ED visits, outpatient encounters drive increased incidence of worsening HF events
The annual incidence of worsening HF events increased during the past decade, largely driven by higher rates of outpatient encounters and ED visits and observation stays, according to an analysis of electronic health records.
Although both the relative proportion and absolute number of worsening HF events were highest for hospitalizations, ED visits/observation stays and outpatient encounters in aggregate accounted for more than 85% of all clinical encounters and approximately 50% of worsening HF events, according to the researchers.
To incentivize health systems to reduce 30-day readmissions, the Affordable Care Act launched the Hospital Readmission Reduction Program in 2012, which penalizes hospitals financially if they have higher than predicted risk-adjusted 30-day readmission rates for major conditions, including HF, Andrew P. Ambrosy, MD, a noninvasive cardiologist at Kaiser Permanente San Francisco Medical Center and a clinician-investigator at Kaiser Permanente Northern California Division of Research, and colleagues wrote in the study background. However, the program may be associated with a shift of some HF-related care to the outpatient setting.
“Many tertiary care centers have developed protocols for administering intravenous therapies in the ED, short-stay observation units, and/or same-day access clinics,” Ambrosy and colleagues wrote. “In addition, recently completed pivotal clinical trials have found that adjudicating episodes of worsening HF ... in ambulatory patients would increase the overall event rate by 25% to 30%. Thus, there is a growing interest in the field to disentangle worsening HF from location of care and move away from using hospitalization as a surrogate for acute decompensated HF. However, little is known about the contemporary epidemiology of outpatient worsening HF.”
Assessing all clinical encounters
Ambrosy and colleagues analyzed EHR data to describe the incidence of worsening HF events across the care continuum from ambulatory encounters to hospitalizations in 103,138 adults with diagnosed HF from 2010 to 2019 in the Kaiser Permanente health system. The mean age of patients was 74 years; 47.5% were women and mean left ventricular ejection fraction was 51.4%. Worsening HF was defined as at least one symptom and at least two objective findings, including at least one sign, and at least one change in HF-related therapy. Symptoms and signs were ascertained from the EHR using natural language processing.
“Natural language processing algorithms for worsening HF were derived and validated against a ‘gold standard’ consisting of manual chart review and validation by two physicians ... with final adjudication by a board-certified cardiologist where discrepancies existed,” the researchers wrote.
Within the cohort, there were 1,136,750 unique encounters. Of those, 65.4% were outpatient encounters, 19.8% were ED visits/observation stays and 14.9% were hospitalizations. Researchers identified 126,008 worsening HF episodes. Of those, 27.6% were outpatient encounters, 22.5% were ED visits or observation stays, and 50% were hospitalizations.
The annual incidence of worsening HF, defined as events per 100 person-years, increased from 25 to 33 per 100 person-years during the study period. Data show outpatient encounters drove the increase, which rose from 7 to 10 per 100 person-years, as did ED visits/observation stays, which rose from 4 to 7 per 100 person-years.
The 30-day rate of hospitalizations for worsening HF ranged from 8.2% for outpatient encounters to 12.4% for hospitalizations.
“ED visits/observation stays and outpatient encounters made up approximately one-half the episodes of worsening HF, and the relative proportion of worsening HF events occurring outside a hospitalized setting is increasing and driving the underlying growth in HF-related morbidity,” the researchers wrote. “The significance of ED visits/observation stays and outpatient encounters for worsening HF is underscored by the high rate of subsequent worsening HF event.”
Worsening HF ‘hiding in plain sight’
In a related editorial, James L. Januzzi Jr., MD, director of the Dennis and Marilyn Barry Fellowship in Cardiology Research at Massachusetts General Hospital, and Cardiology Today Editorial Board Member Javed Butler, MD, MPH, MBA, FACC, FAHA, FESC, president of the Baylor Scott and White Research Institute, senior vice president for Baylor Scott and White Health and distinguished professor of medicine at the University of Mississippi, wrote the findings show worsening HF was more common than inpatient hospital stays for the diagnosis, and its frequency increased during the study.
“These findings provide clarity about something that has been hiding in plain sight the whole time: Worsening HF is highly prevalent, morbid, and represents a valid target for care improvement for preventing it and its subsequent consequence of hospitalization and mortality risk,” Januzzi and Butler wrote.
Januzzi and Butler noted that hospitalizations are important; however, the focus of HF care “must shift” toward preventing the worsening HF that precedes the need for inpatient care. “Immediate institution of therapies proven to reduce the risk of disease progression in HF is the best way to preserve health status, mitigate cardiac remodeling and prevent progression of the diagnosis,” Januzzi and Butler wrote. “This is an all-hands-on deck moment: education, utilization of clinician and patient-facing tools, care prompts within the electronic health record to trigger better guideline-directed medical therapy adherence, or even establishment of ‘[guideline-directed medical therapy] clinics’ are all important steps to rapidly institute quality HF care and are the best chance to keep our patients stable early in their journey, preserve health status and to reduce the risk of later disease progression.”
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