A propensity matched study of the association of education and outcomes in chronic heart failure

Background: Heart failure (HF) patients' knowledge about their disease may improve short-term outcomes and may be related to their level of education. However, the effects of patients and spousal education on long-term outcomes in ambulatory chronic HF are unknown. Methods: Of the 571 patients enrolled in the quality of life sub-study of the Digitalis Investigation Group trial, 159 patients or their spouses reported having higher (> 12 years) education. Propensity score for higher education, calculated for each patient using a logistic regression model, was used to match 112 (70% of 159) higher education patients with 215 patients with high school (≤ 12 years) education. Matched Cox regression analyses were used to estimate associations of high school education with mortality and hospitalizations. Results: All-cause hospitalizations occurred in 56% (rate, 3233/10,000 person-years) of higher education and 65% (rate, 4558/10,000 person-years) of high school education patients (hazard ratio {HR} for high school, compared with higher education = 1.52; 95% confidence interval {CI} = 1.06-2.16; p = 0.022). Hospitalizations due to cardiovascular causes occurred in 42% (rate, 2067/10,000 person-years) of higher education and 50% (rate, 4558/10,000 person-years) of high school education patients (HR = 1.55; 95% CI, 1.05-2.30; p = 0.029). All-cause mortality occurred in 20% (rate, 746/10,000 person-years) of higher education and 30% (rate, 1204/10,000 person-years) of high school education patients (HR = 1.52; 95% CI = 0.89-2.58; p = 0.124). Conclusions: Compared with > 12 years of education, lower education was associated with increased hospitalizations among ambulatory chronic HF patients. Patient and spousal education levels may be used to risk stratify HF patients at high risk for hospitalizations.