Clinical question: In patients presenting to the emergency department (ED) with heart failure (HF) symptoms, are patient outcomes affected by the use of a risk stratification tool to guide the need for admission or discharge with close outpatient follow-up?
Background: ED physicians often rely on clinical judgment to determine if patients presenting with heart failure symptoms need hospital admission or can be safely discharged with outpatient plan follow-up. Lack of access to timely outpatient care is a barrier to safe discharge planning from the ED and can lead to higher rates of hospitalization.
Study design: Step-wedged, cluster-randomized trial
Setting: 10 academic and community hospitals in Canada
Synopsis: 5,452 patients with the clinical diagnosis of HF presenting to the ED with acute heart failure symptoms were enrolled. Nursing home residents and patients with an inability to follow up outpatient were excluded. The intervention arm used the Emergency Heart Failure Mortality Risk Grade for 7- and 30-day mortality to triage patients to low, intermediate, and high risk. Low-risk patients were either discharged from the ED or underwent fewer than three days of observation before discharge with close follow-up appointments with cardiology. High-risk patients were admitted. Clinicians used their judgment on disposition for intermediate-risk patients.
Composite co-primary outcome of all-cause mortality or cardiovascular (CV) hospitalizations in the control versus intervention group was 14.5% versus 12.1% (HR, 0.88; 95% CI, 0.78-0.99) at 30 days and 56.2% versus 54.4% (HR, 0.95; 95% CI, 0.92-0.99) at 20 months. Among patients with early discharge, 27% of patients in the high-risk group were discharged in the control group compared to 19% in the intervention group. The intervention and control groups had similar rates of early discharge for low-risk patients. As the study included two interventions (risk stratification and outpatient follow-up), it is unclear which component was the main driver of the results.
Bottom line: Implementation of a risk-stratification tool to aid in determining disposition for patients with heart failure in the ED coupled with close outpatient follow-up reduces composite CV re-admission or mortality by 12% at 30 days and 1.8% at 20 months.
Citation: Lee DS, Straus SE, et al. Trial of an Intervention to improve acute heart failure outcomes. N Engl J Med. 2023;388(1):22-32.
Dr. Latifi is a hospitalist at Johns Hopkins Hospital and an assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore. Disclosure: She prepares article reviews for Oakstone Practical Reviews in Hospital Medicine and has previously reviewed this article, which has been revised to meet our requirements.