[Physician Comment] An argument against hospital admission for heart failure

Jan 16th- Patients with heart failure experience high readmission rates, but receive only a limited range of interventions as in-patients.

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Image: CC/J.Heilman

Study author Dr. Sean Collins, M.D., talks to 2 Minute Medicine: Director, Clinical Trials Center and Associate Professor of Emergency Medicine

“Many EDs use some version of the Chest Pain Center recommendations that we published a few years ago (Peacock – Critical Care Medicine-OU recommendations)…What we suggested in the JACC paper was based on our prior OU experience- where those without high-risk features could be managed in 24-48 hours and then discharged with close outpatient follow-up.”

1. Patients with heart failure experience high readmission rates, but receive only a limited range of interventions as in-patients.

2. Authors propose a two-tier risk stratification in the ED: first based on the patient’s circumstances leading to decompensation, hemodynamic stability, and comorbidities; and second based on the patient’s response to initial diuretic therapy in the ED.

3. Using this strategy, as many as 50% of patients could safely avoid inpatient admission, at a cost savings of $4,000 per patient.

Drawing parallels with the recent advances in acute coronary syndrome emergency management, the authors of this editorial make the case for a new paradigm for patients presenting in acute HF. With appropriate patient selection, they hypothesize observation units could save a great deal of patient time and expense ($80 million annually in the Unites States by the most conservative estimates) without negatively affecting outcomes. They emphasize the need for a randomized controlled trial comparing a HF-focused observation unit against standard hospital admission.

Click to read the study for free in The Journal of the American College of Cardiology

Click to read an accompanying editorial

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Image: CC/J.Heilman

1. Patients with heart failure experience high readmission rates, but receive only a limited range of interventions as in-patients.

2. Authors propose a two-tier risk stratification in the ED: first based on the patient’s circumstances leading to decompensation, hemodynamic stability, and comorbidities; and second based on the patient’s response to initial diuretic therapy in the ED.

3. Using this strategy, as many as 50% of patients could safely avoid inpatient admission, at a cost savings of $4,000 per patient.

Primer: Heart failure (HF) is one of the most common causes of admission to US hospitals, occurring approximately 800,000 times annually. Retrospective studies of these admissions show that the majority of HF patients received no treatment other than diuretics during their stay. At the same time, these patients experience a 33% rate of death or re-hospitalization in the subsequent 60-90 days. It is important to note that though the rate of readmission for HF patients is high, the rate of readmission for HF patients discharged directly from the ED without ever being admitted is even higher.

With these realities in mind, Collins et al. developed the two-tier risk stratification strategy outlined above to identify a subgroup of HF patients who would benefit from a middle ground between immediate discharge and inpatient admission. They argue a 24-hour observation unit is the ideal setting to administer diuretics and monitor fluid and hemodynamic status, as well as optimize medications and follow-up to prevent readmission. A unit dedicated to HF patients would also be well-suited to standardize the education and coordination of follow-up.

Background reading:

1. Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure.

2. Improving Postdischarge Outcomes in Patients Hospitalized for Acute Heart Failure Syndromes.

3. National Heart, Lung, and Blood Institute working group on emergency department management of acute heart failure: research challenges and opportunities.

In sum: Drawing parallels with the recent advances in acute coronary syndrome emergency management, the authors of this editorial make the case for a new paradigm for patients presenting in acute HF. With appropriate patient selection, they hypothesize observation units could save a great deal of patient time and expense ($80 million annually in the Unites States by the most conservative estimates) without negatively affecting outcomes. They emphasize the need for a randomized controlled trial comparing a HF-focused observation unit against standard hospital admission.

Click to read the study for free in The Journal of the American College of Cardiology

Click to read an accompanying editorial

By [GS] and [AH]

More by this author: Physician Assistant home visits associated with reduced infection-related re-admissions in cardiac surgery patients, Drug-eluting stents in peripheral artery disease: longer patency than bare stents but no significant improvement in long-term limb viability (ACHILLES trial), CABG demonstrates better rates of survival versus PCI in diabetic patients: the FREEDOM trial

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Gina Siddiqui: Gina is a 3rd year M.D. candidate at the University of Pennsylvania.

Allen Ho: Allen is a 4th year M.D. candidate at Harvard Medical School.

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