Point-of-care risk tool in ED, rapid outpatient follow-up improves acute HF outcomes
CHICAGO — Use of a point-of-care tool to support clinical decision-making in addition to rapid outpatient follow-up reduced the risk for death or CV hospitalizations for patients with acute HF presenting to the ED.
“Implementation of this approach may lead to a pathway for early discharge from the hospital or emergency department and improved patient outcomes,” Douglas S. Lee, MD, PhD, FRCPC, the Ted Rogers Chair in Heart Function Outcomes and staff cardiologist at the Peter Munk Cardiac Centre of the University Health Network and professor of medicine at University of Toronto, said during a presentation at the American Heart Association Scientific Sessions.
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Impact of intervention on outcomes
The COACH trial was conducted to determine whether a strategy of using the Emergency Heart Failure Mortality Risk Grade for 30-day mortality (EHMRG30-ST), a validated risk algorithm, in the ED along with standardized rapid outpatient follow-up improves clinical outcomes.
The stepped-wedge cluster randomized clinical trial was conducted at 10 hospitals in Ontario, Canada, which underwent randomization to staggered start dates for crossover from the control phase, when hospitals did not have access to the EHMRG30-ST tool, to implementation of the intervention. In the intervention phase, patients deemed low risk were discharged within 3 days and received standardized outpatient care, whereas those deemed high risk were admitted.
The trial included 5,452 patients who presented to the ED with acute HF. Of those, 2,972 were enrolled during the control phase and 2,480 during the intervention phase.
Within 30 days, use of the intervention strategy led to a 12% lower risk for death from any cause or hospitalization for CV causes, which occurred in 12.1% of patients enrolled during the intervention phase compared with 14.5% of patients enrolled before the intervention (adjusted HR = 0.88; 95% CI, 0.78-0.99; P = .04). Moreover, risk for hospitalization for CV causes was lower during the intervention phase (aHR = 0.85; 95% CI, 0.74-0.98), as was risk for hospitalization for HF (aHR = 0.81; 95% CI, 0.69-0.95), according to the results.
Within 20 months, the composite endpoint occurred in 54.4% of patients during the intervention phase compared with 56.2% during the control phase (aHR = 0.95; 95% CI, 0.92-0.99). Again, the intervention appeared to be associated with lower risk for hospitalization for CV causes and for HF, Lee said.
In other results, early discharge occurred in 27% of high-risk patients enrolled during the control phase and 19.1% of high-risk patients enrolled during the intervention phase, in 44.2% and 50.7% of intermediate-risk patients, and in 58.2% and 57% of low-risk patients, respectively. Among low-risk patients discharged early, median time to first outpatient visit was 4 days for those enrolled in either phase and median time to first outpatient visit with an internist or cardiologist was 6 days for those enrolled during the intervention phase and 12 days for those enrolled during the control phase. Among high-risk patients discharged early, median time to first outpatient visit was slightly longer at 5 days for those enrolled in either phase and median time to first outpatient visit with an internist or cardiologist was 11 and 13 days, respectively, according to the results.
The researchers reported no death or hospitalizations from any cause in patients deemed low- or intermediate-risk prior to the first outpatient visit within 1 week, and fewer than six events within 30 days of discharge.
‘Important implications for health resource utilization’
During a discussion of the trial following the presentation, Harriette Van Spall, MD, MPH, associate professor of medicine in the department of health research methods, evidence and impact at McMaster University, said, “this trial adds important information to fill a large knowledge gap in how to risk stratify and care for patients presenting to the ED with HF.
“Our interferences are that among hemodynamically stable patients presenting to the ED for HF, in the absence of any instability, the clinical endpoints of 30-day death or CV hospitalization is reduced by 12% by this important intervention and the 20-month outcome of death or CV hospitalization is reduced by 5%. This has important implications for health resource utilization and once we have clarity on the process endpoints of patients admitted vs discharged in both groups we will be able to assess overall health care utilization of this intervention.”
Reference:
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Lee DS, et al. LBS.02. Late-Breaking Science: Breakthrough Strategies in the HF Journey. Presented at: American Heart Association Scientific Sessions; Nov. 5-7, 2022; Chicago (hybrid meeting).
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