ED, outpatient visits for worsening heart failure on the rise since 2010

Increased morbidity and mortality due to worsening heart failure are related not only to ED/observation stays but also to outpatient visits, according to a new study.

Researchers performed a cohort study of adults with diagnosed heart failure who received care from 2010-2019 in a large, integrated health care delivery system in California. Data from the electronic health record were obtained for outpatient encounters, ED visits and observation stays, and hospitalizations. Worsening heart failure was defined as at least one symptom, at least two objective findings including at least one sign, and at least one change in heart failure-related therapy, with signs and symptoms determined by natural language processing. The goal of the study was to describe the incidence of worsening heart failure events across the care continuum. The study was funded by Novartis AG and the Kaiser Permanente Northern California Community Benefit Program. The results were published in the July 12 Journal of the American College of Cardiology.

Overall, 103,138 patients were eligible for the study, with a mean age of 73.6 years. Almost half (47.5%) were women, and the mean left ventricular ejection fraction was 51.4%. The study included 1,136,750 unique encounters, of which 743,039 (65.4%) were outpatient encounters, 224,670 (19.8%) were ED visits/observation stays, and 169,041 (14.9%) were hospitalizations. Overall, 126,008 episodes of worsening heart failure were identified, of which 34,758 (27.6%) were outpatient encounters, 28,301 (22.5%) were ED visits/observation stays, and 62,949 (50.0%) were hospitalizations. Annual incidence of worsening heart failure increased from 25 events per 100 person-years to 33 events per 100 person-years during the study period, primarily due to an increase in outpatient encounters and ED visits/observation stays. The 30-day rate of hospitalizations after these worsening heart failure events ranged from 8.2% for outpatient encounters to 12.4% for hospitalizations.

The authors noted that although they used a rigorous definition of worsening heart failure, they were unable to incorporate some therapeutic interventions, such as IV vasoactive medications or long-term renal replacement therapy, among other limitations. They concluded that ED visits/observation stays and outpatient encounters in their study made up approximately 50% of the episodes of worsening heart failure and that more of these events are occurring outside a hospital setting, driving increases in heart failure-related morbidity. “The significance of ED visits/observation stays and outpatient encounters for WHF [worsening heart failure] is underscored by the high rate of subsequent WHF events,” they wrote. “Future patient-oriented research should incorporate composite outcome measures including WHF events across the care continuum from ambulatory encounters to hospitalizations.”

An accompanying editorial stressed that while studying hospitalizations for heart failure is important, preventing worsening heart failure before hospitalization should be a vital goal of care. “Immediate institution of therapies proven to reduce the risk of disease progression in HF [heart failure] is the best way to preserve health status, mitigate cardiac remodeling, and prevent progression of the diagnosis,” the editorialists wrote. “This is an all-hands-on-deck moment: education, utilization of clinician and patient-facing tools, care prompts within the electronic health record to trigger better GDMT [goal-directed medical therapy] adherence, or even establishment of ‘GDMT clinics' are all important steps to rapidly institute quality HF care and are the best chance to keep our patients stable early in their journey, preserve health status, and to reduce the risk of later disease progression.”