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 - 20/07/19
, Xavier Rossello, PhD b, c, d, Víctor Gil, PhD a, Francisco J. Martín-Sánchez, PhD e, Pere Llorens, PhD g, Pablo Herrero-Puente, PhD h, Javier Jacob, PhD i, Pascual Piñera, MD j, Enrique M. Mojarro, MD k, Francisco J. Lucas-Imbernón, MD p, Lluís Llauger, MD l, Carmen Agüera, MD m, María P. López-Díez, MD n, Amparo Valero, MD o, Héctor Bueno, PhD c, f, Stuart J. Pocock, PhD b, con behalf of the
ICA-SEMES Research Group∗
Abstract |
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.
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| Please see page 205 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Clare L. Atzema, MD, MSc. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was partially supported by grants from the Instituto de Salud Carlos III and funds from the Spanish Ministry of Health and Federación Española de Enfermedades Raras (PI15/01019, PI15/00773, PI18/00393, and PI18/00456) and Fundació La Marató de TV3 (2015/2510). The Emergencies: Processes and Pathologies research group of the Institut d'Investigacions Biomèdiques August Pi i Sunyer receives financial support from the Catalonian Government for Consolidated Groups of Investigation (GRC 2009/1385, 2014/0313, and 2017/1424). Dr. Rosselló reports receiving support from the Sociedad Española de Cardiología- Centro Nacional de Investigaciones Cardiológicas CARDIOJOVEN fellowship program. |
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| The ICA-SEMES Research Group has received unrestricted support from Orion Pharma and Novartis. The present study was designed, performed, analyzed, and written exclusively by the authors independently of these pharmaceutical companies. |
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Vol 74 - N° 2
P. 204-215 - août 2019 Retour au numéro
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