Validation of the Acute Heart Failure Index

Hospital at Home as a Treatment Strategy for Worsening Heart Failure

Hospital at home (HaH) is an innovative care model that may be particularly suited for heart failure (HF). Outpatient visits and inpatient care have been the 2 traditional settings for HF care, yet may not match the social and medical needs of patients at all times. Alternative models such as HaH may represent an effective and patient-centered option for select patients with worsening HF. To date, limited research in HF and other disease states has supported HaH as being safe and lower cost than traditional inpatient admission. Supporting HaH are new payment structures, such as Medicare's Acute Hospital Care at Home waiver program. In combination with outpatient visits, outpatient intravenous diuretic clinics, inpatient care, and cardiac intensive care, HaH could be a core component of a comprehensive care model with the potential to match resource utilization with the needs of patients across the spectrum of HF severity, and improve patient outcomes.

Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life

BACKGROUND

Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits.

OBJECTIVE

This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia.

METHODS

This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions.

RESULTS

Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences.

CONCLUSIONS

Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.

Troponin is unrelated to outcomes in heart failure patients discharged from the emergency department

Background

Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management.

Objective

Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED.

Methods

This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED‐HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30‐day cardiovascular death and/or heart failure‐related events.

Results

Of the 491 subjects included in the GUIDED‐HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54‐70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval,  0.49–2.01, P = 0.994)

Conclusion

If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.

Disposition of acute decompensated heart failure from the emergency department: An evidence-based review

INTRODUCTION

Acute heart failure (HF) exacerbation is a serious and common condition seen in the Emergency Department (ED) that has significant morbidity and mortality. There are multiple clinical decision tools that Emergency Physicians (EPs) can use to reach an appropriate evidence-based disposition for these patients.

OBJECTIVE

This narrative review is an evidence-based discussion of clinical decision-making tools aimed to assist EPs risk stratify patients with AHF and determine disposition.

DISCUSSION

Risk stratification in patients with AHF exacerbation presenting to the ED is paramount in reaching an appropriate disposition decision. High risk features include hypotension, hypoxemia, elevated brain natriuretic peptide (BNP) and/or troponin, elevated creatinine, and hyponatremia. Patients who require continuous vasoactive infusions, respiratory support, or are initially treatment-resistant generally require intensive care unit admission. In most instances, new-onset AHF patients should be admitted for further evaluation. Other AHF patients in the ED can be risk stratified with the Ottawa HF Risk Score (OHFRS), the Multiple Estimation of Risk Based on Spanish Emergency Department Score (MEESSI), or the Emergency HF Mortality Risk Grade (EHFMRG). These tools take various factors into account such as mode of arrival to the ED, vital signs, laboratory values like troponin and pro-BNP, and clinical course. If used appropriately, these scores can predict patients at low risk for adverse outcomes.

CONCLUSION

This article discusses evidence-based disposition of patients in acute decompensated HF presenting to the ED. Knowledge of these factors and risk tools can assist emergency clinicians in determining appropriate disposition of patients with HF.

The role of acute heart failure index (AHFI) combined with emergency heart failure mortality risk grade (EHMRG) in the evaluation of clinical outcomes and prognosis in patients with acute heart failure

OBJECTIVE

To investigate clinical value for the risk model of acute heart failure index (AHFI) combined with emergency heart failure mortality risk grade (EHMRG) in evaluating clinical outcomes and prognosis of patients with acute heart failure (AHF).

METHODS

The present prospective observational cohort study enrolled a total of 228 patients with AHF who were admitted to our hospital from January 2019 to January 2020. The AHF patients were divided into four groups: (1) the high AHFI and high EHMRG group, n = 61; (2) the low AHFI and low EHMRG group, n = 92; (3) the high AHFI and low EHMRG group, n = 34; (4) the low AHFI and high EHMRG group, n = 41. AHFI and EHMRG were used to identify the risk of death for AHF patients. Serum levels of Troponin I, B-type natriuretic peptide (BNP), and NT-pro-B-type natriuretic peptide (NT-proBNP) were detected by the ELISA method. Kaplan-Meier curve was performed for analysis of survival time and a logistic regression model was used to analyse 1-year mortality of patients. Pearson's analysis was used to determine the correlation between biomarkers and EHMRG.

RESULTS

AHFI combined with the EHMRG model was associated with cardiac function status and EHMRG score was positively related to the level of Troponin I, BNP, and NT-proBNP. AHF high-risk AHFI and high-risk EHMRG indicated that patients might have a higher incidence of MACEs during hospitalisation. In addition, AHFI and high-risk EHMRG groups had shorter survival times, and AHFI was associated with 1-year mortality and was the risk factor for 1-year mortality.

CONCLUSION

AHFI combined with a high EHMRG risk model was associated with clinical outcomes and prognosis.

Effect of early physician follow-up on mortality and subsequent hospital admissions after emergency care for heart failure: a retrospective cohort study

BACKGROUND

The 1-year mortality rate in patients with heart failure who are discharged from an emergency department is 20%. We sought to determine whether early follow-up after discharge from the emergency department was associated with decreased mortality or subsequent admission to hospital.

METHODS

This retrospective cohort study conducted in Ontario, Canada, included adult patients who were discharged from 1 of 163 emergency departments between April 2007 and March 2014 with a primary diagnosis of heart failure. Using a propensity score-matched landmark analysis, we assessed follow-up in relation to mortality and admissions to hospital for cardiovascular conditions.

RESULTS

Of 34 519 patients, 16 274 (47.1%) obtained follow-up care within 7 days and 28 846 (83.6%) within 30 days. Compared with follow-up between day 8 and 30, patients with follow-up care within 7 days had a lower rate of mortality over 1 year (hazard ratio [HR] 0.92; 95% confidence interval [CI] 0.87-0.97), and a reduced rate of admission to hospital over 90 days (HR 0.87, 95% CI 0.80-0.94) and 1 year (HR 0.92; 95% CI 0.87-0.97); the mortality rate over 90 days in this group trended to a lower rate (HR 0.90, 95% CI 0.10-1.00). Follow-up care within 30 days, compared with patients without 30-day follow-up, was associated with a reduction in 1-year mortality (HR 0.89, 95% CI 0.82-0.97) but not admission to hospital (HR 1.02, 95% CI 0.94-1.10). In this group, there was a trend toward an increase in 90-day admission to hospital (HR 1.14, 95% CI 1.00-1.29).

INTERPRETATION

Follow-up care within 7 days of discharge from the emergency department was associated with lower rates of long-term mortality, as well as subsequent hospital admissions, and a trend to lower short-term mortality rates. Timely access to longitudinal care for patients with heart failure who are discharged from the emergency setting should be prioritized.

External Validation and Refinement of Emergency Heart Failure Mortality Risk Grade Risk Model in Patients With Heart Failure in the Emergency Department

Background

Emergency Heart Failure Mortality Risk Grade (EHMRG) assesses the risk of death within 7 days of emergency department (ED) presentation for patients with acute heart failure (AHF). We aimed to externally validate and refine the EHMRG model in patients who presented to the ED with AHF.

Methods

We performed a cohort study using administrative data for all ambulance-transported patients from Alberta (2012-2016) presenting to the ED with a primary diagnosis of AHF.

Results

Among 6708 patients with AHF, the 7-day mortality was 0.0%, 0.8%, 1.6%, 4.0%, 4.2%, and 12.0% across EHMRG risk categories (1-4, 5A and 5B). The EHMRG score had a c-index of 0.73 (95% confidence interval [CI], 0.71-0.76) for 7-day mortality and 0.71 (95% CI, 0.70-0.73) for 30-day mortality, but lower c-statistics for other outcomes (0.61-0.67). The inclusion of natriuretic peptides to the EHMRG model improved prediction (Net Reclassification Improvement, 0.268; 95% CI, 0.173-0.363; P < 0.01) for 7-day mortality, as did the addition of the Canadian Triage and Acuity Scale (Net Reclassification Improvement, 0.111; 95% CI, 0.005-0.218; P = 0.04).

Conclusion

The EHMRG model exhibited moderate discriminative ability in a large population-based cohort of patients with AHF in the ED. Revision of the EHMRG score through factor inclusion and exclusion could improve the model’s performance.

Critical Appraisal of Multivariable Prognostic Scores in Heart Failure: Development, Validation and Clinical Utility

Optimal management of heart failure requires accurate risk assessment. Many prognostic risk models have been proposed for patient with chronic and acute heart failure. Methodological critical issues are the data source, the outcome of interest, the choice of variables entering the model, the validation of the model in external population. Up to now, the proposed risk models can be a useful tool to help physician in the clinical decision-making. The availability of big data and of new methods of analysis may lead to developing new models in the future.

Design and rationale of a randomized trial: Using short stay units instead of routine admission to improve patient centered health outcomes for acute heart failure patients (SSU-AHF)

Nearly 85% of acute heart failure (AHF) patients who present to the emergency department (ED) with acute heart failure are hospitalized. Once hospitalized, within 30 days post-discharge, 27% of patients are re-hospitalized or die. Attempts to improve outcomes with novel therapies have all failed. The evidence for existing AHF therapies are poor: No currently used AHF treatment is known to improve long-term outcomes. ED treatment is largely the same today as 40 years ago. Admitting patients who could have avoided hospitalization may contribute to adverse outcomes. Hospitalization is not benign; patients enter a vulnerable phase post-discharge, at increased risk for morbidity and mortality. When hospitalization is able to be shortened or avoid completely, certain risks can be mitigated, including risk of medication errors, in-hospital falls, delirium, nosocomial infections, and other iatrogenic complications. Additionally, patients would prefer to be home, not hospitalized. Furthermore, hospitalization and re-hospitalization for AHF predominantly affects patients of lower socioeconomic status (SES). Avoiding hospitalization in patients who do not require admission may improve outcomes and quality of life, while reducing costs. Short stay unit (SSU: <24 h, also referred to as an 'observation unit') management of AHF may be effective for lower risk patients. However, to date there have only been small studies or retrospective analyses on the SSU management for AHF patients. In addition, SSU management has been considered 'cheating' for hospitals trying to avoid 30-day readmission penalties, as SSUs or observation units do not count as an admission. However, more recent analyses demonstrate differential use of observation status has not led to decreases in re-admission, suggesting this concern may be misplaced. Thus, we propose a robust clinical effectiveness trial to demonstrate the effectiveness of this patient-centered strategy.

What's Next for Acute Heart Failure Research?

Each year over one million patients with acute heart failure (AHF) present to a United States emergency department (ED). The vast majority are hospitalized for further management. The length of stay and high postdischarge event rate in this cohort have changed little over the past decade. Therapeutic trials have failed to yield substantive improvement in postdischarge outcomes; subsequently, AHF care has changed little in the past 40 years. Prior research studies have been fragmented as either "inpatient" or "ED-based." Recognizing the challenges in identification and enrollment of ED patients with AHF, and the lack of robust evidence to guide management, an AHF clinical trials network was developed. This network has demonstrated, through organized collaboration between cardiology and emergency medicine, that many of the hurdles in AHF research can be overcome. The development of a network that supports the collaboration of acute care and HF researchers, combined with the availability of federally funded infrastructure, will facilitate more efficient conduct of both explanatory and pragmatic trials in AHF. Yet many important questions remain, and in this document our group of emergency medicine and cardiology investigators have identified four high-priority research areas.

Acute Heart Failure in the Emergency Department: the SAFE-SIMEU Epidemiological Study

BACKGROUND

Patients with acute heart failure (AHF) have high rates of attendance to emergency departments (EDs), with significant health care costs.

OBJECTIVES

We aimed to describe the clinical characteristics of patients attending Italian EDs for AHF and their diagnostic and therapeutic work-up.

METHODS

We carried out a retrospective analysis on 2683 cases observed in six Italian EDs for AHF (January 2011 to June 2012).

RESULTS

The median age of patients was 84 years (interquartile range 12), with females accounting for 55.8% of cases (95% confidence interval [CI] 53.5-57.6%). A first episode of AHF was recorded in 55.3% (95% CI 55.4-57.2%). Respiratory disease was the main precipitating factor (approximately 30% of cases), and multiple comorbidities were recorded in > 50% of cases (history of acute coronary syndrome, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, valvular heart disease). The treatment was based on oxygen (69.7%; 67.9-71.5%), diuretics (69.2%; 67.9-71.5%), nitroglycerin (19.7%; 18.3-21.4%), and noninvasive ventilation (15.2%; 13.8-16.6%). Death occurred within 6 h in 2.5% of cases (2.0-3.1%), 6.4% (5.5-7.3%) were referred to the care of their general practitioners within a few hours from ED attendance or after short-term (< 24 h) observation 13.9% (12.6-15.2%); 60.4% (58.5-62.2%) were admitted to the hospital, and 16.8% (15.4-18.3%) were cared for in intensive care units according to disease severity.

CONCLUSIONS

Our study reporting the "real-world" clinical activity indicates that subjects attending the Italian EDs for AHF are rather different from those reported in international registries. Subjects are older, with a higher proportion of females, and high prevalence of cardiac and noncardiac comorbidities.

Design and rationale of the high-sensitivity Troponin T Rules Out Acute Cardiac Insufficiency Trial

Background

Acute heart failure (AHF) is a common presentation in the Emergency Department (ED), and most patients are admitted to the hospital. Identification of patients with AHF who have a low risk of adverse events and are suitable for discharge from the ED is difficult, and an objective tool would be useful.

Methods

The highly sensitive Troponin T Rules Out Acute Cardiac Insufficiency Trial (TACIT) will enroll ED patients being treated for AHF. Patients will undergo standard ED evaluation and treatment. High-sensitivity troponin T (hsTnT) will be drawn at the time of enrollment and 3 hours after the initial draw. The initial hsTnT draw will be no more than 3 hours after initiation of therapy for AHF (vasodilator, loop diuretic, noninvasive ventilation). Treating clinicians will be blinded to hsTnT results. We will assess whether hsTnT, as a single measurement or in series, can accurately predict patients at low risk of short-term adverse events.

Conclusion

TACIT will explore the value of hsTnT measurements in isolation, or in combination with other markers of disease severity, for the identification of ED patients with AHF who are at low risk of short-term adverse events.

Acute Heart Failure: Alternatives to Hospitalization

Acute heart failure (HF) is a major public health problem with substantial associated economic costs. Because most patients who present to hospitals are admitted irrespective of their level of risk, novel approaches to manage acute HF are needed, such as the use of same-day access clinics for outpatient diuresis and observation units from the emergency department. Current published data lacks a comprehensive overview of the present state of acute HF management in various clinical settings. This review summarizes the strengths and limitations of acute HF care in the outpatient and emergency department settings. Finally, a variety of innovative technologies that have the potential to improve acute HF management are discussed.

Prospective and Explicit Clinical Validation of the Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative NT-proBNP

OBJECTIVES

We previously developed the Ottawa Heart Failure Risk Scale (OHFRS) to assist with disposition decisions for acute heart failure patients in the emergency department (ED). We sought to prospectively evaluate the accuracy, acceptability, and potential impact of OHFRS.

METHODS

This prospective observational cohort study was conducted at six tertiary hospital EDs. Patients with acute heart failure were evaluated by ED physicians for the 10 OHFRS criteria and then followed for 30 days. Quantitative NT-proBNP was measured where feasible. Serious adverse event (SAE) was defined as death within 30 days, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction, or relapse resulting in hospital admission within 14 days.

RESULTS

We enrolled 1,100 patients with mean (±SD) age 77.7 (±10.7) years. SAEs occurred in 170 (15.5%) cases (19.4% if admitted and 10.2% if discharged). Compared to actual practice, using an admission threshold of OHFRS score > 1 would have increased sensitivity (71.8% vs. 91.8%) but increased admissions (57.2% vs. 77.6%). For 684 cases with NT-proBNP values, using a threshold score > 1 would have significantly increased sensitivity (69.8% vs. 95.8%) while increasing admissions (60.8% vs. 88.0%). In only 11.9% of cases did physicians indicate discomfort with use of OHFRS.

CONCLUSION

Prospective clinical validation found the OHFRS tool to be highly sensitive for SAEs in acute heart failure patients, albeit with an increase in admission rates. When available, NT-proBNP values further improve sensitivity. With adequate physician training, OHFRS should help improve and standardize admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients.

Combining training in knowledge translation with quality improvement reduced 30-day heart failure readmissions in a community hospital: a case study

RATIONALE, AIMS AND OBJECTIVES

Training programmes in evidence-based practice (EBP) frequently fail to translate their content into practice change and care improvement. We linked multidisciplinary training in EBP to an initiative to decrease 30-day readmissions among patients admitted to a community teaching hospital for heart failure (HF).

METHODS

Hospital staff reflecting all services and disciplines relevant to care of patients with HF attended a 3-day innovative capacity building conference in evidence-based health care over a 3-year period beginning in 2009. The team, facilitated by a conference faculty member, applied a knowledge-to-action model taught at the conference. We reviewed published research, profiled our population and practice experience, developed a three-phase protocol and implemented it in late 2010. We tracked readmission rates, adverse clinical outcomes and programme cost.

RESULTS

The protocol emphasized patient education, medication reconciliation and transition to community-based care. Senior administration approved a full-time nurse HF coordinator. Thirty-day HF readmissions decreased from 23.1% to 16.4% (adjusted OR = 0.64, 95% CI = 0.42-0.97) during the year following implementation. Corresponding rates in another hospital serving the same population but not part of the programme were 22.3% and 20.2% (adjusted OR = 0.87, 95% CI = 0.71-1.08). Adherence to mandated HF quality measures improved. Following a start-up cost of $15 000 US, programme expenses balanced potential savings from decreased HF readmissions.

CONCLUSION

Training of a multidisciplinary hospital team in use of a knowledge translation model, combined with ongoing facilitation, led to implementation of a budget neutral programme that decreased HF readmissions.

Use of High-Sensitivity Troponin T to Identify Patients With Acute Heart Failure at Lower Risk for Adverse Outcomes: An Exploratory Analysis From the RELAX-AHF Trial

OBJECTIVES

The aim of this study was to determine if a baseline high-sensitivity troponin T (hsTnT) value ≤99th percentile upper reference limit (0.014 μg/l ["low hsTnT"]) identifies patients at low risk for adverse outcomes.

BACKGROUND

Approximately 85% of patients who present to emergency departments with acute heart failure are admitted. Identification of patients at low risk might decrease unnecessary admissions.

METHODS

A post-hoc analysis was conducted from the RELAX-AHF (Serelaxin, Recombinant Human Relaxin-2, for Treatment of Acute Heart Failure) trial, which randomized patients within 16 h of presentation who had systolic blood pressure >125 mm Hg, mild to moderate renal impairment, and N-terminal pro-brain natriuretic peptide ≥1,600 ng/l to serelaxin versus placebo. Linear regression models for continuous endpoints and Cox models for time-to-event endpoints were used.

RESULTS

Of the 1,076 patients with available baseline hsTnT values, 107 (9.9%) had low hsTnT. No cardiovascular (CV) deaths through day 180 were observed in the low-hsTnT group compared with 79 CV deaths (7.3%) in patients with higher hsTnT. By univariate analyses, low hsTnT was associated with lower risk for all 5 primary outcomes: 1) days alive and out of the hospital by day 60; 2) CV death or rehospitalization for heart failure or renal failure by day 60; 3) length of stay; 4) worsening heart failure through day 5; and 5) CV death through day 180. After multivariate adjustment, only 180-day CV mortality remained significant (hazard ratio: 0.0; 95% confidence interval: 0.0 to 0.736; p = 0.0234; C-index = 0.838 [95% confidence interval: 0.798 to 0.878]).

CONCLUSIONS

No CV deaths through day 180 were observed in patients with hsTnT levels ≤0.014 μg/l despite high N-terminal pro-brain natriuretic peptide levels. Low baseline hsTnT may identify patients with acute heart failure at very low risk for CV mortality.

Predicting mortality in patients with acute heart failure: Role of risk scores

Acute heart failure is a leading cause of hospitalization and death, and it is an increasing burden on health care systems. The correct risk stratification of patients could improve clinical outcome and resources allocation, avoiding the overtreatment of low-risk subjects or the early, inappropriate discharge of high-risk patients. Many clinical scores have been derived and validated for in-hospital and post-discharge survival; predictive models include demographic, clinical, hemodynamic and laboratory variables. Data sets are derived from public registries, clinical trials, and retrospective data. Most models show a good capacity to discriminate patients who reach major clinical end-points, with C-indices generally higher than 0.70, but their applicability in real-world populations has been seldom evaluated. No study has evaluated if the use of risk score-based stratification might improve patient outcome. Some variables (age, blood pressure, sodium concentration, renal function) recur in most scores and should always be considered when evaluating the risk of an individual patient hospitalized for acute heart failure. Future studies will evaluate the emerging role of plasma biomarkers.

Identification of Emergency Department Patients With Acute Heart Failure at Low Risk for 30-Day Adverse Events: The STRATIFY Decision Tool

OBJECTIVES

No prospectively derived or validated decision tools identify emergency department (ED) patients with acute heart failure (AHF) at low risk for 30-day adverse events who are thus potential candidates for safe ED discharge. This study sought to accomplish that goal.

BACKGROUND

The nearly 1 million annual ED visits for AHF are associated with high proportions of admissions and consume significant resources.

METHODS

We prospectively enrolled 1,033 patients diagnosed with AHF in the ED from 4 hospitals between July 20, 2007, and February 4, 2011. We used an ordinal outcome hierarchy, defined as the incidence of the most severe adverse event within 30 days of ED evaluation (acute coronary syndrome, coronary revascularization, emergent dialysis, intubation, mechanical cardiac support, cardiopulmonary resuscitation, and death).

RESULTS

Of 1,033 patients enrolled, 126 (12%) experienced at least one 30-day adverse event. The decision tool had a C statistic of 0.68 (95% confidence interval: 0.63 to 0.74). Elevated troponin (p < 0.001) and renal function (p = 0.01) were significant predictors of adverse events in our multivariable model, whereas B-type natriuretic peptide (p = 0.09), tachypnea (p = 0.09), and patients undergoing dialysis (p = 0.07) trended toward significance. At risk thresholds of 1%, 3%, and 5%, we found 0%, 1.4%, and 13.0% patients were at low risk, with negative predictive values of 100%, 96%, and 93%, respectively.

CONCLUSIONS

The STRATIFY decision tool identifies ED patients with AHF who are at low risk for 30-day adverse events and may be candidates for safe ED discharge. After external testing, and perhaps when used as part of a shared decision-making strategy, it may significantly affect disposition strategies. (Improving Heart Failure Risk Stratification in the ED [STRATIFY]; NCT00508638).

[Key messages for the initial management of the elderly patient with acute heart failure]

Acute heart failure is a high prevalence geriatric syndrome that has become one of the most frequent causes of visits to emergency departments, as well as hospital admission, and is associated with high morbidity, mortality and functional impairment. There has been an increasing amount of information published in recent years on the initial management of acute heart failure and the results of the short-term outcomes, as well as the natural history of the disease. The objective of this study is to provide several recommendations that should be taken into account in the initial management of the elderly patient with acute heart failure in the emergency departments, and to review the most interesting currently on-going clinical trials.

Prognostic scores in heart failure - Critical appraisal and practical use

Survival in patients with heart failure in the last two decades has significantly improved, owing to availability of new drugs, devices, and technologies. However, these new therapeutic tools are often costly and not without attendant risks. Thus, accurate and reproducible risk stratification is required to assess appropriateness of therapy. Although a growing body of evidence has characterized various predictors of poor outcomes, the application of comprehensive prognostic models in clinical practice remains limited. Herein, we critically evaluate the utility of prognostic scores in heart failure, discussing the strategies to select the most efficient and appropriate risk estimator in the individual patient.

An early warning scoring system for the prevention of acute heart failure

BACKGROUND

Early prediction and identification of the onset of acute heart failure (AHF) in high-risk patients are of great significance for preemptive treatment and a better prognosis. We sought to find a scoring system to predict the onset of AHF in patients in the acute heart failure unit (AHFU).

METHODS

Data for 433 patients at of AHF in the AHFU were analyzed. We recorded sex, age, history of coronary artery disease, hypertension, diabetes, and primary percutaneous coronary intervention. We also reviewed temperature, pulse, SpO₂, respiratory rate, urine volume, and emotional state every hour before the onset of AHF. All admission and follow-up data were retrieved from hospital charts. Factors were analyzed using a binary logistic regression model to create the SUPER (SpO₂, urine volume, pulse, emotional state, and respiratory rate) scoring model. We divided the scoring system into four levels: low-, intermediate-, high-, and extremely high-risk. Patients fitting the four risk levels were followed up for 6 to 24 months.

RESULTS

SpO₂, hourly urine volume, pulse, emotional state and respiratory rates were associated with an independent increased risk for the onset of AHF. The SUPER score for the patients in the AHFU predicted the onset of AHF 3.90 ± 1.94 h (1-17 h) earlier. The areas under the ROC curve for the SUPER score and the modified early warning score were 0.811 and 0.662 (p<0.05), indicating that the SUPER score provided a better warning of the AHF. A low-, intermediate-, high-, and very high-risk SUPER predicted the likelihood of AHF at 17.3%, 61.3%, 84.4%, and 94.0%, respectively. The differences in mortality rates between the four levels were statistically significant (p<0.05).

CONCLUSIONS

In patients at high risk of AHF, the SUPER scoring system could predict the onset of AHF 2 to 6h earlier. Preemptive treatment according to the SUPER score may prevent or delay AHF occurrence to improve quality of life and reduce mortality.

Cardiopulmonary resuscitation of pregnant women in the emergency department

AIM

Little is known about outcomes of cardiopulmonary resuscitation (CPR) in pregnancy. The purpose of this study was to determine the prognostic value of pregnancy in women receiving CPR in the emergency department (ED).

METHODS

We conducted a population-based, matched cohort study using the Nationwide Emergency Department Sample (NEDS) from 2006 to 2010. A cohort of pregnant women receiving CPR in the ED was compared to an age-matched cohort of non-pregnant women at a 1:10 ratio. Conditional logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence intervals (95% CIs) for variables of interest and survival.

RESULTS

Among 8162 women requiring CPR in the ED, we identified 157 pregnant women. Pregnancy was associated with better overall survival of 36.9% compared to 25.9% in non-pregnant women, OR 1.89 (1.32-2.70), p < 0.01. Traumatic injury was identified as a significant predictor of outcome in pregnancy. In non-trauma patients, pregnant women had significantly better odds of surviving CPR than non-pregnant women, OR 2.10 (1.41-3.13), p < 0.01. In cases of trauma, no significant difference was observed between groups.

CONCLUSION

Although further studies are needed, CPR in pregnancy is associated with a better prognosis compared to non-pregnant women, with trauma status being a key factor predicting outcome in the pregnant patient.

Early management of patients with acute heart failure: state of the art and future directions. A consensus document from the society for academic emergency medicine/heart failure society of America acute heart failure working group

Heart failure (HF) afflicts nearly 6 million Americans, resulting in one million emergency department (ED) visits and over one million annual hospital discharges. An aging population and improved survival from cardiovascular diseases is expected to further increase HF prevalence. Emergency providers play a significant role in the management of patients with acute heart failure (AHF). It is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics and alternatives to hospitalization. Further, clinical trials must be conducted in the ED in order to improve the evidence base and drive optimal initial therapy for AHF. Should ongoing and future studies suggest early phenotype-driven therapy improves in-hospital and post-discharge outcomes, ED treatment decisions will need to evolve accordingly. The potential impact of future studies which incorporate risk-stratification into ED disposition decisions cannot be underestimated. Predictive instruments that identify a cohort of patients safe for ED discharge, while simultaneously addressing barriers to successful outpatient management, have the potential to significantly impact quality of life and resource expenditures.

Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis

OBJECTIVES

A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death.

METHODS

A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome.

RESULTS

A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%.

CONCLUSIONS

Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult.

Early management of patients with acute heart failure: state of the art and future directions--a consensus document from the SAEM/HFSA acute heart failure working group

Heart failure (HF) afflicts nearly 6 million Americans, resulting in 1 million emergency department (ED) visits and over 1 million annual hospital discharges. The majority of inpatient admissions originate in the ED; thus, it is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics, and alternatives to hospitalization. This article discusses contemporary ED management as well as the necessary next steps for ED-based acute HF research.

Moving toward comprehensive acute heart failure risk assessment in the emergency department: the importance of self-care and shared decision making

Nearly 700,000 emergency department (ED) visits were due to acute heart failure (AHF) in 2009. Most visits result in a hospital admission and account for the largest proportion of a projected $70 billion to be spent on heart failure care by 2030. ED-based risk prediction tools in AHF rarely impact disposition decision making. This is a major factor contributing to the 80% admission rate for ED patients with AHF, which has remained unchanged over the last several years. Self-care behaviors such as symptom monitoring, medication taking, dietary adherence, and exercise have been associated with decreased hospital readmissions, yet self-care remains largely unaddressed in ED patients with AHF and thus represents a significant lost opportunity to improve patient care and decrease ED visits and hospitalizations. Furthermore, shared decision making encourages collaborative interaction between patients, caregivers, and providers to drive a care path based on mutual agreement. The observation that “difficult decisions now will simplify difficult decisions later” has particular relevance to the ED, given this is the venue for many such issues. We hypothesize patients as complex and heterogeneous as ED patients with AHF may need both an objective evaluation of physiologic risk as well as an evaluation of barriers to ideal self-care, along with strategies to overcome these barriers. Combining physician gestalt, physiologic risk prediction instruments, an evaluation of self-care, and an information exchange between patient and provider using shared decision making may provide the critical inertia necessary to discharge patients home after a brief ED evaluation.

The role of the emergency department in the patient with acute heart failure

The diagnosis and management of the patient with acute decompensated heart failure (ADHF) presents a unique challenge to the emergency medicine (EM) physician. ADHF is one of the most common cardiac emergencies managed in the emergency department (ED). ED presentations for ADHF will grow as survival rates after myocardial infarction continue to increase and thus, the incidence and prevalence of heart failure (HF) increases. There are very little data to aid EM physicians when trying to identify low-risk patients who are safe for ED discharge and observation units are not yet universally utilized. This results in 80% of patients with ADHF getting admitted to the hospital. The aim of this review is to evaluate current strategies for diagnosis, treatment, and disposition of the ADHF patient in the ED while highlighting new approaches for treatment and disposition, and areas in need of additional research.

Acute decompensated heart failure: update on new and emerging evidence and directions for future research

Acute decompensated heart failure (ADHF) is a complex clinical event associated with excess morbidity and mortality. Managing ADHF patients is challenging because of the lack of effective treatments that both reduce symptoms and improve clinical outcomes. Existing guideline recommendations are largely based on expert opinion, but several recently published trials have yielded important data to inform both current clinical practice and future research directions. New insight has been gained regarding volume management, including dosing strategies for intravenous loop diuretics and the role of ultrafiltration in patients with heart failure and renal dysfunction. Although the largest ADHF trial to date (ASCEND-HF, using nesiritide) was neutral, promising results with other investigational agents have been reported. If these findings are confirmed in phase III trials, novel compounds, such as relaxin, omecamtiv mecarbil, and ularitide, among others, may become therapeutic options. Translation of research findings into quality clinical care can not be overemphasized. Although many gaps in knowledge exist, ongoing studies will address issues around delivery of evidence-based care to achieve the goal of improving the health status and clinical outcomes of patients with ADHF.

Initial management of patients with acute heart failure

Pressure exists to manage patients with acute decompensated heart failure (ADHF) efficiently in the acute-care environment. Although most patients present with worsening of chronic heart failure, some may present with undifferentiated dyspnea and new-onset heart failure. Others have significant comorbidities that complicate both the diagnosis and treatment. The treatment of patients with ADHF is prioritized based on vital signs and presenting phenotype. The risk stratification of patients is the subject of ongoing evaluation. The disposition of patients to areas other than a monitored inpatient bed, such as an emergency department-based observation unit, may prove effective.

Variation exists in rates of admission to intensive care units for heart failure patients across hospitals in the United States

BACKGROUND

Despite increasing attention on reducing relatively costly hospital practices while maintaining the quality of care, few studies have examined how hospitals use the intensive care unit (ICU), a high-cost setting, for patients admitted with heart failure (HF). We characterized hospital patterns of ICU admission for patients with HF and determined their association with the use of ICU-level therapies and patient outcomes.

METHODS AND RESULTS

We identified 166 224 HF discharges from 341 hospitals in the 2009-2010 Premier Perspective database. We excluded hospitals with <25 HF admissions, patients <18 years old, and transfers. We defined ICU as including medical ICU, coronary ICU, and surgical ICU. We calculated the percent of patients admitted directly to an ICU. We compared hospitals in the top quartile (high ICU admission) with the remaining quartiles. The median percentage of ICU admission was 10% (interquartile range, 6%-16%; range, 0%-88%). In top-quartile hospitals, treatments requiring an ICU were used less often; the percentage of ICU days receiving mechanical ventilation was 6% for the top quartile versus 15% for the others; noninvasive positive pressure ventilation, 8% versus 19%; vasopressors and/or inotropes, 9% versus 16%; vasodilators, 6% versus 12%; and any of these interventions, 26% versus 51%. Overall HF in-hospital risk-standardized mortality was similar (3.4% versus 3.5%; P=0.2).

CONCLUSIONS

ICU admission rates for HF varied markedly across hospitals and lacked association with in-hospital risk-standardized mortality. Greater ICU use correlated with fewer patients receiving ICU interventions. Judicious ICU use could reduce resource consumption without diminishing patient outcomes.

A risk scoring system to identify emergency department patients with heart failure at high risk for serious adverse events

OBJECTIVES

There are no validated guidelines to guide physicians with difficult disposition decisions for emergency department (ED) patients with heart failure (HF). The authors sought to develop a risk scoring system to identify HF patients at high risk for serious adverse events (SAEs).

METHODS

This was a prospective cohort study at six large Canadian EDS that enrolled adult patients who presented with acute decompensated HF. Each patient was assessed for standardized clinical and laboratory variables as well as for SAEs defined as death, intubation, admission to a monitored unit, or relapse requiring admission. Adjusted odds ratios for predictors of SAEs were calculated by stepwise logistic regression.

RESULTS

In 559 visits, 38.1% resulted in patient admission. Of 65 (11.6%) SAE cases, 31 (47.7%) occurred in patients not initially admitted. The multivariate model and resultant Ottawa Heart Failure Risk Scale consists of 10 elements, and the risk of SAEs varied from 2.8% to 89.0%, with good calibration between observed and expected probabilities. Internal validation showed the risk scores to be very accurate across 1,000 replications using the bootstrap method. A threshold of 1, 2, or 3 total scores for admission would be associated with sensitivities of 95.2, 80.6, or 64.5%, respectively, all better than current practice.

CONCLUSIONS

Many HF patients are discharged home from the ED and then suffer SAEs or death. The authors have developed an accurate risk scoring system that could ultimately be used to stratify the risk of poor outcomes and to enable rational and safe disposition decisions.

Risk stratification in acute heart failure: rationale and design of the STRATIFY and DECIDE studies

BACKGROUND

A critical challenge for physicians facing patients presenting with signs and symptoms of acute heart failure (AHF) is how and where to best manage them. Currently, most patients evaluated for AHF are admitted to the hospital, yet not all warrant inpatient care. Up to 50% of admissions could be potentially avoided and many admitted patients could be discharged after a short period of observation and treatment. Methods for identifying patients that can be sent home early are lacking. Improving the physician's ability to identify and safely manage low-risk patients is essential to avoiding unnecessary use of hospital beds.

METHODS

Two studies (STRATIFY and DECIDE) have been funded by the National Heart Lung and Blood Institute with the goal of developing prediction rules to facilitate early decision making in AHF. Using prospectively gathered evaluation and treatment data from the acute setting (STRATIFY) and early inpatient stay (DECIDE), rules will be generated to predict risk for death and serious complications. Subsequent studies will be designed to test the external validity, utility, generalizability and cost-effectiveness of these prediction rules in different acute care environments representing racially and socioeconomically diverse patient populations.

RESULTS

A major innovation is prediction of 5-day as well as 30-day outcomes, overcoming the limitation that 30-day outcomes are highly dependent on unpredictable, post-visit patient and provider behavior. A novel aspect of the proposed project is the use of a comprehensive cardiology review to correctly assign post-treatment outcomes to the acute presentation.

CONCLUSIONS

Finally, a rigorous analysis plan has been developed to construct the prediction rules that will maximally extract both the statistical and clinical properties of every data element. Upon completion of this study we will subsequently externally test the prediction rules in a heterogeneous patient cohort.

Predicting costs of care in heart failure patients

BACKGROUND

Identifying heart failure patients most likely to suffer poor outcomes is an essential part of delivering interventions to those most likely to benefit. We sought a comprehensive account of heart failure events and their cumulative economic burden by examining patient characteristics that predict increased cost or poor outcomes.

METHODS

We collected electronic medical data from members of a large HMO who had a heart failure diagnosis and an echocardiogram from 1999-2004, and followed them for one year. We examined the role of demographics, clinical and laboratory findings, comorbid disease and whether the heart failure was incident, as well as mortality. We used regression methods appropriate for censored cost data.

RESULTS

Of the 4,696 patients, 8% were incident. Several diseases were associated with significantly higher and economically relevant cost changes, including atrial fibrillation (15% higher), coronary artery disease (14% higher), chronic lung disease (29% higher), depression (36% higher), diabetes (38% higher) and hyperlipidemia (21% higher). Some factors were associated with costs in a counterintuitive fashion (i.e. lower costs in the presence of the factor) including age, ejection fraction and anemia. But anemia and ejection fraction were also associated with a higher death rate.

CONCLUSIONS

Close control of factors that are independently associated with higher cost or poor outcomes may be important for disease management. Analysis of costs in a disease like heart failure that has a high death rate underscores the need for economic methods to consider how mortality should best be considered in costing studies.

Eating a larger number of high-salt foods is not associated with short-term risk of acute decompensation in patients with chronic heart failure

BACKGROUND

Risk factors for exacerbation of congestive heart failure have not been consistently validated.

OBJECTIVE

Our objective was to examine the role of short-term dietary sodium intake in acute decompensated heart failure.

METHODS

Patients with chronic congestive heart failure presenting to the Emergency Department for either acute decompensated heart failure (cases) or for other reasons (controls) were included in a case-control study. Cases and controls were compared with respect to age, smoking, recent sodium intake, medication nonadherence, coronary artery disease, and hypertension. A food frequency questionnaire was utilized to estimate recent sodium intake, defined as the number of food types consumed in the previous 3 days from the 12 highest-sodium food categories.

RESULTS

There were 182 patients enrolled. One patient was excluded due to uncertainty about the primary diagnosis. When adjusted for age, smoking, medication nonadherence, coronary artery disease, and hypertension, acute decompensated heart failure was not associated with short-term dietary sodium intake. The odds ratio for acute decompensated heart failure for each increase in the number of high-sodium food types consumed was 1.1 (95% confidence interval 0.9-1.3; p = 0.3). Acute decompensated heart failure was associated with medication nonadherence, with an odds ratio for decompensation of 2.5 (95% confidence interval 1.2-5.1; p = 0.01).

CONCLUSIONS

Patients with chronic congestive heart failure who presented to the Emergency Department with acute decompensated heart failure were no more likely to report consuming a greater number of high-sodium foods in the 3 days before than were patients with chronic congestive heart failure who presented with unrelated symptoms. On the other hand, those who presented with acute decompensated heart failure were significantly more likely to report nonadherence with medications.

The challenge of heart failure discharge from the emergency department

Acute decompensated heart failure is a common reason for presentation to the emergency department and is associated with high rates of admission to hospital. Distinguishing between higher-risk patients needing hospitalization and lower-risk patients suitable for discharge home is important to optimize both cost-effectiveness and clinical outcomes. However, this can be challenging and few validated risk stratification tools currently exist to help clinicians. Some prognostic variables predict risks broadly in those who are admitted or discharged from the emergency department. Risk stratification methods such as the Emergency Heart Failure Mortality Risk Grade and Acute Heart Failure Index clinical decision support tools, which utilize many of these predictors, have been found to be accurate in identifying low-risk patients. The use of observation units may also be a cost-effective adjunctive strategy that can assist in determining disposition from the emergency department.

Validating the acute heart failure index for patients presenting to the emergency department with decompensated heart failure

BACKGROUND

The acute heart failure index (AHFI) is a previously derived prediction rule to identify patients presenting to emergency departments (ED) with decompensated heart failure (DHF) at low risk of early life-threatening events.

STUDY OBJECTIVES

To validate the AHFI prospectively.

METHODS

Using a prospective cohort study, adult patients presenting to an urban university hospital ED with DHF were included. Data on 21 variables were gathered to calculate the AHFI. Primary endpoints included inpatient death and non-fatal serious outcomes (myocardial infarction, ventricular fibrillation, cardiogenic shock, cardiac arrest, intubation, or cardiac reperfusion). Secondary endpoints included death from any cause or readmission for heart failure within 30 days. Primary and secondary endpoint rates were calculated with 95% CI for the low and higher-risk subgroups.

RESULTS

259 patients were enrolled. 245/259 (95%) were admitted. 60/259 (23%) met low-risk criteria, of whom 1/60 (1.7%, CI 0.04 to 8.9) was discharged after sustaining pulseless electrical activity arrest. The comparable primary outcome rate in the derivation study was 1.4% (CI 1.1 to 1.7). 17/199 (8.5%, CI 5.1 to 13.3) higher-risk patients experienced an endpoint, compared with 13.3% (CI 12.9 to 13.7) in the derivation cohort. One low-risk patient (1.7%, CI 0.04 to 8.9) died within 30 days, and five (8.3%, CI 2.8 to 18.4) were readmitted. Corresponding rates in the derivation study were 2% and 5%, respectively.

CONCLUSION

The results are consistent with those previously reported for the low-risk subgroup of the AHFI. Further research is needed to determine the impact, safety and full range of generalisability of the AHFI as an adjunct to decision making.

Brain natriuretic peptide in the evaluation of emergency department dyspnea: is there a role?

BACKGROUND

Acute decompensated congestive heart failure (ADCHF) is a common etiology of dyspnea in emergency department (ED) patients. Delayed diagnosis of ADCHF increases morbidity and mortality. Two cardiac biomarkers, N-terminal-pro brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) have demonstrated excellent sensitivity in diagnostic accuracy studies, but the clinical impact on patient-oriented outcomes of these tests remains in question.

CLINICAL QUESTION

Does emergency physician awareness of BNP or NT-proBNP level improve ADCHF patient-important outcomes including ED length of stay, hospital length of stay, cardiovascular mortality, or overall health care costs?

EVIDENCE REVIEW

Five trials have randomized clinicians to either knowledge of or no knowledge of ADCHF biomarker levels in ED patients with dyspnea and some suspicion for heart failure. In assessing patient-oriented outcomes such as length-of-stay, return visits, and overall health care costs, the randomized controlled trials fail to provide evidence of unequivocal benefit to patients, clinicians, or society.

CONCLUSION

Clinician awareness of BNP or NT-proBNP levels in ED dyspnea patients does not necessarily improve outcomes. Future ADCHF biomarker trials must assess patient-oriented outcomes in conjunction with validated risk-stratification instruments.

Multivariate risk scores and patient outcomes in advanced heart failure

Significant improvements in survival have occurred for patients with advanced heart failure, with an increasing array of therapeutic options sharing quite varied properties of cost, invasiveness, and impact on life expectancy. Risk models allow patients and providers to achieve a better understanding of prognosis than is possible through unstructured holistic assessment. This article reviews scoring systems for heart failure prognostication in the general sense and in the setting of providing answers to specific clinical queries. Topics addressed include outpatient survival, risk of inpatient and post-discharge mortality, potential changes to clinician decision-making through better understanding of prognosis, and mortality after having a left ventricular assist device placed or receiving an implantable cardiac-defibrillator.

Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care

The decision to admit a patient to the hospital after an emergency department (ED) visit is expensive, frequently not evidence-based, and variable. Outpatient critical pathways are a promising approach to reduce hospital admission after emergency care. Critical pathways exist to risk stratify patients for potentially serious diagnoses (e.g., acute myocardial infarction [AMI]) or evaluate response to therapy (e.g., community-acquired pneumonia) within a short time period (i.e., less than 36 hours), to determine if further hospital-based acute care is needed. Yet, such pathways are variably used while many patients are admitted for conditions for which they could be treated as outpatients. In this article, the authors propose a model of post-ED critical pathways, describe their role in emergency care, list common diagnoses that are amenable to critical pathways in the outpatient setting, and propose a research agenda to address barriers and solutions to increase the use of outpatient critical pathways. If emergency providers are to routinely conduct rapid evaluations in outpatient or observation settings, they must have several conditions at their disposal: 1) evidence-based tools to accurately risk stratify patients for protocolized care, 2) systems of care that reliably facilitate workup in the outpatient setting, and 3) a medical environment conducive to noninpatient pathways, with aligned risks and incentives among patients, providers, and payers. Increased use of critical pathways after emergency care is a potential way to improve the value of emergency care.

Optimized retrieval of primary care clinical prediction rules from MEDLINE to establish a Web-based register

OBJECTIVES

Identifying clinical prediction rules (CPRs) for primary care from electronic databases is difficult. This study aims to identify a search filter to optimize retrieval of these to establish a register of CPRs for the Cochrane Primary Health Care field.

STUDY DESIGN AND SETTING

Thirty primary care journals were manually searched for CPRs. This was compared with electronic search filters using alternative methodologies: (1) textword searching; (2) proximity searching; (3) inclusion terms using specific phrases and truncation; (4) exclusion terms; and (5) combinations of methodologies.

RESULTS

We manually searched 6,344 articles, revealing 41 CPRs. Across the 45 search filters, sensitivities ranged from 12% to 98%, whereas specificities ranged from 43% to 100%. There was generally a trade-off between the sensitivity and specificity of each filter (i.e., the number of CPRs and total number of articles retrieved). Combining textword searching with the inclusion terms (using specific phrases) resulted in the highest sensitivity (98%) but lower specificity (59%) than other methods. The associated precision (2%) and accuracy (60%) were also low.

CONCLUSION

The novel use of combining textword searching with inclusion terms was considered the most appropriate for updating a register of primary care CPRs where sensitivity has to be optimized.