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Trial of an Intervention to Improve Acute Heart Failure Outcomes
Quick Takes
- A clinical decision-making tool can be used to assess risk when deciding whether to admit or early discharge an acute HF patient to significantly lower all-cause death or hospitalization for CV causes within 20 months of ED presentation.
- A structured outpatient transitional care HF clinic staffed by nurses with cardiologist supervision allows for rapid follow-up and a cost-effective alternative to hospitalization for lower-risk acute HF patients who are discharged directly from the ED or early within 3 days of hospital admission.
Study Questions:
Can a clinical decision-making tool be used to assess risk when deciding whether to admit or early discharge an acute heart failure (HF) patient presenting to the emergency department (ED)?
Methods:
The COACH trial was a cross-sectional, stepped-wedge, cluster-randomized trial enrolling 5,452 acute HF patients (2,972 control phase and 2,480 intervention phase) presenting to the ED at 10 hospitals in Ontario, Canada. The validated Emergency Heart Failure Mortality Risk Grade for 30-day mortality tool (EHMRG30-ST) was used by ED staff in the intervention group to assess risk, whereas the control group used clinical judgment. The tool algorithm determined if patients were low-, intermediate-, or high-risk for hospital admission or early discharge (<3 days). Patients discharged early were given access to the RAPID-HF transitional care clinic staffed by nurses and supervised by a cardiologist and outpatient clinic care for 30 days. Coprimary outcomes within 30 days were death from all causes or hospitalization for cardiovascular (CV) causes and the composite outcomes within 20 months included the coprimary outcomes or ED visits.
Results:
The control group assessed 18.2% low-risk, 28% intermediate-risk, and 53.6% high-risk, whereas the intervention group assessed 23.5% low-risk, 32.1% intermediate-risk, and 44.4% high-risk patients. Early discharge occurred among high-risk patients in 27.0% of the control group versus 19.1% of the intervention group; among intermediate-risk patients in 44.2% control group versus 50.7% intervention group; and among low-risk patients in 58.2% control group versus 57.9% intervention group. The median time to the first outpatient visit for the low-risk patients was 4 days for both groups; intermediate-risk patient was 4 days for intervention group versus 5 days for control group; and high-risk patients was 5 days for both groups.
Within 30 days of discharge, the intervention group, as compared to the control group, had significantly reduced death from any cause (6.3% vs. 6.8% low-risk; 8.6% vs. 12.1% intermediate-risk; 17.5% vs. 18.2% high-risk, respectively). Within 30 days, the composite death or hospitalization for CV causes was 12.1% for the intervention group versus 14.5% for the control group (adjusted hazard ratio, 0.88; 95% confidence interval [CI], 0.78-0.99; p = 0.04). Within 20 months, the cumulative incidence of death from any cause or hospitalization for CV causes was 54.4% (95% CI, 48.6-59.9) among the intervention group and 56.2% (95% CI, 54.2-58.1) among the control group (adjusted hazard ratio, 0.95; 95% CI, 0.92-0.99).
Conclusions:
A clinical decision-making tool can be used to assess risk when deciding whether to admit or early discharge an acute HF patient to significantly lower all-cause death or hospitalization for CV causes within 20 months of ED presentation.
Perspective:
Predicting the risk for early hospital discharge may reduce hospital readmissions or delay outpatient care. This study found that a clinical decision-making tool to assign low-, intermediate-, and high-risk acute HF patients, in combination with a standardized transitional care clinic staffed by nurses with cardiologist supervision, significantly reduced the all-cause death and hospitalizations for CV causes within 20 months after presenting to the ED. This study demonstrates the implications for artificial intelligence methodology that may enable ED staff to more accurately estimate risk and to determine patient safety for early discharge. In addition to the efficiency and cost savings for patients and institutions, this study demonstrates the effectiveness of protocol-driven HF clinics to reduce all-cause death and readmissions for CV causes.
Clinical Topics: Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure
Keywords: Ambulatory Care Facilities, Artificial Intelligence, Heart Failure, Nurses, Outpatients, Patient Care Team, Patient Discharge, Patient Readmission, Risk Assessment, Secondary Prevention, Transitional Care
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