Critical Elements of Clinical Follow-up After Hospital Discharge for HF
Critical Elements of Clinical Follow-up After Hospital Discharge for HF
Aims Hospitalized heart failure (HF) patients are at high risk for death and readmission. We examined the incremental value of data obtained 1 week after HF hospital discharge in predicting mortality and readmission.
Methods and results In the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with tolvaptan, 1528 hospitalized patients (ejection fraction ≤40%) with a physical examination, laboratories, and health status [Kansas City Cardiomyopathy Questionnaire (KCCQ)] assessments 1 week after discharge were included. The ability to predict 1 year cardiovascular rehospitalization and mortality was assessed with Cox models, c-statistics, and the integrated discrimination improvement (IDI). Not using a beta-blocker, rales, pedal oedema, hyponatraemia, lower creatinine clearance, higher brain natriuretic peptide, and worse health status were independent risk factors for rehospitalization and death. The c-statistic for the base model (history and medications) was 0.657. The model improved with physical examination, laboratory, and KCCQ results, with IDI increases of 4.9, 7.0, and 3.2%, respectively (P < 0.001 each). The combination of all three offered the greatest incremental gain (c-statistic 0.749; IDI increase 10.8%).
Conclusion Physical examination, laboratories, and KCCQ assessed 1 week after discharge offer important prognostic information, suggesting that all are critical components of outpatient evaluation after HF hospitalization.
Following hospitalization for acute heart failure (HF) syndromes, patients are at a significantly increased risk for adverse outcomes, with mortality rates as high as 10% and rehospitalization rates as high as 30% 3 months after discharge. Further, patients hospitalized with HF have the highest 30-day readmission rates of any admission diagnosis among Medicare beneficiaries. The ability to identify high-risk patients following hospitalization is particularly important given the opportunity to aggressively treat those patients at greatest risk to improve their outcomes. For example, medication titration, more intense follow-up, and the use of HF disease management programmes have been shown to reduce hospitalizations and mortality. Accordingly, increased attention has been focused on transitions of care for patients with HF.
While serial monitoring of chronic HF patients is a class I recommendation, and guidelines suggest patients are followed-up 7–10 days after hospital discharge for acute HF syndromes, the specific components of early follow-up evaluation that are most predictive of adverse outcomes are unknown. As patients are likely to see a different set of providers during a hospitalization, and direct communication between hospital physicians and outpatient providers at the time of hospital discharge occurs <20% of the time, information from hospitalization may not be available at the time of outpatient evaluation. The evaluation after hospital discharge may include a clinic visit with history and physical examination, a formal health status assessment, and/or laboratory studies. Although each of these have been shown to be prognostic in HF, they have not been studied for their capacity to stratify patients' risk in the period shortly after discharge, nor have they been compared to determine if they incrementally, or redundantly, contribute to risk stratification. By clarifying which domains of follow-up evaluation are most important, more efficient strategies for following discharged HF patients could be designed. For example, if health status assessments provided the most important information, merely calling patients after discharge might enable accurate risk stratification and guide future treatment decisions. If biomarkers conferred the most discrimination, a laboratory visit with review of results by phone might suffice. If physical examination is needed to discriminate prognosis, than a clinic visit would be required.
To address these gaps in knowledge, we evaluated which components of the 1-week follow-up visit, including physical examination, laboratories, and health status, offered the greatest incremental value in predicting cardiovascular rehospitalization and mortality in a cohort of patients enrolled in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) Trial. These analyses were designed to improve risk stratification and lend support for recommendations about appropriate clinical monitoring of patients recovering from acute HF syndromes.
Abstract and Introduction
Abstract
Aims Hospitalized heart failure (HF) patients are at high risk for death and readmission. We examined the incremental value of data obtained 1 week after HF hospital discharge in predicting mortality and readmission.
Methods and results In the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with tolvaptan, 1528 hospitalized patients (ejection fraction ≤40%) with a physical examination, laboratories, and health status [Kansas City Cardiomyopathy Questionnaire (KCCQ)] assessments 1 week after discharge were included. The ability to predict 1 year cardiovascular rehospitalization and mortality was assessed with Cox models, c-statistics, and the integrated discrimination improvement (IDI). Not using a beta-blocker, rales, pedal oedema, hyponatraemia, lower creatinine clearance, higher brain natriuretic peptide, and worse health status were independent risk factors for rehospitalization and death. The c-statistic for the base model (history and medications) was 0.657. The model improved with physical examination, laboratory, and KCCQ results, with IDI increases of 4.9, 7.0, and 3.2%, respectively (P < 0.001 each). The combination of all three offered the greatest incremental gain (c-statistic 0.749; IDI increase 10.8%).
Conclusion Physical examination, laboratories, and KCCQ assessed 1 week after discharge offer important prognostic information, suggesting that all are critical components of outpatient evaluation after HF hospitalization.
Introduction
Following hospitalization for acute heart failure (HF) syndromes, patients are at a significantly increased risk for adverse outcomes, with mortality rates as high as 10% and rehospitalization rates as high as 30% 3 months after discharge. Further, patients hospitalized with HF have the highest 30-day readmission rates of any admission diagnosis among Medicare beneficiaries. The ability to identify high-risk patients following hospitalization is particularly important given the opportunity to aggressively treat those patients at greatest risk to improve their outcomes. For example, medication titration, more intense follow-up, and the use of HF disease management programmes have been shown to reduce hospitalizations and mortality. Accordingly, increased attention has been focused on transitions of care for patients with HF.
While serial monitoring of chronic HF patients is a class I recommendation, and guidelines suggest patients are followed-up 7–10 days after hospital discharge for acute HF syndromes, the specific components of early follow-up evaluation that are most predictive of adverse outcomes are unknown. As patients are likely to see a different set of providers during a hospitalization, and direct communication between hospital physicians and outpatient providers at the time of hospital discharge occurs <20% of the time, information from hospitalization may not be available at the time of outpatient evaluation. The evaluation after hospital discharge may include a clinic visit with history and physical examination, a formal health status assessment, and/or laboratory studies. Although each of these have been shown to be prognostic in HF, they have not been studied for their capacity to stratify patients' risk in the period shortly after discharge, nor have they been compared to determine if they incrementally, or redundantly, contribute to risk stratification. By clarifying which domains of follow-up evaluation are most important, more efficient strategies for following discharged HF patients could be designed. For example, if health status assessments provided the most important information, merely calling patients after discharge might enable accurate risk stratification and guide future treatment decisions. If biomarkers conferred the most discrimination, a laboratory visit with review of results by phone might suffice. If physical examination is needed to discriminate prognosis, than a clinic visit would be required.
To address these gaps in knowledge, we evaluated which components of the 1-week follow-up visit, including physical examination, laboratories, and health status, offered the greatest incremental value in predicting cardiovascular rehospitalization and mortality in a cohort of patients enrolled in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) Trial. These analyses were designed to improve risk stratification and lend support for recommendations about appropriate clinical monitoring of patients recovering from acute HF syndromes.
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