THE USE OF HOTELLING’S T^2 STATISTICS IN ANALYSING DATA ON HEART DISEASE PATIENT (CASE STUDY OF COOUTH [CHUKWUEMEKA ODUMEGU OJUKWU UNIVERSITY TEACHING HOSPITAL

ABSTRACT

 

Congestive heart failure in the pediatric population is a significant cause of morbidity and mortality. It has a wide variety of etiologies. These causes vary widely among different geographical regions globally, ages and social classes(1). There is a paucity of data on the epidemiology, etiology, and management of congestive heart failure in children as compared to major advances in research in adult heart failure(2). Primary caregivers of children with congestive heart failure face various challenges when caring for their children. This study sought to identify the etiology of congestive heart failure as well as the types of drugs used in its management among children in Chukwuemeka odumegu ojukwu university teaching hospital. It also sought to investigate the challenges faced by parents and guardians in the care of these children. A cross-sectional study was done involving pediatric patients with heart failure whose medical records were reviewed. This was done to determine the etiologies and types of drugs used in the management of heart failure among children. Challenges facing parents and guardians of children with heart failure were also explored. Fifty three records of the patients were selected from the COOUTH records department and thirty parents and guardians of the children recruited from the pediatric wards. The data was entered into Excel 2013 and analyzed using Hotelling t-squared statistics. It was then summarized and presented in pie charts, bar graphs, and tables. The major etiology for heart failure among the 53 patients whose records were reviewed was infections (58.5%), this included respiratory tract and urinary tract infections. Other etiologies included; congenital heart disease (34%,) pulmonary hypertension (26%), cardiomyopathies (15.1%) and rheumatic heart disease (13.2 %). The most commonly prescribed drugs were furosemide (98.1%), digoxin (67.9%). Only 22.6% of the patients were on the prescribed drug combination for heart failure in children according to the Nigeria national clinical guidelines. The major challenges faced by the 30 parents and guardians recruited were; financial constraint (90%), disruption of their work or business (73.3%), frequent readmissions (70%) and discrimination (53.3%). The etiology of congestive heart failure in the pediatric patients was multifaceted and there was poor adherence to the Nigeria National guidelines for the management of heart failure in children. This is in regard to the choice of drugs for heart failure as well as the dosing. Numerous challenges face parents and guardians of children with heart failure. Prompt treatment of infections in children with underlying heart disease to prevent the development of heart failure is recommended. Further research on the lack of prescriber preference for Enalapril in the management of pediatric heart failure should be done. Strengthening of prescriber capacity in the management of congestive heart failure in children should be done.

 

CHAPTER ONE

INTRODUCTION

1.1  Study background

Congestive heart failure is a medical condition in which the heart is progressively unable to pump blood at a rate commensurate with the body’s metabolic needs. The pumping action of the heart grows weaker over time resulting in heart failure(1). In most cases, both sides of the heart are affected but either side right or left can be affected. Among young children and infants, the condition commonly manifests as respiratory distress, tachycardia, feeding difficulties, tender hepatomegaly, profuse sweating, gallop rhythm and arrested growth and development. In older children, it presents as orthopnea, dependent edema, crepitations, fatigue, and exercise intolerance together with raised jugular venous pressure (3).

The prevalence of heart failure has increased with time making it a global epidemic affecting at least 26 million people worldwide (4). There exists little data on the prevalence and incidence of heart failure among the pediatric population. This is due to changes in patterns, etiologies, geographical areas, ages and social classes that make it difficult to come up with formidable research data (1). It is also quite challenging to diagnose heart failure in young infants and children due to its overlap with other pathological conditions. Early mortality also contributes to the under-reporting of the cases (5).

A few studies have attempted to describe the prevalence of heart failure in the pediatric population amidst the above-mentioned challenges. Pediatric hospitalizations due to heart failure in the United States occur in about 11,000 to 14,000 children annually with a mortality of about 7% (6). A 10-year hospital-based study done in a tertiary hospital in Belgium indicated a 10.4%   prevalence of heart failure among children with various forms of heart disease (7). Regionally, reported prevalence data for the period 2012 to 2015 from Ethiopia at a tertiary health center was about 2.9% of all pediatric admissions (5). A Nigerian study in a tertiary hospital indicated that heart failure consists of about 1:1000 hospital admissions in the pediatrics department(8).

Heart failure morbidity and mortality in the pediatric population carries with it a high socio-economic burden. This is especially due to reduced economic productivity by the parents as well as the magnified economic impact due to the loss of potentially productive years per death. The costs of hospitalization due to heart failure in children are also inevitably higher than those of adults because of the frequent requirement for catheter-based and surgical interventions (1).

A wide range of etiologies for pediatric heart failure exists ranging from simple myocarditis to complex structural heart disease. These etiologies vary widely across different countries and also different parts of large countries such as India. In developing countries, these mainly include rheumatic heart disease, tropical diseases, and nutritional deficiencies. Other conditions resulting in heart failure include congenital heart disease, cardiomyopathies, and myocarditis affecting children both in the western world and in developing countries (9).

Management of heart failure in children generally includes supportive, pharmacological and surgical measures. Supportive measures include bed rest in cardiac position, restriction of salt and fluid intake, oxygen by nasal prongs or catheter in severe heart failure. Pharmacological measures involve the use of anti-failure medications which include among others: Diuretics, digoxin and angiotensin-converting enzyme inhibitors (3). Surgical measures are also many times indicated for structural heart problems.

 

1.2  Problem Statement

It has been found that developing countries face a different pattern of etiologies for heart failure due to tropical diseases as well as a low socio-economic status. This predisposes the children to nutritional deficiencies that are a major cause of anemia and cardiac cachexia resulting in the development of heart failure. Causes of heart failure also vary with geographical locations globally and different age groups among children. It is therefore important to study the etiology of heart failure in different settings. There is a paucity of data in Nigeria in the area of congestive heart failure in the pediatric population.

The management of congestive heart failure in children often requires the use of several medications, more so in a case where there is a co-morbid condition. This increases the cost as well as the possibility for drug-drug interactions and challenges with adherence.

The relatively small numbers of children with heart failure are not reflective of the overall economic and social impact of congestive heart failure. This is because the average cost of management of this condition in children is higher. Children frequently need surgical and catheter-based procedures and interventions that are quite costly. They also have frequent hospitalizations resulting in high hospital costs as well as negatively affecting the economic productivity of parents.

Many of the existing formulations for drugs used in heart failure in the market are unsuitable for use by the pediatric population, consequently, adult formulations are used. This, therefore, creates a loophole for medication errors including inaccurate dose administration that complicates the management of the condition. Due to the high rates of recurrence of heart failure and frequent readmissions, parents and guardians of these children face various challenges in the care of these children.

 

1.3  Study justification

Many studies have been carried out on heart failure in the adult population, however, few studies exist on heart failure among pediatric patients especially in sub-Saharan Africa. The causes of pediatric heart failure vary widely across geographical regions(1). It is important to identify the causes of pediatric heart failure in COOUTH. Drug use in pediatric heart failure management varies due to lack of current evidence-based solutions. This study evaluated the types of drugs used in COOUTH in comparison to the recommendations in the Nigeria National Guidelines(3). No study has been carried out locally about the unique challenges faced by parents and guardians of children with congestive heart failure. This study provides an insight on these challenges.

 

1.4  Purpose of the study

This study sought to add to the scarce body of literature available on heart failure among pediatric patients in developing countries as well as to point to the need to improve the pharmacological management of pediatric patients suffering from the disease by improving compliance to guidelines

The study also forms a basis for understanding the major challenges faced by caregivers of children with heart failure and encourage clinicians to counsel them accordingly.

 

1.5  Study objectives

1.5.1  Broad objective

To evaluate the etiology and management of heart failure in children below 12 years and the challenges faced by their parents or guardians at Chukwuemeka odumegu ojukwu university teaching hospital.

1.5.2  Specific objectives

1. To determine the etiologies of congestive heart failure among children below 12 years at Chukwuemeka odumegu ojukwu university teaching hospital.
2. To evaluate the types of drugs used in the management of congestive heart failure among children below 12 years at Chukwuemeka odumegu ojukwu university teaching hospital and the conformity to the Nigeria national guidelines
3. To determine the challenges faced by the parents or guardians of children with congestive heart failure at Chukwuemeka odumegu ojukwu university teaching hospital.

 

1.6  Research Questions

1. What are the etiologies of congestive heart failure among children below 12 years at Chukwuemeka odumegu ojukwu university teaching hospital?
2. What types of drugs are used in the management of congestive heart failure among children at Chukwuemeka odumegu ojukwu university teaching hospital and how does the treatment of these patients conform to the Nigeria National guidelines for the management of this condition?
3. What are the challenges faced by parents or guardians of children with congestive heart failure care at Chukwuemeka odumegu ojukwu university teaching hospital?

 

1.7  Significance and anticipated output

The findings of this study are useful to clinicians to increase their vigilance on the major causative factors of pediatric heart failure and therefore optimizing management of these risk factors before pediatric heart failure sets in.

Identification of the challenges in the management of congestive heart failure among children is helpful in preparing the caregivers of the children as well as informing economic decisions on availing some of the necessary requirements such as drugs lacking in the management of this condition. The study is also useful for researchers wishing to do further research on pediatric heart failure given the scarcity of data in this area.

 

1.8  Limitations

Finding out the etiology and the types of drugs used for the management of pediatric heart failure involved a retrospective study that relied entirely on the accuracy of the patient records available. The study involved the collection of data from the caregivers of children with congestive heart failure and therefore the likelihood of information bias.

THE USE OF HOTELLING’S T^2 STATISTICS IN ANALYSING DATA ON HEART DISEASE PATIENT (CASE STUDY OF COOUTH [CHUKWUEMEKA ODUMEGU OJUKWU UNIVERSITY TEACHING HOSPITAL

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