1. A hospital-based strategy to support clinical decision-making and rapid follow-up resulted in a lower risk of death and hospitalization in patients with acute heart failure.

2. These outcome improvements were sustained at up to 20 months of follow-up.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Over 25 million people are affected by heart failure. Many patients with heart failure are frequently hospitalized, with a high mortality rate. The risks of readmission and repeat events in patients hospitalized due to heart failure have remained high despite improved care guidelines. One improvement opportunity is in managing patients’ initial presentation to the emergency department for acute heart failure. The provider’s decision to admit or discharge these patients is critical to their prognosis. Further, early follow-up post-discharge is instrumental in reducing readmission rates and future exacerbations. The current study was a cluster-randomized trial assessing the impact of a point-of-care algorithm to guide admission decisions of patients with acute heart failure based on the risk of death, coupled with rapid follow-up, on heart failure outcomes. Compared to the control phase, the intervention phase had a lower risk of death from any cause or hospitalization for cardiovascular causes at 30 days and 20 months. Furthermore, few deaths or hospitalizations occurred in patients classified as low- or intermediate-risk by the algorithm. The study’s generalizability was limited due to the lack of evaluation of its individual components and might necessitate a learning curve, which could underestimate its benefits. Overall, these findings demonstrated that an intervention to augment clinical decision-making and rapid follow-up improved outcomes among patients with acute heart failure.

Click here to read the study in NEJM

In-Depth [randomized controlled trial]: The current study is a cross-sectional, multicenter, cluster-randomized trial conducted across ten hospitals in Canada. It assessed the impact of a guide for clinical decision-making coupled with rapid post-discharge follow-up on outcomes in patients with acute heart failure. Adult patients 18 years or older presenting to the emergency department with acute heart failure were eligible. Exclusion criteria included end-stage disease or an inability to attend outpatient visits. The decision-making intervention utilized the Emergency Heart Failure Mortality Risk Grade (EHMRG30-ST) for 30-day mortality, where patients were stratified into low, intermediate, or high risk of death. Low-risk patients were recommended to be discharged early, while those at high risk were recommended to be admitted. Those at intermediate risk were further subdivided into intermediate-to-high and low-to-intermediate risks. During the control phase, EHMRG30-ST was not used. A total of 5,452 patients were enrolled and randomized to be in the control or intervention phase. The co-primary outcomes were a composite death from any cause or hospitalization from cardiovascular causes at 30 days and 20 months. At 30 days, the primary outcome occurred in 12.1% of patients in the intervention phase and 14.5% of those in the control phase (Adjusted Hazard Ratio [AHR] 0.88, 95% Confidence Interval [CI] 0.78 to 0.99; p=0.04). At 20 months, the incidence of the primary outcome was 54.4% in patients in the intervention phase and 56.2% in those in the control phase (AHR 0.94, 95% CI 0.92 to 0.99). These results demonstrated that the combination of a clinical decision-making tool and rapid follow-up lowered the risks of death from any cause or hospitalization for cardiovascular events among patients presenting with acute heart failure.

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