 4 Allen and colleagues 1 very nobly contend that mortality should not be the only outcome that we focus on, and that improving quality of life should be an important aim. How can one disagree with this assertion? To help to achieve this goal, the authors assessed the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan) trial database 5 to identify factors related to 6-month mortality or unfavorable quality of life (defined as Kansas City Cardiomyopathy Questionnaire scores Ͻ45) after discharge for decompensated heart failure. As might be expected from a large data set analysis, several variables related to the defined outcome were identified. A risk score was developed that had moderate discrimination (C statistic, 0.72). In a parallel analysis, the authors highlight the fact that the predictors of quality of life were different from those for death or rehospitalization. They conclude that routine clinical characteristics are associated with risk for persistently unfavorable quality of life or death. Interesting, they also conclude that, " such information can target patients for whom aggressive treatment options (eg, devices or transplantation), and end-of-life discussions should be strongly considered before discharge. " The first part of the conclusion is a …