Factors associated with in-hospital mortality and adverse outcomes during the vulnerable post-discharge phase after the first episode of acute heart failure: results of the NOVICA-2 study.

OBJECTIVE: To identify patients at risk of in-hospital mortality and adverse outcomes during the vulnerable post-discharge period after the first acute heart failure episode (de novo AHF) attended at the emergency department. METHODS: This is a secondary review of de novo AHF patients included in the prospective, multicentre EAHFE (Epidemiology of Acute Heart Failure in Emergency Department) Registry. We included consecutive patients with de novo AHF, for whom 29 independent variables were recorded. The outcomes were in-hospital all-cause mortality and all-cause mortality and readmission due to AHF within 90 days post-discharge. A follow-up check was made by reviewing the hospital medical records and/or by phone. RESULTS: We included 3422 patients. The mean age was 80 years, 52.1% were women. The in-hospital mortality was 6.9% and was independently associated with dementia (OR = 2.25, 95% CI = 1.62-3.14), active neoplasia (1.97, 1.41-2.76), functional dependence (1.58, 1.02-2.43), chronic treatment with beta-blockers (0.62, 0.44-0.86) and severity of decompensation (6.38, 2.86-14.26 for high-/very high-risk patients). The 90-day post-discharge combined endpoint was observed in 19.3% of patients and was independently associated with hypertension (HR = 1.40, 1.11-1.76), chronic renal insufficiency (1.23, 1.01-1.49), heart valve disease (1.24, 1.01-1.51), chronic obstructive pulmonary disease (1.22, 1.01-1.48), NYHA 3-4 at baseline (1.40, 1.12-1.74) and severity of decompensation (1.23, 1.01-1.50; and 1.64, 1.20-2.25; for intermediate and high-/very high-risk patients, respectively), with different risk factors for 90-day post-discharge mortality or rehospitalisation. CONCLUSIONS: The severity of decompensation and some baseline characteristics identified de novo AHF patients at increased risk of developing adverse outcomes during hospitalisation and the vulnerable post-discharge phase, without significant differences in these risk factors according to patient age at de novo AHF presentation.

Analysis of standards of quality for outcomes in acute heart failure patients directly discharged home from emergency departments and their relationship with the emergency department direct discharge rate.

OBJECTIVE: Experts recommended that direct discharge without hospitalization (DDWH) for emergency departments (EDs) able to observe acute heart failure (AHF) patients should be >40%, and these discharged patients should fulfil the following outcome standards: 30-day all-cause mortality <2% (outcome A); 7-day ED revisit due to AHF < 10% (outcome B); and 30-day ED revisit/hospitalization due to AHF < 20% (outcome C). We investigated these outcomes in a nationwide cohort and their relationship with the ED DDWH percentage. METHODS: We analyzed the EAHFE registry (includes about 15% of Spanish EDs), calculated DDWH percentage of each ED, and A/B/C outcomes of DDWH patients, overall and in each individual ED. Relationship between ED DDWH and outcomes was assessed by linear and quadratic regression models, non-weighted and weighted by DDWH patients provided by each ED. RESULTS: Among 17,420 patients, 4488 had DDWH (25.8%, median ED stay = 0 days, IQR = 0-1). Only 12.9% EDs achieved DDWH > 40%. Considering DDWH patients altogether, outcomes A/C were above the recommended standards (4.3%/29.4%), while outcome B was nearly met (B = 10.1%). When analyzing individual EDs, 58.1% of them achieved the outcome B standard, while outcomes A/C standards were barely achieved (19.3%/9.7%). We observed clinically relevant linear/quadratic relationships between higher DDWH and worse outcomes B (weighted R2 = 0.184/0.322) and C (weighted R2 = 0.430/0.624), but not with outcome A (weighted R2 = 0.002/0.022). CONCLUSIONS: The EDs of this nationwide cohort do not fulfil the standards for AHF patients with DDWH. High DDWH rates negatively impact ED revisit or hospitalization but not mortality. This may represent an opportunity for improvement in better selecting patients for early ED discharge and in ensuring early follow-up after ED discharge.

[Medication-related negative outcomes in patients with permanent atrial fibrillation attended in a hospital emergency department]. / Resultados negativos asociados a la medicación en los pacientes con fibrilación auricular permanente atendidos en un servicio de urgencias hospitalario.

OBJECTIVES: To detect the frequency of negative outcomes associated with medication in patients with permanent atrial fibrillation (AF) who are attended in a hospital emergency department, and to assess type and severity of such outcomes related to AF medications as well as the rate of preventable negative outcomes. MATERIAL AND METHODS: Descriptive, observational cross-sectional study in patients with permanent AF who were attended in the emergency department of a tertiary care hospital during a 3-month period. A pharmacist interviewed the patients to record demographic characteristics, health problems, degree of functional impairment, and current drug treatments. An emergency physician and a pharmacist reviewed the patients' questionnaires and medical histories and evaluated them using the Dader method of pharmacotherapeutic follow-up. RESULTS: Of the 210 patients assessed, 198 entered the final analysis. They had a mean (SD) age of 80.5 (7.3) years, and 114 (57.5%) were women. One handred and thirty-four (67.7%) patients had medication-related negative outcomes; 61 (45.5%) of the outcomes were related to treatment for permanent AF. Twenty-four of these 61 patients (39.3%) had problems affecting safety; 36 (59%) of the problems were caused by drugs to control heart rate. Of the 73 patients with negative outcomes unrelated to AF medication, 34 (46.6%) were related to necessary medications and 38 (52.1%) were taking antibiotics. The frequencies of avoidable negative outcomes were significantly different between the group of patients with problems related to drug therapy for AF (where 55.7% were due to medications considered unnecessary) and those with problems unrelated to AF medications (where 78.1% were from avoidable medications) (P=.010). However, the level of seriousness was similar. CONCLUSION: Nearly two-thirds of patients with permanent AF who come to the emergency department have a medication- related negative outcome that may or may not be related to AF treatment. Problems from drugs taken for reasons other than AF could more easily be avoided.

OBJETIVO: Detectar la frecuencia de resultados negativos asociados a la medicación (RNM) en los pacientes con fibrilación auricular permanente (FAP) atendidos en un servicio de urgencias hospitalario (SUH), y evaluar su tipología, evitabilidad y gravedad en función de su relación con la terapia farmacológica para la fibrilación auricular (FA). METODO: Estudio observacional descriptivo de una serie de casos con análisis transversal que incluyó a los pacientes atendidos con FAP en un servicio de urgencias (SU) de un hospital de tercer nivel durante 3 meses. Un farmacéutico entrevistó a los pacientes recogiendo datos demográficos, problemas de salud, grado de dependencia y terapia farmacológica. Un grupo evaluador, formado por un urgenciólogo y un farmacéutico, revisaron los cuestionarios y las historias clínicas para la evaluación de los RNM según el método Dáder. RESULTADOS: Del total de 210 pacientes evaluados se incluyeron finalmente 198 pacientes con una edad media de 80,5 (DE 7,3) años, de los cuales 114 (57,5%) fueron mujeres. Ciento treinta y cuatro (67,7%) pacientes sufrieron un RNM, de los cuales 61 (45,5%) estaban relacionadas con el tratamiento de la FA (RNM-RTFA). De los 61 pacientes con RNM-RTFA, 24 (39,3%) fueron RNM de seguridad y 36 (59%) estaban causados por los fármacos para el control de la frecuencia. De los 73 pacientes con RNM no relacionadas con el tratamiento de la FA (RNM-NRTFA), 34 (46,6%) fueron RNM de necesidad y 38 (52,1%) eran por antibióticos. Entre los dos grupos, hubo diferencias estadísticamente significativas en cuanto a la evitabilidad (RNM-RTFA 55,7% vs RNM-NRTFA 78,1%; p = 0,010), pero no para la gravedad (p = 0,265). CONCLUSIONES: Casi dos tercios de los pacientes con FAP que acuden a un SUH sufren un RNM relacionado o no con la medicación específica para la FA, siendo más evitables los RNM del grupo de fármacos no relacionados con el tratamiento de esta enfermedad.

[Factors associated with short stays for patients admitted with acute heart failure]. / Factores asociados a estancias cortas en los pacientes ingresados por insuficiencia cardiaca aguda.

OBJECTIVES: To identify factors associated with short hospital stays for patients admitted with acute heart failure (AHF) admitted to hospitals with short-stay units (SSU). MATERIAL AND METHODS: Multicenter nonintervention study in a multipurpose cohort of patients with AHF to 10 Spanish hospitals with short-stay units; patients were followed prospectively. We recorded demographic data, medical histories, baseline cardiorespiratory and function variables on arrival in the emergency department, on admission, and at 30 days. The outcome variable was a short hospital stay (<= 4 days). We built receiver operating characteristic curves of simple and mixed predictive models for short stays and calculated the area under the curves. RESULTS: A total of 1359 patients with a mean (SD) age of 78.7 (9.9) years (53.9% women) were included; 568 (41.8%) had short stays. Five hundred ninety patients (43.4%) were admitted to SSU and 769 (56.6%) were admitted to conventional wards. The variables associated with a short-stay according to the mixed regression model were hypertensive crisis (odds ratio [OR], 1.79; 95% CI, 1.17-2.73; P=.007) and admission to a SSU (OR, 16.6; 95% CI, 10.0-33.3; P<.001). Hypotensive AHF (OR, 0.49; 95% CI, 0.26-0.91; P=.025), hypoxemia (OR, 0.68; 95% CI, 0.53-0.88; P=.004); and admission on a Wednesday, Thursday, or Friday (OR, 0.62; 95% CI, 0.49-0.77; P<.001) were associated with a long stay. The area under the receiver operating characteristic curve was 0.827 (95% CI, 0.80-0.85; P<.001). Thirty-day mortality and readmission rates did not differ between patients with short vs long stays (mortality, 0.5% in both cases, P=.959; and readmission, 22.9% vs 27.7%, respectively; P=.059). CONCLUSION: Both clinical and administrative factors are independently related to whether patients with AHF have short stays in the hospitals studied, and among therapy, it is remaslcasle the existence of a SSU.

OBJETIVO: Identificar factores asociados a un tiempo de estancia hospitalaria (TDEH) corto en pacientes ingresados por insuficiencia cardiaca aguda (ICA) en hospitales con unidad de corta estancia (UCE). METODO: Estudio de cohorte multipropósito y multicéntrico no intervencionista, con seguimiento prospectivo de pacientes con ICA ingresados en 10 hospitales españoles con UCE. Se recogieron variables demográficas, antecedentes personales, situación basal cardiorrespiratoria y funcional, de urgencias, del ingreso y de seguimiento a 30 días. La variable resultado fue un TDEH corto (<= 4 días). Se realizaron curvas de rendimiento diagnóstico (ROC) de modelos simples y mixtos predictivos de TDEH corto y se calculó el área bajo la curva (ABC) de la característica operativa del receptor (COR). RESULTADOS: Se incluyeron 1.359 pacientes con una edad 78,7 (DE: 9,9) años, el 53,9% mujeres, 568 (41,8%) tuvieron un TDE de 4 o menos días. Ingresaron 590 pacientes (43,4%) en UCE y 769 (56,6%) en salas de hospitalización convencional. En el modelo de regresión mixto ajustado al centro, la crisis hipertensiva (OR 1,79, IC 95%: 1,17-2,73; p = 0,007) y el ingresar en UCE (OR 16,6, IC95%: 10,0-33,3; p < 0,001) se asociaron a TDEH corto, y la ICA hipotensiva (OR 0,49, IC 95%: 0,26-0,91; p = 0,025), la hipoxemia, (OR 0,68, IC 95%: 0,53-0,88; p = 0,004) e ingresar en miércoles, jueves o viernes (OR 0,62, IC 95%: 0,49-0,77; p < 0,001) a TDEH largo. El ABC COR del modelo mixto ajustada al centro fue 0,827 (IC 95%: 0,80-0,85; p < 0,001). La mortalidad a 30 días y el reingreso a 30 días no difirieron entre ambos grupos (0,5% frente a 0,5%, p = 0,959; y 22,9% frente a 27,7%, p = 0,059, respectivamente). CONCLUSIONES: En pacientes con ICA existen factores clínicos y organizativos en cada centro que se relacionan de forma independiente con un TDEH corto, entre los que destaca el tener una UCE.

[Prolonged hospitalization in patients admitted for acute heart failure in the short stay unit (EPICA-UCE study): study of associated factors]. / Estancia prolongada en pacientes ingresados por insuficiencia cardiaca aguda en la Unidad de Corta Estancia (estudio EPICA-UCE): factores asociados.

BACKGROUND AND OBJECTIVE: To study the factors associated with prolonged hospitalization in patients admitted for acute heart failure (AHF) in Spanish short-stay units (SSUs). PATIENTS AND METHODS: This was a multicentre, multipurpose cohort study with prospective follow-up including all patients admitted for AHF in the 11 SSUs of the EAHFE registry. Demographic data, previous illness, baseline cardiorespiratory and functional status, acute episode and admission and follow up variables at 60 days were recorded. The primary outcome was prolonged hospitalization in the SSU (>72h). A logistic regression model was used to control the effects of confounding factors. RESULTS: Eight-hundred and nineteen patients were included with a mean age of 80.9 (SD 8.4) years, 483 (59.0%) being women. The median length stay was 3.0 (IQR 2.0-5.0) days with an in-hospital mortality of 2.7%. The independent factors associated with prolonged hospitalization were the coexistence of chronic obstructive pulmonary disease (odds ratio [OR] 1.56; 95% IC 1.02-2.38; P=.040) and anaemia (OR 1.72; 95% CI 1.21-2.44; P=.002), basal oxygen saturation<90% on arrival to the Emergency Department (OR 2.21, 95% CI 1.51-3.23; P<.001), hypertensive episode as the precipitating factor of the AHF (protective factor OR 0.49; 95% CI 0.26-0.93; P=.028) and admission on Thursday (OR 1.90; 95% CI 1.19-3.05; P=.008). There were no significant differences between both groups regarding to in-hospital mortality (2.4 vs. 3.0%), mortality (4.1 vs. 4.2%) or revisit at 60 days (18.4 vs. 21.6%). CONCLUSIONS: Several factors including hypertensive episode, insufficiency respiratory, anaemia, chronic obstructive pulmonary disease, and admission on Thursday should be taken into account in patients with AHF admitted in SSU stay to avoid prolonged hospitalization.