Does a strategy using a risk-stratification tool with early discharge and rapid outpatient follow-up for low-risk patients improve outcomes in patients with acute heart failure?
For patients who present to the ED with acute HF, a strategy using a validated point-of-care tool for risk stratification, with a recommendation for early discharge with rapid follow-up for lower risk patients, leads to decreased hospitalization for cardiovascular causes both at 30 days and at 20 months. As this strategy has multiple components (risk stratification and early outpatient follow-up), it is unclear which aspect of the intervention was responsible for the finding.
Cross-over trial (randomized)
Inpatient (any location) with outpatient follow-up
In this study from Canada, investigators enrolled patients presenting to the emergency departments (EDs) of 10 hospitals with acute heart failure (HF). Patients with end-stage disease or those receiving palliative care were excluded. Hospitals were randomized to staggered start dates to cross over from a control phase to an intervention phase. Patients who presented during the control phase (n = 2972) received usual care. Those who presented during the intervention phase (n = 2480) were assessed using a clinical decision-making support strategy. With this strategy, clinicians had access to a validated point-of-care tool for risk stratification (EHMRG30-ST) of patients to low, intermediate, or high risk of death at 7 days and 30 days. Patients at low risk were recommended for early discharge, either directly from the ED or after a brief observation period of up to 3 days, followed by transitional care in a HF clinic for up to 30 days. Patients at high risk were recommended for admission to the hospital. Intermediate-risk patients were triaged based on clinical judgment (early discharge for low-to-intermediate risk, admission for intermediate-to-high risk). The intervention and control groups were balanced at baseline with mean age of 78 years and 45% female participants. Although both groups had a similar number of early discharges in low-risk patients, the intervention group had an increased rate of early discharges in the intermediate-risk group (51% vs 44%) and a decreased rate in the high-risk group (19% vs 27%). The primary outcome of all-cause death or non-elective hospitalization for cardiovascular causes was lower in the intervention group at 30 days (12.1% vs 14.5%; hazard ratio [HR] 0.88; 95% CI 0.78 - 0.99) and at 20 months (54.4% vs 56.2%; HR 0.95; 0.92 - 0.99). This was primarily driven by fewer cardiovascular hospitalizations in the intervention group (8.1% vs 10.6% at 30 days; HR 0.85; 0.74 - 0.98).
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine