General characteristics of patients with heart failure
This study found was found to be mostly similar with previous studies in patients with HF. For instance, women suffered from HF more than men (17-21). The mean age ranged from 60-67 years and more than 60% were married. Approximately three quarters used UHC coverage and had elementary educational attainment or below. The average income was less than 260 US$. Moreover, compared with the Thai ADHERE registry, the only published study on HF epidemiology in Thailand, the demographic data were similar in the current study (22). The majority of patients with HF in Thailand have been found to have low education, income, and used the UHC scheme.
However, our study provided more information regarding the changing of the community toward urbanization. Thai government administrations have traditionally invested and developed infrastructure mostly in urban areas such as Bangkok, with outlying provinces and rural communities significantly underfunded (23). As a result, many people migrate toward Bangkok to work and support their family members who are left behind in rural areas. Moreover, the family structure has changed from extended to nuclear families or single in Bangkok (24). Hence, the findings in our study aligned with the population structures in urban areas—that patients in super tertiary care were more likely to reside alone due to the high percentage of single, divorced, or widowed marital status compared with other tertiary care settings. However, patients in super tertiary care had higher educational attainment and income than tertiary care patients due to the opportunity to pursue higher education and higher paying jobs.
The Thai ADHERE registry (22) found that 66.5% of participants had a prior admission for HF while our study found 45.7%. The most common underlying diseases in the Thai ADHERE registry included ischemic heart disease, diabetes mellitus, chronic kidney disease, and previous stroke or transient ischemic attack, which concurred with our study. Previous studies have shown increasing risks of CVD among rural-urban migrants (24-27). Urban area residence and migrant lifetime exposure to urban environments were both related to greater odds of hypertension, diabetes, and overweight. These comorbidities can develop into HF in the future. Therefore, our study found that patients in super tertiary care had higher average Charlson comorbidity index scores than patients in tertiary care settings. Moreover, the prevalence of each comorbidity was also greater, such as the prevalence of HF, renal disease, malignancy, and diabetes.
Availability of modern technology, heart failure guidelines and specialist multidisciplinary teams
The super tertiary hospitals in Bangkok are some of the largest hospital systems in Thailand. Since the super tertiary hospitals provide advanced treatment, modern technology, evidence-based practice applying to routine care, and are excellent healthcare centers with specialized multidisciplinary teams, they are routinely referred to as “university hospitals.” These hospitals are equipped with the best resources in Thailand, considering that they are medical schools for teaching and research. Hence, healthcare providers in super tertiary care in this study were able to assess patients’ medical conditions with more advanced technology than tertiary care hospitals, such as echocardiography and coronary angiography. Patients in super tertiary hospitals were treated by modern technology and complicated treatments such as nitroglycerine and inotrope infusion, and invasive mechanical ventilation more than patients in the tertiary care hospitals. In addition, a higher percentage of patients in super tertiary care were treated by nominated general practitioners than in tertiary care hospitals.
According to HF guidelines, treating comorbidities are important in HF management (28). Poorly controlled comorbidities affect treatment of HF and worsen the symptoms. The current guidelines identify where the presence of HF should change the way a comorbidity would normally be treated. In this study, most of the admissions for HF were caused by ischemic heart disease. The guidelines recommend the use of a beta blocker as the first line drug to relieve symptoms and advise avoiding the use of calcium channel blockers in patients with ischemic heart disease. In addition, the treatment should focus on controlling blood pressure because hypertension is related to an increased risk of developing HF. ACE-inhibitors and beta blockers are recommended for controlling blood pressure and calcium channel blocker groups are to be avoided (28).
Both settings followed the HF guidelines by prescribing not only diuretics but also antihypertensive, lipid-lowering agents, and other medications for controlling comorbidities. Super tertiary hospitals prescribed more beta blockers, vasodilators, lipid-lowering agents, and nitrates than tertiary hospitals. The average total number of medications per day on discharge were higher in super tertiary care settings.
Both hospital groups had almost the same symptom severity such as low ejection fraction and HF stages and functional classifications; however, patients in super tertiary care had worse health outcomes than patients in tertiary care hospitals. Patients in super tertiary care were found to be more frail, depressed, and poorer functional status than patients in tertiary care. In addition, super tertiary care hospitals also had higher rates of death during hospitalization and rehospitalization after discharge and tended to live alone after discharge.
Our findings could be partially explained by changes in cultural values, family structure, and lifestyle. According to Thai culture, citizens live with extended family members who are often caregivers for the sick family members (29). In addition to assisting with healthcare needs, extended family members may also provide psychological, instrumental and informational social support in the form of preparing meals, reminding to take medication, supporting exercise and transferring to hospital (30). Urbanization has completely changed this culture. People in metropolitan areas now live alone or in nuclear families. As family members become more self-reliant, sick family members become vulnerable to adverse health outcomes.
Heart failure treatment, social determinants of health and health outcomes
Patients in super tertiary care are exposed to modern treatment, clinical practice guidelines, and technology with healthcare provider specialists. However, the intensive treatment and care from multidisciplinary teams in super tertiary care are not completely effective for improving the outcome of patients with HF in urban areas. Urbanization is considered a determinant of health and one of the key drivers of non-communicable diseases, especially in low- and middle-income countries (27). HF is a complex system in which behavior is affected by multiple individual-level and socioenvironmental factors. These factors are heterogeneous and interdependent, and they interact dynamically (31). Health behavior is consistent with biological, social, and environmental influences in that people are assumed to engage based on their preferences and attitudes. It becomes multilevel in that a person is constrained by factors that exert regulatory controls on their behaviors (6).
Interventions targeted directly at patients alone may not be beneficial for long-term outcomes. Shifting healthcare systems from hospital-based care toward community-based care is a potential strategy (32). Using the strength of Thai culture by integrating family and caregivers into healthcare planning may improve the outcomes of patients with HF in Thailand. Thai patients with HF need family and caregivers to fulfill their healthcare planning for controlling the symptoms and avoiding the exacerbation due to the limitation of patient demographics including elderly, low-education, and low-income (33).
The sample from this study were not able to include patients from all regions in Thailand. The study omitted one region due to the IRB application process, and budgetary limitations. However, this study presented data by level of hospital (super tertiary and tertiary care) providing a review of the spectrum of care. Moreover, social determinants of health of Thai patients may not vary regionally since as many cultures and beliefs are shared nationwide.