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Jiang GY, Lee C, Kearing SA, Wadhera RK, Gavin MC, Wasfy JH, Zeitler EP. IV Diuresis in Alternative Treatment Settings for the Management of Heart Failure: Implications for Mortality, Hospitalizations and Cost. J Card Fail 2024; 30:4-11. [PMID: 37714260 PMCID: PMC10840839 DOI: 10.1016/j.cardfail.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Recent advances in heart failure (HF) care have sought to shift management from inpatient to outpatient and observation settings. We evaluated the association among HF treatment in the (1) inpatient; (2) observation; (3) emergency department (ED); and (4) outpatient settings with 30-day mortality, hospitalizations and cost. METHODS Using 100% Medicare inpatient, outpatient and Part B files from 2011-2018, 1,534,708 unique patient encounters in which intravenous (IV) diuretics were received for a primary diagnosis of HF were identified. Encounters were sorted into mutually exclusive settings: (1) inpatient; (2) observation; (3) ED; or (4) outpatient IV diuretic clinic. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 30-day hospitalization and total 30-day costs. Multivariable logistic and linear regression were used to examine the association between treatment location and the primary and secondary outcomes. RESULTS Patients treated in observation and outpatient settings had lower 30-day mortality rates (observation OR 0.67, 95% CI 0.66-0.69; P < 0.001; outpatient OR 0.53, 95% CI 0.51-0.55; P < 0.001) compared to those treated in inpatient settings. Observation and outpatient treatment were also associated with decreased 30-day total cost compared to inpatient treatment. Observation relative cost -$5528.77, 95% CI -$5613.63 to -$5443.92; outpatient relative cost -$7005.95; 95% CI -$7103.94 to -$6907.96). Patients treated in the emergency department and discharged had increased mortality rates (OR 1.15, 95% CI 1.13-1.17; P < 0.001) and increased rates of hospitalization (OR 1.72, 95% CI 1.70-1.73; P < 0.001) compared to patients treated as inpatients. CONCLUSIONS Medicare beneficiaries who received IV diuresis for acute HF in the outpatient and observation settings had lower mortality rates and decreased costs of care compared to patients treated as inpatients. Outpatient and observation management of acute decompensated HF, when available, is a safe and cost-effective strategy in certain populations of patients with HF.
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Affiliation(s)
- Ginger Y Jiang
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christopher Lee
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Stephen A Kearing
- The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, NH
| | - Rishi K Wadhera
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michael C Gavin
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Emily P Zeitler
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, NH.
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Pathangey G, D’Anna SP, Moudgal RA, Min DB, Manning KA, Taub CC, Gilstrap LG. Outpatient intravenous diuresis in a rural setting: safety, efficacy, and outcomes. Front Cardiovasc Med 2023; 10:1155957. [PMID: 37304943 PMCID: PMC10248139 DOI: 10.3389/fcvm.2023.1155957] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Purpose To evaluate the safety, efficacy, and outcomes of outpatient intravenous diuresis in a rural setting and compare it to urban outcomes. Methods A single-center study was conducted on 60 patients (131 visits) at the Dartmouth-Hitchcock Medical Center (DHMC) from 1/2021-12/2022. Demographics, visit data, and outcomes were collected and compared to urban outpatient IV centers, and inpatient HF hospitalizations from DHMC FY21 and national means. Descriptive statistics, T-tests and chi-squares were used. Results The mean age was 70 ± 13 years, 58% were male, and 83% were NYHA III-IV. Post-diuresis, 5% had mild-moderate hypokalemia, 16% had mild worsening of renal function, and 3% had severe worsening of renal function. No hospitalizations occurred due to adverse events. The mean infusion-visit urine output was 761 ± 521 ml, and post-visit weight loss was -3.9 ± 5.0 kg. No significant differences were observed between HFpEF and HFrEF groups. 30-day readmissions were similar to urban outpatient IV centers, DHMC FY21, and the national mean (23.3% vs. 23.5% vs. 22.2% vs. 22.6%, respectively; p = 0.949). 30-day mortality was similar to urban outpatient IV centers but lower than DHMC FY21 and the national means (1.7% vs. 2.5% vs. 12.3% vs. 10.7%, respectively; p < 0.001). At 60 days, 42% of patients had ≥1 clinic revisit, 41% had ≥1 infusion revisit, 33% were readmitted to the hospital, and two deaths occurred. The clinic avoided 21 hospitalizations, resulting in estimated cost savings of $426,111. Conclusion OP IV diuresis appears safe and effective for rural HF patients, potentially decreasing mortality rates and healthcare expenses while mitigating rural-urban disparities.
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Affiliation(s)
- Girish Pathangey
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Susan P D’Anna
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Rohitha A. Moudgal
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David B. Min
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Katharine A. Manning
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Cynthia C. Taub
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Lauren G. Gilstrap
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Herrera-Leaño N, Barahona-Correa JE, Muñoz-Velandia O, Fernández-Ávila DG, Mariño-Correa A, Alberto García Á. Evaluation of diuretic efficiency of intravenous furosemide in patients with advanced heart failure in a heart failure clinic. Ther Adv Cardiovasc Dis 2023; 17:17539447231184984. [PMID: 37417658 PMCID: PMC10331187 DOI: 10.1177/17539447231184984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/12/2023] [Indexed: 07/08/2023] Open
Abstract
INTRODUCTION Diuretic efficiency (DE) is an independent predictor of all-cause mortality in acute heart failure (HF) at long-term follow-up. The performance of DE in advanced HF and the outpatient scenario is unclear. METHODS Survival function analysis on a retrospective cohort of patients with advanced HF followed at the outpatient clinic of Hospital Universitario San Ignacio (Bogotá, Colombia) between 2017 and 2021. DE was calculated as the average of total diuresis in milliliters divided by the dose of IV furosemide in milligrams for each 6-h session, considering all the sessions in which the patient received levosimendan and IV furosemide. We stratified DE in high or low using the median value of the cohort as the cutoff value. The primary outcome was a composite of all-cause mortality and HF hospitalizations during a 12-month follow-up. Kaplan-Meier curves and log-rank test were used to compare patients with high and low DE. RESULTS In all, 41 patients (66.5 ± 13.2 years old, 75.6% men) were included in the study, with a median DE of 24.5 mL/mg. In total, 20 patients were categorized as low and 21 as high DE. The composite outcome occurred more often in the high DE group (13 versus 5, log-rank test p = 0.0385); the all-cause mortality rate was 29.2% and was more frequent in the high DE group (11 versus 1, log-rank test p = 0.0026). CONCLUSION In patients with advanced HF on intermittent inotropic therapy, a high DE efficiency is associated with a higher risk of mortality or HF hospitalization in a 12-month follow-up period.
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Affiliation(s)
- Nancy Herrera-Leaño
- Department of Internal Medicine, Pontificia Universidad Javeriana, Carrera 7 no 40-62, Bogotá, Colombia
| | | | - Oscar Muñoz-Velandia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Department of Internal Medicine, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Daniel G. Fernández-Ávila
- Department of Internal Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Rheumatology Unit, San Ignacio University Hospital, Bogotá, Colombia
| | - Alejandro Mariño-Correa
- Department of Internal Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Cardiology Unit, San Ignacio University Hospital, Bogotá, Colombia
| | - Ángel Alberto García
- Department of Internal Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Cardiology Unit, San Ignacio University Hospital, Bogotá, Colombia
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Tran P, Long T, Smith J, Kuehl M, Mahdy T, Banerjee P. Developing a contemporary community clinic for patients with heart failure with preserved ejection fraction within the current National Health Service model. Open Heart 2022; 9:openhrt-2022-002101. [PMID: 36332941 PMCID: PMC9639156 DOI: 10.1136/openhrt-2022-002101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction The diagnostic and therapeutic arsenal for heart failure with preserved ejection (HFpEF) has expanded. With novel therapies (eg, sodium-glucose co-transporter 2 inhibitors) and firmer recommendations to optimise non-cardiac comorbidities, it is unclear if outpatient HFpEF models can adequately deliver this. We; therefore, evaluated the efficacy of an existing dedicated HFpEF clinic to find innovative ways to design a more comprehensive model tailored to the modern era of HFpEF. Methods A single-centre retrospective analysis of 202 HFpEF outpatients was performed over 12 months before the COVID-19 pandemic. Baseline characteristics, clinic activities (eg, medication changes, lifestyle modifications, management of comorbidities) and follow-up arrangements were compared between a HFpEF and general cardiology clinic to assess their impact on mortality and morbidity at 6 and 12 months. Results Between the two clinic groups, the sample population was evenly matched with a typical HFpEF profile (mean age 79±9.6 years, 55% female and a high prevalence of cardiometabolic comorbidities). While follow-up practices were similar, the HFpEF clinic delivered significantly more interventions on lifestyle changes, blood pressure and heart rate control (p<0.0001) compared with the general clinic. Despite this, no significant differences in all-cause hospitalisation and mortality were observed. This may be attributed to the fact that clinic activities were primarily cardiology-focused. Importantly, non-cardiovascular admissions accounted for >60% of hospitalisation, including causes of recurrent admissions. Conclusion This study suggests that existing general and emerging dedicated HFpEF clinics may not be adequate in addressing the multifaceted aspects of HFpEF as clinic activities concentrated primarily on cardiological measures. Although the small cohort and short follow-up period are important limitations, this study reminds clinicians that HFpEF patients are more at risk of non-cardiac than HF-related events. We have therefore proposed a pragmatic framework that can comprehensively deliver the modern guideline-directed recommendations and management of non-cardiac comorbidities through a multidisciplinary approach.
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Affiliation(s)
- Patrick Tran
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Centre for Sport, Exercise & Life Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - Thomas Long
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Jessica Smith
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Michael Kuehl
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Tarek Mahdy
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Prithwish Banerjee
- Centre for Sport, Exercise & Life Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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5
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Baker E, Facultad JL, Slade H, Lee G. A new tool to measure acuity in the community: a case study. Br J Community Nurs 2021; 26:482-492. [PMID: 34632789 DOI: 10.12968/bjcn.2021.26.10.482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The provision of acute healthcare within patients own home (i.e. hospital in the home) is an important method of providing individualised patient-centred care that reduces the need for acute hospital admissions and enables early hospital discharge for appropriate patient groups. The Hospital in the Home (HitH) model of care ensures that this approach maximises patient safety and limits potential risk for patients. As HitH services have seen record numbers of patient referrals in the past 2 years, there is now a greater need to measure and understand the acuity and dependency levels of the caseload. Through an expert clinician development process at one NHS trust, aspects of procedural complexity, interdisciplinary working, risk stratification and comorbidities were used to quantify acuity and dependency. This paper uses a case study approach to present a new method of measuring this important concept.
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Affiliation(s)
- Edward Baker
- Lecturer in Applied Technology for Clinical Care, King's College London, King's College Hospital NHS Foundation Trust
| | - Jose Loreto Facultad
- Associate Chief Nurse-Workforce Transformation and Professional Practice, Buckinghamshire Healthcare NHS Trust
| | - Harriet Slade
- Clinical Development Matron, @home service, Guy's and St Thomas' NHS Foundation Trust
| | - Geraldine Lee
- Reader in Applied Technology for Clinical Care, King's College London
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Ahmed FZ, Taylor JK, John AV, Khan MA, Zaidi AM, Mamas MA, Motwani M, Cunnington C. Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective. ESC Heart Fail 2021; 8:3906-3916. [PMID: 34382749 PMCID: PMC8497198 DOI: 10.1002/ehf2.13368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/06/2021] [Accepted: 04/01/2021] [Indexed: 11/12/2022] Open
Abstract
Aims This study aims to establish the feasibility, safety, and efficacy of outpatient intravenous (IV) diuretic treatment for the management of decompensated heart failure (HF) for patients enrolled in the HeartFailure@Home service. Methods and results We retrospectively analysed the clinical episodes of decompensated HF for patients enrolled in the HeartFailure@Home service, managed by ambulatory IV diuretic treatment either at home or on a day‐case unit. A control group consisting of HF patients admitted to hospital for IV diuretics (standard‐of‐care) was also evaluated. In total, 203 episodes of decompensated HF (n = 154 patients) were evaluated. One hundred and fourteen episodes in 79 patients were managed exclusively by the ambulatory IV diuretic service—78 (68.4%) on a day‐case unit and 36 (31.6%) domiciliary; 84.1% of patient episodes under the HF@Home service were successfully managed entirely in an out‐patient setting without hospitalization. Eleven patients required admission in order to administer higher doses of IV diuretics than could be provided in the ambulatory setting. During follow‐up, there were 20 (17.5%) 30 day re‐admissions with HF or death in the ambulatory IV group and 29 (32.6%) in the standard‐of‐care arm (P = 0.02). There was no difference in 30 day HF readmissions between the two groups (14.9% ambulatory vs. 13.5% inpatients, P = 0.8), but 30 day mortality was significantly lower in the ambulatory group (3.5% vs. 21.3% inpatients, P < 0.001). Conclusions Outpatient ambulatory management of decompensated HF with IV diuretics given either on a day case unit or in a domiciliary setting is feasible, safe, and effective in selected patients with decompensated HF. This should be explored further as a model in delivering HF services in the outpatient setting during COVID‐19.
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Affiliation(s)
- Fozia Z Ahmed
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Joanne K Taylor
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Anju V John
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Muhammad A Khan
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Amir M Zaidi
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - Manish Motwani
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Colin Cunnington
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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7
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Hamo CE, Abdelmoneim SS, Han SY, Chandy E, Muntean C, Khan SA, Sunkesula P, Meykler M, Ramachandran V, Rosenberg E, Klem I, Sacchi TJ, Heitner JF. OUTpatient intravenous LASix Trial in reducing hospitalization for acute decompensated heart failure (OUTLAST). PLoS One 2021; 16:e0253014. [PMID: 34170908 PMCID: PMC8232441 DOI: 10.1371/journal.pone.0253014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/21/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hospitalization for acute decompensated heart failure (ADHF) remains a major source of morbidity and mortality. The current study aimed to investigate the feasibility, safety, and efficacy of outpatient furosemide intravenous (IV) infusion following hospitalization for ADHF. METHODS In a single center, prospective, randomized, double-blind study, 100 patients were randomized to receive standard of care (Group 1), IV placebo infusion (Group 2), or IV furosemide infusion (Group 3) over 3h, biweekly for a one-month period following ADHF hospitalization. Patients in Groups 2/3 also received a comprehensive HF-care protocol including bi-weekly clinic visits for dose-adjusted IV-diuretics, medication adjustment and education. Echocardiography, quality of life and depression questionnaires were performed at baseline and 30-day follow-up. The primary outcome was 30-day re-hospitalization for ADHF. RESULTS Overall, a total of 94 patients were included in the study (mean age 64 years, 56% males, 69% African American). There were a total of 14 (15%) hospitalizations for ADHF at 30 days, 6 (17.1%) in Group 1, 7 (22.6%) in Group 2, and 1 (3.7%) in Group 3 (overall p = 0.11; p = 0.037 comparing Groups 2 and 3). Patients receiving IV furosemide infusion experienced significantly greater urine output and weight loss compared to those receiving placebo without any significant increase creatinine and no significant between group differences in echocardiography parameters, KCCQ or depression scores. CONCLUSION The use of a standardized protocol of outpatient IV furosemide infusion for a one-month period following hospitalization for ADHF was found to be safe and efficacious in reducing 30-day re-hospitalization.
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Affiliation(s)
- Carine E. Hamo
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sahar S. Abdelmoneim
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - Seol Young Han
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - Elizabeth Chandy
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - Cornelia Muntean
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - Saadat A. Khan
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - Prasanthi Sunkesula
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - Marcella Meykler
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - Vidhya Ramachandran
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - Emelie Rosenberg
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - Igor Klem
- The Duke Clinical Research Institute, Durham, North Carolina, United States of America
| | - Terrence J. Sacchi
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
| | - John F. Heitner
- Division of Cardiology, Brooklyn New York-Presbyterian Hospital, Brooklyn, New York, United States of America
- * E-mail:
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Wierda E, Dickhoff C, Handoko ML, Oosterom L, Kok WE, de Rover Y, de Mol BAJM, van Heerebeek L, Schroeder-Tanka JM. Outpatient treatment of worsening heart failure with intravenous and subcutaneous diuretics: a systematic review of the literature. ESC Heart Fail 2020; 7:892-902. [PMID: 32159279 PMCID: PMC7261522 DOI: 10.1002/ehf2.12677] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 01/20/2020] [Accepted: 02/18/2020] [Indexed: 12/15/2022] Open
Abstract
Aims In the coming decade, heart failure (HF) represents a major global healthcare challenge due to an ageing population and rising prevalence combined with scarcity of medical resources and increasing healthcare costs. A transitional care strategy within the period of clinical worsening of HF before hospitalization may offer a solution to prevent hospitalization. The outpatient treatment of worsening HF with intravenous or subcutaneous diuretics as an alternative strategy for hospitalization has been described in the literature. Methods and results In this systematic review, the available evidence for the efficacy and safety of outpatient treatment with intravenous or subcutaneous diuretics of patients with worsening HF is analysed. A search was performed in the electronic databases MEDLINE and EMBASE. Of the 11 included studies 10 were single‐centre, using non‐randomized, observational registries of treatment with intravenous or subcutaneous diuretics for patients with worsening HF with highly variable selection criteria, baseline characteristics, and treatment design. One study was a randomized study comparing subcutaneous furosemide with intravenous furosemide. In a total of 984 unique individual patients treated in the reviewed studies, only a few adverse events were reported. Re‐hospitalization rates for HF at 30 and 180 days were 28 and 46%, respectively. All‐cause re‐hospitalization rates at 30 and 60 days were 18–37 and 22%, respectively. The highest HF re‐hospitalization was 52% in 30 days in the subcutaneous diuretic group and 42% in 30 days in the intravenous diuretic group. Conclusions The reviewed studies present practice‐based results of treatment of patients with worsening HF with intravenous or subcutaneous diuretics in an outpatient HF care unit and report that it is effective by relieving symptoms with a low risk of adverse events. The studies do not provide satisfactory evidence for reduction in rates of re‐hospitalization or improvement in mortality or quality of life. The conclusions drawn from these studies are limited by the quality of the individual studies. Prospective randomized studies are needed to determine the safety and effectiveness of outpatient intravenous or subcutaneous diuretic treatment for patient with worsening HF.
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Affiliation(s)
- Eric Wierda
- Department of Cardiology, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | | | - Martin Louis Handoko
- Department of Cardiology, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, The Netherlands
| | - Liane Oosterom
- Department of Cardiology, Dijklander Ziekenhuis, Purmerend, The Netherlands
| | - Wouter Emmanuel Kok
- Department of Cardiology, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, The Netherlands
| | - Y de Rover
- Department of Medical Library, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | - B A J M de Mol
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Loek van Heerebeek
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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9
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Lee C, Beleznai T, Hassan S, Rawat A, Douglas H, Kanagala P, Sankaranarayanan R. Ambulatory management of acute decompensation in heart failure. Br J Hosp Med (Lond) 2019; 80:40-45. [DOI: 10.12968/hmed.2019.80.1.40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Cheuk Lee
- Cardiology Clinical Fellow, Department of Cardiology, Aintree University Hospitals NHS Foundation Trust, Liverpool
| | - Timea Beleznai
- Cardiology Clinical Fellow, Department of Cardiology, Aintree University Hospitals NHS Foundation Trust, Liverpool
| | - Salimah Hassan
- Cardiology Advanced Nurse Practitioner, Department of Cardiology, Aintree University Hospitals NHS Foundation Trust, Liverpool
| | - Anju Rawat
- Cardiology Advanced Nurse Practitioner, Department of Cardiology, Aintree University Hospitals NHS Foundation Trust, Liverpool
| | - Homeyra Douglas
- Consultant Cardiologist, Department of Cardiology, Aintree University Hospitals NHS Foundation Trust, Liverpool
| | - Prathap Kanagala
- Consultant Cardiologist, Department of Cardiology, Aintree University Hospitals NHS Foundation Trust, Liverpool
| | - Rajiv Sankaranarayanan
- Consultant Cardiologist, Department of Cardiology, Aintree University Hospitals NHS Foundation Trust, Liverpool L9 7AL
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10
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Fitch K, Lau J, Engel T, Medicis JJ, Mohr JF, Weintraub WS. The cost impact to Medicare of shifting treatment of worsening heart failure from inpatient to outpatient management settings. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:855-863. [PMID: 30588047 PMCID: PMC6298883 DOI: 10.2147/ceor.s184048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The aim of this study was to quantify the potential cost savings to Medicare of shifting the site of treatment for worsening heart failure (HF) from inpatient to outpatient (OP) settings for a subset of worsening HF episodes among the Medicare fee-for-service (FFS) population. Materials and methods A cross-sectional analysis of a random 5% sample of 2014 FFS Medicare beneficiaries was conducted. Incidence and cost of worsening HF episodes in both inpatient and OP settings were identified. These results were used to calculate cost savings associated with shifting a proportion of worsening HF episodes from the inpatient to OP settings. Results A total of 151,908 HF beneficiaries were identified. The estimated annual cost for the treatment of worsening HF across both inpatient and OP settings ranged from US$9.3 billion to US$17.0 billion or 2.4%–4.3% of total Medicare FFS spend. The cost saving associated with shifting worsening HF treatment from inpatient hospital setting to OP settings was US$667.5 million or 0.17% of total Medicare spend when 10% of HF admissions were targeted and 60% of targeted HF admissions were successfully shifted. The cost savings increased to US$2.098 billion or 0.53% of total Medicare spend when 20% of HF admissions were targeted and 90% of targeted HF admissions were successfully shifted. Conclusion Treatment options that can shift costly hospital admissions for worsening HF treatment to less expensive OP settings potentially lead to significant cost savings to Medicare. Pursuit of OP therapy options for treating worsening HF might be considered a viable alternative.
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Morélot-Panzini C, O'Donnell CR, Lansing RW, Schwartzstein RM, Banzett RB. Aerosol furosemide for dyspnea: Controlled delivery does not improve effectiveness. Respir Physiol Neurobiol 2017; 247:146-155. [PMID: 29031573 DOI: 10.1016/j.resp.2017.10.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 09/29/2017] [Accepted: 10/02/2017] [Indexed: 01/23/2023]
Abstract
Aerosolized furosemide has been shown to relieve dyspnea; nevertheless, all published studies have shown great variability in response. This dyspnea relief is thought to result from the stimulation of slowly adapting pulmonary stretch receptors simulating larger tidal volume. We hypothesized that better control over aerosol administration would produce more consistent dyspnea relief; we used a clinical ventilator to control inspiratory flow and tidal volume. Twelve healthy volunteers inhaled furosemide (40mg) or placebo in a double blind, randomized, crossover study. Breathing Discomfort was induced by hypercapnia during constrained ventilation before and after treatment. Both treatments reduced breathing discomfort by 20% full scale. Effectiveness of aerosol furosemide treatment was weakly correlated with larger tidal volume. Response to inhaled furosemide was inversely correlated to furosemide blood level, suggesting that variation among subjects in the fate of deposited drug may determine effectiveness. We conclude that control of aerosol delivery conditions does not improve consistency of treatment effect; we cannot, however, rule out placebo effect.
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Affiliation(s)
- Capucine Morélot-Panzini
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA; Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale, F-75013, Paris, France.
| | - Carl R O'Donnell
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA; Harvard Med School, Boston, MA, 02115, USA
| | - Robert W Lansing
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA
| | - Richard M Schwartzstein
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA; Harvard Med School, Boston, MA, 02115, USA
| | - Robert B Banzett
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA; Harvard Med School, Boston, MA, 02115, USA
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12
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Zsilinszka R, Mentz RJ, DeVore AD, Eapen ZJ, Pang PS, Hernandez AF. Acute Heart Failure: Alternatives to Hospitalization. JACC-HEART FAILURE 2017; 5:329-336. [PMID: 28285117 DOI: 10.1016/j.jchf.2016.12.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 11/11/2016] [Accepted: 12/15/2016] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
| | - Robert J Mentz
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
| | - Zubin J Eapen
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
| | - Peter S Pang
- Department of Emergency Medicine and the Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adrian F Hernandez
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina.
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13
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Sanclemente-Ansó C, Bosch X, Salazar A, Moreno R, Capdevila C, Rosón B, Corbella X. Cost-minimization analysis favors outpatient quick diagnosis unit over hospitalization for the diagnosis of potentially serious diseases. Eur J Intern Med 2016; 30:11-17. [PMID: 26944565 DOI: 10.1016/j.ejim.2015.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Quick diagnosis units (QDUs) are a promising alternative to conventional hospitalization for the diagnosis of suspected serious diseases, most commonly cancer and severe anemia. Although QDUs are as effective as hospitalization in reaching a timely diagnosis, a full economic evaluation comparing both approaches has not been reported. AIMS To evaluate the costs of QDU vs. conventional hospitalization for the diagnosis of cancer and anemia using a cost-minimization analysis on the proven assumption that health outcomes of both approaches were equivalent. METHODS Patients referred to the QDU of Bellvitge University Hospital of Barcelona over 51 months with a final diagnosis of severe anemia (unrelated to malignancy), lymphoma, and lung cancer were compared with patients hospitalized for workup with the same diagnoses. The total cost per patient until diagnosis was analyzed. Direct and non-direct costs of QDU and hospitalization were compared. RESULTS Time to diagnosis in QDU patients (n=195) and length-of-stay in hospitalized patients (n=237) were equivalent. There were considerable costs savings from hospitalization. Highest savings for the three groups were related to fixed direct costs of hospital stays (66% of total savings). Savings related to fixed non-direct costs of structural and general functioning were 33% of total savings. Savings related to variable direct costs of investigations were 1% of total savings. Overall savings from hospitalization of all patients were €867,719.31. CONCLUSION QDUs appear to be a cost-effective resource for avoiding unnecessary hospitalization in patients with anemia and cancer. Internists, hospital executives, and healthcare authorities should consider establishing this model elsewhere.
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Affiliation(s)
- Carmen Sanclemente-Ansó
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain.
| | - Xavier Bosch
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques Auguts Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Albert Salazar
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Ramón Moreno
- Department of Economic Development, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Cristina Capdevila
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Beatriz Rosón
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Xavier Corbella
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain; Albert J. Jovell Institute of Public Health and Patients, Faculty of Medicine and Health Sciences, Universitat International de Catalunya, Barcelona, Catalonia, Spain
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14
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Creaser JW, DePasquale EC, Vandenbogaart E, Rourke D, Chaker T, Fonarow GC. Team-Based Care for Outpatients with Heart Failure. Heart Fail Clin 2016; 11:379-405. [PMID: 26142637 DOI: 10.1016/j.hfc.2015.03.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Management of heart failure requires a multidisciplinary team-based approach that includes coordination of numerous team members to ensure guideline-directed optimization of medical therapy, frequent and regular assessment of volume status, frequent education, use of cardiac rehabilitation, continued assessment for the use of advanced therapies, and advance care planning. All of these are important aspects of the management of this complex condition.
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Affiliation(s)
- Julie W Creaser
- Division of Cardiology, Department of Medicine, Ahmanson-UCLA Cardiomyopathy Center, University of California, 100 UCLA Medical Plaza, Suite 630 East, Los Angeles, CA 90095, USA.
| | - Eugene C DePasquale
- Division of Cardiology, Department of Medicine, Ahmanson-UCLA Cardiomyopathy Center, University of California, 100 UCLA Medical Plaza, Suite 630 East, Los Angeles, CA 90095, USA
| | - Elizabeth Vandenbogaart
- Division of Cardiology, Department of Medicine, Ahmanson-UCLA Cardiomyopathy Center, University of California, 100 UCLA Medical Plaza, Suite 630 East, Los Angeles, CA 90095, USA
| | - Darlene Rourke
- Division of Cardiology, Department of Medicine, Ahmanson-UCLA Cardiomyopathy Center, University of California, 100 UCLA Medical Plaza, Suite 630 East, Los Angeles, CA 90095, USA
| | - Tamara Chaker
- Division of Cardiology, Department of Medicine, Ahmanson-UCLA Cardiomyopathy Center, University of California, 100 UCLA Medical Plaza, Suite 630 East, Los Angeles, CA 90095, USA
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, Ahmanson-UCLA Cardiomyopathy Center, University of California, 100 UCLA Medical Plaza, Suite 630 East, Los Angeles, CA 90095, USA
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15
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Austin J, Hockey D, Williams WR, Hutchison S. Assessing parenteral diuretic treatment of decompensated heart failure in the community. Br J Community Nurs 2013; 18:528-534. [PMID: 24471224 DOI: 10.12968/bjcn.2013.18.11.528] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Referrals of 46 patients with decompensated end-stage heart failure were reviewed by a community heart-failure specialist nurse as part of a pilot study to determine patient numbers suitable for parenteral diuretic treatment at home, and the appropriateness of the Mini Nutritional Assessment (MNA), Edmonton Symptom Assessment System (ESAS) and Carer's Stress Scales. Triage of patients resulted in the following care pathways: 14 (30%) received intravenous therapy, 11 (24%) received subcutaneous therapy, 9 (20%) required adjustment of medication, 8 (17%) could not be treated because of limited staffing resource, 4 (9%) met study exemption criteria. There were no adverse events following furosemide infusion. The majority of intravenous and subcutaneous treatments took 1-7 days (total 187 days). Parenteral diuretic therapy prevented admissions and reduced the severity heart failure symptoms in particular oedema. Patients and carers appreciated the service, which had a positive effect on carers stress. Of the nursing tools, the ESAS and the Carer's Stress Scales proved useful in the management of patients.
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Affiliation(s)
- Jackie Austin
- Heart Failure Services and Cardiac Rehabilitation, Aneurin Bevan University Health Board, Nevill Hall Hospital, Abergavenny.
| | | | - W Robert Williams
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd
| | - Stephen Hutchison
- Aneurin Bevan University Health Board, Nevill Hall Hospital, Abergavenny
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16
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Quaglio G, Karapiperis T, Van Woensel L, Arnold E, McDaid D. Austerity and health in Europe. Health Policy 2013; 113:13-9. [DOI: 10.1016/j.healthpol.2013.09.005] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 09/09/2013] [Accepted: 09/16/2013] [Indexed: 11/25/2022]
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17
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Pericás JM, Aibar J, Soler N, López-Soto A, Sanclemente-Ansó C, Bosch X. Should alternatives to conventional hospitalisation be promoted in an era of financial constraint? Eur J Clin Invest 2013; 43:602-15. [PMID: 23590593 DOI: 10.1111/eci.12087] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/10/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow-up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded. MATERIALS AND METHODS Narrative review. RESULTS The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost-effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital-at-home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness. CONCLUSIONS Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.
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Affiliation(s)
- Juan M Pericás
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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