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Care Setting Intensity and Outcomes After Emergency Department Presentation Among Patients With Acute Heart Failure

View Article: PubMed Central - PubMed

ABSTRACT

Background: Patients with heart failure (HF) presenting to the emergency department (ED) can be admitted to care settings of different intensity, where the intensive care unit (ICU) is the highest intensity, ward admission is intermediate intensity, and those discharged home are of lowest intensity. Despite the costs associated with higher‐intensity care, little is known about disposition decisions and outcomes of HF patients treated in different care settings.

Methods and results: We identified predictors of ICU or ward admission and determined whether survival differs in patients admitted to higher‐intensity versus lower‐intensity care settings (ie, ICU vs ward, or ward vs ED‐discharged). Among 9054 patients (median, 78 years; 51% men) presenting to an ED in Ontario, Canada, 1163 were ICU‐admitted, 5240 ward‐admitted, and 2651 were ED‐discharged. Predictors of ICU (vs ward) admission included: use of noninvasive positive pressure ventilation (adjusted odds ratio [OR], 2.01; 95% CI, 1.36–2.98), higher respiratory rate (OR, 1.10 per 5 breaths/min; 95% CI, 1.05–1.15), and lower oxygen saturation (OR, 0.90 per 5%; 95% CI, 0.86–0.94; all P<0.001). Predictors of ward‐admitted versus ED‐discharged were similar. Propensity‐matched analysis comparing lower‐risk ICU to ward‐admitted patients demonstrated a nonsignificant trend at 100 days (relative risk [RR], 0.69; 95% CI, 0.43–1.10; P=0.148). At 1 year, however, survival was higher among those initially admitted to ICU (RR, 0.68; 95% CI, 0.49–0.94; P=0.022). There was no survival difference among low‐risk ward‐admitted versus ED‐discharged patients.

Conclusions: Respiratory factors were associated with admission to higher‐intensity settings. There was no difference in early survival between some lower‐risk patients admitted to higher‐intensity units compared to those treated in lower‐intensity settings.

No MeSH data available.


Comparison of 1‐year survival estimate in the propensity‐score–matched patients between ICU and ward by Kaplan–Meier curve: time to death for propensity score‐matched cohort. ICU indicates intensive care or coronary care unit. CCU indicates coronary care unit; ICU, intensive care unit.
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jah31644-fig-0006: Comparison of 1‐year survival estimate in the propensity‐score–matched patients between ICU and ward by Kaplan–Meier curve: time to death for propensity score‐matched cohort. ICU indicates intensive care or coronary care unit. CCU indicates coronary care unit; ICU, intensive care unit.

Mentions: A total of 509 pairs of 1:1 propensity‐matched patients, who were admitted to the ICU or the ward, were examined. Lower‐risk ICU patients with lower‐than‐median predicted probability of 30‐day mortality (EHMRG30‐ST ≤ median) were well‐matched for all covariates to ward patients, with standardized differences shown in Table S3. The characteristics of the matched cohort are shown in Table S4. Compared to the ICU‐admitted population, matched patients tended to be younger and less often presented to hospital by ambulance. The ward‐ and ICU‐admitted patients were also well matched on the composite EHMRG 7‐day risk score, with standardized difference 0.03 after propensity‐score matching. There was no difference in early mortality at 100 days, with an adjusted relative risk of 0.69 (95% CI, 0.43–1.10; P=0.148). However, the propensity‐matched survival curves diverged after 100 days (Figure 6). At 1‐year follow‐up, the relative risk for death comparing ICU‐admitted patients to ward‐admitted patients was 0.68 (95% CI, 0.49–0.94) in the propensity‐matched sample (Table 4, bottom), indicating significantly improved survival up to 1 year among those initially admitted to the ICU (P=0.022). There was no significant time‐ICU interaction (P=0.746).


Care Setting Intensity and Outcomes After Emergency Department Presentation Among Patients With Acute Heart Failure
Comparison of 1‐year survival estimate in the propensity‐score–matched patients between ICU and ward by Kaplan–Meier curve: time to death for propensity score‐matched cohort. ICU indicates intensive care or coronary care unit. CCU indicates coronary care unit; ICU, intensive care unit.
© Copyright Policy - creativeCommonsBy-nc-nd
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5015368&req=5

jah31644-fig-0006: Comparison of 1‐year survival estimate in the propensity‐score–matched patients between ICU and ward by Kaplan–Meier curve: time to death for propensity score‐matched cohort. ICU indicates intensive care or coronary care unit. CCU indicates coronary care unit; ICU, intensive care unit.
Mentions: A total of 509 pairs of 1:1 propensity‐matched patients, who were admitted to the ICU or the ward, were examined. Lower‐risk ICU patients with lower‐than‐median predicted probability of 30‐day mortality (EHMRG30‐ST ≤ median) were well‐matched for all covariates to ward patients, with standardized differences shown in Table S3. The characteristics of the matched cohort are shown in Table S4. Compared to the ICU‐admitted population, matched patients tended to be younger and less often presented to hospital by ambulance. The ward‐ and ICU‐admitted patients were also well matched on the composite EHMRG 7‐day risk score, with standardized difference 0.03 after propensity‐score matching. There was no difference in early mortality at 100 days, with an adjusted relative risk of 0.69 (95% CI, 0.43–1.10; P=0.148). However, the propensity‐matched survival curves diverged after 100 days (Figure 6). At 1‐year follow‐up, the relative risk for death comparing ICU‐admitted patients to ward‐admitted patients was 0.68 (95% CI, 0.49–0.94) in the propensity‐matched sample (Table 4, bottom), indicating significantly improved survival up to 1 year among those initially admitted to the ICU (P=0.022). There was no significant time‐ICU interaction (P=0.746).

View Article: PubMed Central - PubMed

ABSTRACT

Background: Patients with heart failure (HF) presenting to the emergency department (ED) can be admitted to care settings of different intensity, where the intensive care unit (ICU) is the highest intensity, ward admission is intermediate intensity, and those discharged home are of lowest intensity. Despite the costs associated with higher‐intensity care, little is known about disposition decisions and outcomes of HF patients treated in different care settings.

Methods and results: We identified predictors of ICU or ward admission and determined whether survival differs in patients admitted to higher‐intensity versus lower‐intensity care settings (ie, ICU vs ward, or ward vs ED‐discharged). Among 9054 patients (median, 78 years; 51% men) presenting to an ED in Ontario, Canada, 1163 were ICU‐admitted, 5240 ward‐admitted, and 2651 were ED‐discharged. Predictors of ICU (vs ward) admission included: use of noninvasive positive pressure ventilation (adjusted odds ratio [OR], 2.01; 95% CI, 1.36–2.98), higher respiratory rate (OR, 1.10 per 5 breaths/min; 95% CI, 1.05–1.15), and lower oxygen saturation (OR, 0.90 per 5%; 95% CI, 0.86–0.94; all P<0.001). Predictors of ward‐admitted versus ED‐discharged were similar. Propensity‐matched analysis comparing lower‐risk ICU to ward‐admitted patients demonstrated a nonsignificant trend at 100 days (relative risk [RR], 0.69; 95% CI, 0.43–1.10; P=0.148). At 1 year, however, survival was higher among those initially admitted to ICU (RR, 0.68; 95% CI, 0.49–0.94; P=0.022). There was no survival difference among low‐risk ward‐admitted versus ED‐discharged patients.

Conclusions: Respiratory factors were associated with admission to higher‐intensity settings. There was no difference in early survival between some lower‐risk patients admitted to higher‐intensity units compared to those treated in lower‐intensity settings.

No MeSH data available.