Short-stay units for low-risk acute HF could reduce cost, improve quality of life
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Key takeaways:
- Transfer to a short-stay unit may improve costs and quality of life in low-risk patients in the ED with acute HF.
- However, the trial was underpowered due to pandemic-era low enrollment.
A short-stay strategy designed to lower cost of care may improve quality of life of low-risk patients with acute HF in the ED, but the trial was underpowered due to low enrollment during the COVID-19 pandemic, researchers reported.
The results of the multicenter randomized SSU-AHF trial were published in JAMA Network Open.
Image: Adobe Stock
“The cost of heart failure is projected to increase from $3.7 billion in 2012 to $69.8 billion in 2030, with hospitalization for acute HF being the greatest contributor. Hospitalization is also a marker for serious adverse events,” Peter S. Pang, MD, MS, chair of the department of emergency medicine at Indiana University School of Medicine, and colleagues wrote. “Brief observation (< 24 hours), often referred to as short-stay unit (SSU) management, has been supported for lower-risk patients with acute HF by observational studies and consensus statements. Prior work has shown a shorter length of stay in SSU patients compared with risk-matched inpatients (25.7 vs. 58.5 hours), but past studies were limited by their nonrandomized design. Thus, we designed the SSU-AHF trial to overcome prior limitations and evaluate outcomes in the setting of a randomized trial.”
Design of the SSU-AHF trial
For this trial, Pang and colleagues enrolled 193 low-risk patients with acute HF (mean age, 65 years; 41% women; 56% Black) and randomly assigned them 1:1 to SSUs for less than 24 hours or hospital from the ED.
The primary outcome was quality of life as measured by the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12) score at 30 days after discharge.
Short-stay unit vs. hospitalization from ED
At discharge, more than 97% of trial participants completed the KCCQ-12, with mean scores of 35.5 in the short-stay arm and 33.1 in the hospital arm (P = .47).
Among 64 participants in the short-stay arm and 67 in the hospitalization arm, 30-day KCCQ-12 scores improved significantly from discharge and there was no significant difference between the two groups (SSU mean score, 51.3; hospitalization mean score, 45.8; P = .19).
The researchers also evaluated any differences in days alive and out of hospital between the two groups, of which more were observed in the short-stay arm compared with the hospital arm (median, 26.9 days vs. 25.4 days; P = .02).
Among those randomly assigned to the SSU, 41.9% crossed over to hospitalization after SSU treatment and none in the hospitalization arm crossed over to the short-stay strategy.
Among participants who required hospitalization from the SSU, number of hospital days, including the ED stay, was greater compared with those randomly assigned to the hospitalization arm (median, 4 day vs. 3.1 days; P = .03); however, the number of days in the hospital and ED, including initial hospital stay, was not significantly different between the two arms (SSU, 7.6 days; hospitalization, 5.6 days; P = .09).
The researchers reported no additional deaths in either arm after hospital discharge through 30 days and no differences in 30- or 90-day all-cause death or rehospitalization, according to the study.
“While both treatment strategies resulted in clinically important changes in KCCQ-12 scores from baseline, lower-than-expected enrollment during the COVID-19 pandemic left the study underpowered to detect a significant difference between the strategies,” the researchers wrote. “Given that 41.9% of SSU participants required hospitalization and had a longer combined ED and hospital length of stay than those randomized to hospitalization, the significant difference in 30-day days alive and out of hospital favoring SSU is notable. Additionally, the high number of SSU treatment failures suggests that further refinement of SSU eligibility criteria, SSU management procedures, or both may strengthen the SSU strategy.”
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