<s="Early Initiation of IV Vasoactive Therapy Improves HF Outcomes:">
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The rest of the presentation takes a closer look at specific strategies for improving treatment outcomes and reducing hospital costs in the treatment of acute heart failure.
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First, we'll look at an analysis we did using ADHERE Registry data that examines outcomes based on where patients initiated their IV vasoactive therapy.
<ss="The ADHERE« Registry">
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At the time of the analysis there were 260 hospitals in the registry with 46,599 patient care episodes. All patients in the database were coded with a discharge diagnosis of heart failure. Our analysis excluded patients with a history of MI or who were hypotensive. All patients in the analysis received an IV vasoactive, which could consist of nesiritide, nitroglycerin, nitroprusside, milrinone, dobutamine, or dopamine. Around 7500 patients out of the 46,000 in the database received some type of IV vasoactive therapy. Our analysis examined: (1) one group of 4096 patients who had IV vasoactive therapy initiated in the ED; and (2) a second group of 3499 patients whose IV vasoactive therapy began in the inpatient unit.
<ss="Baseline Characteristics (%)">
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Because the study population numbers are so big, even small differences in the baseline characteristics are statistically significant, but probably not clinically relevant. The creatinine is a little higher in patients who had their drug delayed, as was the incidence of CRF. And patients with ischemia or systolic heart failure tended to have their therapy as an inpatient instead of in the ED. This is important because we will see that patients whose therapy is delayed tend to do poorly. The question is, why do we delay treatment in these people?
<ss="Time to Treatment (Hours) vs Where Vasoactive Started">
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Patients who received therapy in the ED got it within an hour. The patients who received it as an inpatient got it almost a day later, at 22 hours. My assumption is that the patients who received it in the ED looked sicker than those who didn't obtain it right away, but who ended up being admitted and getting sicker themselves. So there is something important that we are missing about this second group. Of course, there may be other reasons patients did not receive vasoactive therapy in the ED, the most prominent being hospital policy. Some institutions mandate that vasoactives may only be used in an ICU setting.
<ss="In-Hospital Mortality (%) vs Where Vasoactive Started">
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If you look at in-hospital mortality based on when and where patients got therapy, it's 4.2% for patients who received therapy in the ED vs 10.9% for patients who received it after they were admitted as an inpatient. That's an increase of more than 100%. This is the only HF trial that I'm aware of that shows an in-hospital mortality difference based on ED-initiated therapy.
<ss="ICU Transfer (%) vs Where Vasoactive Started">
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If you look at the number of patients who were decompensated and had to be transferred to intensive care, it's only 4% if patients got vasoactive therapy started in the ED vs 20% if they had to wait to receive it upstairs.
<ss="Hospital LOS (Days) vs Where Vasoactive Started">
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If you look at hospital length of stay based on when and where vasoactive therapy started, it's 4.5 days for patients who received therapy in the ED vs 7 days for patients who received it after being admitted as an inpatient. Remember that 4.5 days is about the break-even point on your DRG.
<ss="ICU LOS (Median Days) vs Where Vasoactive Started">
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Looking at $1500-per-night ICU length of stay, we see that it is 2 days for patients who received vasoactive therapy in the ED compared to 3.1 days for patients who received it in an inpatient setting.
<ss="Invasive Procedures (%) vs Where Vasoactive Started">
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Invasive procedures are another drain on cost. We examined the rate of invasive procedures on these two populations. Invasive procedures were not wimpy and included CABG, Swan-Ganz placement, intubation, percutaneous coronary intervention, LVAD placement, CPR, and death. Here we can see that 19% of patients who received vasoactive therapy early in the ED needed an invasive procedure compared to 27% of patients who had vasoactive therapy delayed.
<ss="Conclusions">
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This analysis is limited by the fact that it uses registry data. It shows associations only and does not describe cause and effect. The variables are also uncontrolled, and the physicians could do what they wanted. The strength of the analysis is that it looks at a large population of patients, which allows it to establish strong statistical significance.
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The summary of this analysis shows that early initiation of vasoactive agents is associated with significantly fewer deaths, fewer invasive procedures, fewer ICU transfers, and shorter ICU and hospital length of stay, all of which result in better outcomes for the patient and lower costs to the hospital. My interpretation of this analysis is that physicians tend to start vasoactives on patients that appear sick, so those who received therapy in the ED probably were the sick-looking patients. But clearly there is a population of patients who may not look sick initially, but who become sick later, do ultimately require vasoactive therapy, and actually end up doing much worse than they would have if they had gone ahead and gotten their vasoactives earlier in the ED. This is all the more puzzling since the patients who don't receive therapy until they are admitted tend to have a higher incidence of elevated creatinine, a higher incidence of chronic renal failure, more HF that is ischemic in origin, and lower ejection fractions at baselineùall predictors of an increased risk of an adverse outcome. It is important to note that all of this information should be available to the ED physicians while they are evaluating patients. Clearly, we need to figure out what it is that we are missing about these patients in order to improve their care and save costs for the hospital.
<ss="To continue select: ^"Nesiritide^" ">
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Welcome to our program on Acute Heart Failure: The Emergency Department and the Economics of Care. This is a CME-accredited program that focuses on optimizing treatment strategies in the Emergency Department in order to improve outcomes and reduce overall costs to the hospital.
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When you think about the overall hospital costs of a 5-day admission for an acute condition that often requires ICU care and invasive procedures, you don't necessarily think about the Emergency Department. After all, the patient is usually only in the ED for a few short hours, compared to the several days they will spend as an inpatient. But when it comes to treating acute heart failure, we are beginning to learn that what occurs during those critical initial hours in the Emergency Department has a direct and significant impact on overall treatment outcomes, including the length of stay as an inpatient, the utilization of expensive resources, and the likelihood of readmission to the hospital within the near term.
