Study Shows High Admission and Variation of Acute HF in the ED

Each year heart failure (HF) affects approximately five million Americans, resulting in nearly one million hospital stays. Of those admitted, the vast majority of patients are originally evaluated and managed in the emergency department, and according to a study published April 30 in JACC: Heart Failure, more than 80 percent of emergency department patients with acute HF are admitted to the hospital and have a median inpatient length of stay of 3.4 days. In addition, among these patients, there is "significant variation in disposition and procedural decisions based on region of the country and type of insurance, even after adjusting for potential confounding."

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The investigators, led by Alan Storrow, MD, Department of Emergency Medicine, Vanderbilt University School of Medicine, utilized the Nationwide Emergency Department Sample (NEDS) database from 2006 to 2010 to describe admission proportion, hospital length of stay, and emergency department charges as a surrogate for resource utilization, and then compared those results across U.S. regions, patient insurance status, and hospital characteristics. The investigators found that during the time period, 958,167 mean yearly emergency department visits for acute HF occurred in the U.S. Overall, 83.7 percent were admitted, with the median length of stay measuring 3.4 days. While there was a small decrease in median length of stay when comparing 2006 to 2010, the proportion admitted did not change and that the financial costs of initial acute HF care increased over time. Of the geographic variations observed, the odds of admission, adjusting for age, sex, hospital characteristic (academic and safety net status), and insurance (Medicare, Medicaid, private, self-pay/no charge) were highest in the Northeast. Additionally academic hospitals were more likely to admit than nonacademic hospitals.

The authors conclude that while the results of the analysis suggest that the burden of acute HF remains high on the nation’s emergency departments, a closer examination of regional variability in admission decisions may provide important implications for health care expenditure models. Moving forward, strategies are needed to "reduce this clinical and economic burden," they add.

"Most striking are the findings related to uninsured patients, who were defined as self-pay or no charge, compared with all others," writes Peter Pang, MD, FACC, in a related editorial comment. "Uninsured patients were nearly 25 years younger, more likely to have hypertension, but less likely to have coronary artery disease. After accounting for these differences, uninsured patients were far more likely to be discharged from the emergency department, but when admitted, had a shorter median length of stay and underwent a greater number of diagnostic and therapeutic procedures. These findings should provoke further investigation, especially if outcomes differ. Given their younger age, one possible explanation is that uninsured patients appeared less sick, but once hospitalized, the potential lack of follow-up for these patients prompted a more in-depth assessment. A better understanding of these differences is needed to determine whether they represent disparities in quality of care or just in utilization."

Keywords: Coronary Artery Disease, Follow-Up Studies, Insurance Coverage, Medicaid, Emergency Service, Hospital, Cost of Illness, Patient Discharge, Length of Stay, Medically Uninsured, Emergency Medicine, Heart Failure, Health Expenditures, Medicare, Hypertension

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