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:
Miro, O, Rossello, X, Gil, V, Martin-Sanchez, FJ, Llorens, P, Herrero-Puente, P, Jacob, J, Pinera, P, Mojarro, EM, Lucas-Imbernon, FJ, Llauger, L, Aguera, C, Lopez-Diez, MP, Valero, A, Bueno, H, Pocock, SJ, Gil, MF, Salvo, E, Escoda, R, Aguilo, S, Xipell, C, Sanchez, C, Gaytan, JM, Noval, A, Torres, JM, Aguirre, A, Pedragosa, MA, Torres-Garate, R, Alonso, MI, Ruiz, F, Franco, JM, Sanchez, S, Alquezar, A, Rizzi, MA, Herrera, S, Cabello, I, Roset, A, Alonso, H, Adrada, ER, Garcia, GL, Perez, JMA, Mecina, AB, Alvarez, JV, Gonzalez, MS, Prieto, B, Garcia, MG, Marquina, V, Jimenez, I, Javaloyes, P, Hernandez, N, Brouzet, B, Lopez, A, Andueza, JA, Romero, R, Calvache, R, Lorca, MT, Calderon, L, Arriaga, BA, Sierra, B, Nicolas, JAS, Mojarra, EM, Becquer, LT, Garcia, LL, La Salle, GC, Urbano, CA, Ferrer, ES
Publicada:
1 ago 2019
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:
Miro, O:
Univ Barcelona, Emergency Dept, Hosp Clin, IDIBAPS, Barcelona, Spain
Rossello, X:
London Sch Hyg & Trop Med, Dept Med Stat, London, England
CNIC, Madrid, Spain
CIBER Enfermedades Cardiovasc CIBERCV, Madrid, Spain
Gil, V:
Univ Barcelona, Emergency Dept, Hosp Clin, IDIBAPS, Barcelona, Spain
Martin-Sanchez, FJ:
Univ Complutense, Hosp Clin San Carlos, Emergency Dept, Madrid, Spain
Llorens, P:
Hosp Gen Alicante, Short Stay Unit & Home Hospitalizat, Emergency Dept, Alicante, Spain
Herrero-Puente, P:
Hosp Univ Cent Asturias, Emergency Dept, Oviedo, Asturias, Spain
Jacob, J:
Hosp Univ Bellvitge, Emergency Dept, Barcelona, Catalonia, Spain
Pinera, P:
Hosp Reina Sofia Murcia, Emergency Dept, Murcia, Spain
Hosp Gen Univ Reina Sofia Murcia, Murcia, Spain
Mojarro, EM:
Hosp St Pau & Santa Tecla Tarragona, Emergency Dept, Tarragona, Catalonia, Spain
Lucas-Imbernon, FJ:
Hosp Gen Univ Albacete, Albacete, Spain
Llauger, L:
Hosp Univ Vic, Emergency Dept, Barcelona, Catalonia, Spain
Aguera, C:
Hosp Costa del Sol, Emergency Dept, Malaga, Spain
Lopez-Diez, MP:
Hosp Univ Burgos, Emergency Dept, Burgos, Spain
Valero, A:
Hosp Doctor Peset, Emergency Dept, Valencia, Spain
Hosp Dr Peset Valencia, Valencia, Spain
Bueno, H:
CNIC, Madrid, Spain
Univ Complutense, Cardiol Dept, Hosp 12 Octubre, Madrid, Spain
Pocock, SJ:
London Sch Hyg & Trop Med, Dept Med Stat, London, England
CNIC, Madrid, Spain
Gil, MF:
Hosp Univ Salamanca, Salamanca, Spain
Salvo, E:
Hosp La Fe Valencia, Valencia, Spain
Escoda, R:
Hosp Clin Barcelona, Barcelona, Spain
Aguilo, S:
Hosp Clin Barcelona, Barcelona, Spain
Xipell, C:
Hosp Clin Barcelona, Barcelona, Spain
Sanchez, C:
Hosp Clin Barcelona, Barcelona, Spain
Gaytan, JM:
Hosp Clin Barcelona, Barcelona, Spain
Noval, A:
Hosp Insular Las Palmas de Gran Canaria, Las Palmas Gran Canaria, Spain
Torres, JM:
Hosp Reina Sofia Cordoba, Cordoba, Spain
Aguirre, A:
Hosp Mar Barcelona, Barcelona, Spain
Pedragosa, MA:
Hosp Mar Barcelona, Barcelona, Spain
Torres-Garate, R:
Hosp Severo Ochoa Leganes, Madrid, Spain
Alonso, MI:
Hosp Valme Sevilla, Seville, Spain
Ruiz, F:
Hosp Valme Sevilla, Seville, Spain
Franco, JM:
Hosp Miguel Servet Zaragoza, Zaragoza, Spain
Sanchez, S:
Hosp Rio Ortega Valladolid, Valladolid, Spain
Alquezar, A:
Hosp San Pau Barcelona, Barcelona, Spain
Rizzi, MA:
Hosp San Pau Barcelona, Barcelona, Spain
Herrera, S:
Hosp San Pau Barcelona, Barcelona, Spain
Cabello, I:
Hosp Univ Bellvitge, Barcelona, Spain
Roset, A:
Hosp Univ Bellvitge, Barcelona, Spain
Alonso, H:
Hosp Marques de Valdecilla Santander, Santander, Spain
Adrada, ER:
Hosp Clin San Carlos, Madrid, Spain
Garcia, GL:
Hosp Clin San Carlos, Madrid, Spain
Perez, JMA:
Hosp Univ Burgos, Burgos, Spain
Mecina, AB:
Hosp Univ Fdn Alcorcon, Madrid, Spain
Alvarez, JV:
Hosp Univ Cent Asturias, Oviedo, Spain
Gonzalez, MS:
Hosp Univ Cent Asturias, Oviedo, Spain
Prieto, B:
Hosp Univ Cent Asturias, Oviedo, Spain
Garcia, MG:
Hosp Univ Cent Asturias, Oviedo, Spain
Marquina, V:
Hosp Gen Alicante, Alicante, Spain
Jimenez, I:
Hosp Gen Alicante, Alicante, Spain
Javaloyes, P:
Hosp Gen Alicante, Alicante, Spain
Hernandez, N:
Hosp Gen Alicante, Alicante, Spain
Brouzet, B:
Hosp Gen Alicante, Alicante, Spain
Lopez, A:
Hosp Gen Alicante, Alicante, Spain
Andueza, JA:
Hosp Gen Univ Gregorio Maranon Madrid, Madrid, Spain
Romero, R:
Hosp Getafe Madrid, Getafe, Spain
Calvache, R:
Hosp Henares Madrid, Coslada, Spain
Lorca, MT:
Hosp Tajo Madrid, Madrid, Spain
Calderon, L:
Hosp Tajo Madrid, Madrid, Spain
Arriaga, BA:
Hosp Clin Lozano Blesa Zaragoza, Zaragoza, Spain
Sierra, B:
Hosp Clin Lozano Blesa Zaragoza, Zaragoza, Spain
Nicolas, JAS:
Hosp Gen Univ Reina Sofia Murcia, Murcia, Spain
Mojarra, EM:
Hosp St Pau & Santa Tecla Tarragona, Tarragona, Spain
Becquer, LT:
Hosp Univ Canarias Tenerife, Tenerife, Spain
Garcia, LL:
Hosp Univ Vic Barcelona, Barcelona, Spain
La Salle, GC:
Hosp Univ Vic Barcelona, Barcelona, Spain
Urbano, CA:
Hosp Costa del Sol de Marbella, Malaga, Spain
Ferrer, ES:
Hosp Josep Trueta Girona, Girona, Spain
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