Analysis of How Emergency Physicians' Decisions to Hospitalize or Discharge Patients With Acute Heart Failure Match the Clinical Risk Categories of the MEESSI-AHF Scale
Por:
Miró Ò, Rossello X, Gil V, Martín-Sánchez FJ, Llorens P, Herrero-Puente P, Jacob J, Piñera P, Mojarro EM, Lucas-Imbernón FJ, Llauger L, Agüera C, López-Díez MP, Valero A, Bueno H, Pocock SJ and ICA-SEMES Research Group
Publicada:
1 ago 2019
Ahead of Print:
27 may 2019
Categoría:
Emergency medicine
Resumen:
Study objective: The Multiple Estimation of Risk Based on the Emergency Department Spanish Score in Patients With Acute Heart Failure (MEESSI-AHF) is a validated clinical decision tool that characterizes risk of mortality in emergency department (ED) acute heart failure patients. The objective of this study is to compare the distribution of risk categories between hospitalized and discharged ED patients with acute heart failure.
Methods: We included consecutive acute heart failure patients from 34 Spanish EDs. Patients were retrospectively classified according to MEESSI-AHF risk categories. We calculated the odds of hospitalization (versus direct discharge from the ED) across MEESSI-AHF risk categories. Next, we assessed the following 30-day postdischarge outcomes: ED revisit, hospitalization, death, and their combination. We used Cox hazards models to determine the adjusted association between ED disposition decision and the outcomes among patients who were stratified into low-and increased-risk categories.
Results: We included 7,930 patients (80.5 years [SD 10.1 years]; women 54.7%; hospitalized 75.3%). Compared with that for low-risk MEESSI-AHF patients, odds ratios for hospitalization of patients in intermediate-, high-, and very-high-risk categories were 1.83 (95% confidence interval [CI] 1.64 to 2.05), 3.05 (95% CI 2.48 to 3.76), and 3.98 (95% CI 3.13 to 5.05), respectively. However, almost half (47.6%) of all discharged patients were categorized as being at increased risk by MEESSI-AHF, and 19.0% of all the increased-risk patients were discharged from the ED. Among the low-risk MEESSI-AHF patients, the 30-day postdischarge mortality did not differ by ED disposition (hazard ratio [HR] for discharged patients with respect to hospitalized ones 0.65; 95% CI 0.70 to 1.11), nor did it differ in the increased-risk group (HR 0.88; 95% CI 0.63 to 1.23). The discharged low-risk MEESSI-AHF patients had higher risks of 30-day ED revisit and hospitalization (HR 1.86, 95% CI 1.57 to 2.20; and HR 1.92, 95% CI 1.54 to 2.40, respectively) compared with the admitted patients, as did the discharged patients in the increased-risk group (HR 1.62, 95% CI 1.39 to 1.89; and HR 1.40, 95% CI 1.16 to 1.68, respectively), with similar results for the combined endpoint.
Conclusion: The disposition decisions made in current clinical practice for ED acute heart failure patients calibrate with MEESSI-AHF risk categories, but nearly half of the patients currently discharged from the ED fall into increased-risk MEESSI-AHF categories.
Filiaciones:
Miró Ò:
Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
Rossello X:
Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
Gil V:
Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
Martín-Sánchez FJ:
Emergency Department, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
Llorens P:
Emergency Department, Short-Stay Unit and Home Hospitalization, Hospital General de Alicante, Alicante Spain
Herrero-Puente P:
Emergency Department, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
Jacob J:
Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
Piñera P:
Emergency Department, Hospital Reina Sofia de Murcia, Murcia, Spain
Mojarro EM:
Emergency Department, Hospital Sant Pau i Santa Tecla de Tarragona, Tarragona, Catalonia, Spain
Lucas-Imbernón FJ:
Hospital General Universitario de Albacete, Albacete, Spain
Llauger L:
Emergency Department, Hospital Universitari de Vic, Barcelona, Catalonia, Spain
Agüera C:
Emergency Department, Hospital Costa del Sol, Marbella, Málaga, Spain
López-Díez MP:
Emergency Department, Hospital Universitario de Burgos, Burgos, Spain
:
Emergency Department, Hospital Doctor Peset, Valencia, Spain
Bueno H:
Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
Cardiology Department, Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
Pocock SJ:
Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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