Trial of an intervention to improve outcomes in acute heart failure

Trial of an intervention to improve outcomes in acute heart failure

Abstract

Background

Patients with acute heart failure are often either systematically hospitalized, often because the risk of side effects is uncertain and the possibilities for rapid follow-up are insufficient. It remains uncertain whether the use of a strategy to support clinicians in making decisions about discharging or admitting patients, together with rapid follow-up in the outpatient clinic, will affect outcomes.

Methods

In a wedge-cluster randomized trial conducted in Ontario, Canada, we randomly assigned 10 hospitals with staggered start dates for a one-way transition from a control phase (usual care) to an intervention phase, which involved the use of a point-of-care algorithm to stratify patients with acute failure of the heart according to the risk of death. During the intervention phase, low-risk patients were discharged early (in ≤3 days) and received standardized outpatient care, and high-risk patients were admitted to the hospital. Coprimary outcomes were a composite of death from any cause or hospitalization for cardiovascular causes within 30 days of presentation and a composite outcome within 20 months.

the results

A total of 5452 patients were included in the trial (2972 during the control phase and 2480 during the intervention phase). Within 30 days, death from any cause or hospitalization for cardiovascular causes occurred in 301 patients (12.1%) enrolled during the intervention phase and in 430 patients (14.5%) enrolled during the control phase ( adjusted hazard ratio, 0.88; 95% confidence interval [CI]0.78 to 0.99; P=0.04). Within 20 months, the cumulative incidence of the primary outcome event was 54.4% (95% CI, 48.6 to 59.9) among patients enrolled during the intervention phase and 56.2% (95% CI, 54, 2 to 58.1) among patients enrolled during the follow-up phase (adjusted hazard ratio, 0.95; 95% CI, 0.92 to 0.99). Fewer than six deaths or hospitalizations for any reason occurred in low- or intermediate-risk patients before the first outpatient visit within 30 days of discharge.

Findings

Among patients with acute heart failure who sought emergency care, use of a hospital-based strategy for clinical decision support and rapid follow-up resulted in a lower risk of death from any cause or hospitalization for cardiovascular causes within 30 years. days from usual care. (Funded by the Ontario SPOR Support Unit and others; COACH ClinicalTrials.gov number, NCT02674438.)

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