Diverting Acute HF Patients From Hospitalization: Case Builds for Short Stay Units

For patients presenting to the emergency department (ED) with acute heart failure (AHF), sending select low-risk individuals to the short stay unit (SSU) did not prove to be better than routine hospitalization — but at least it did not appear unsafe, the small randomized SSU-AHF trial showed.

Quality of life at 30 days postdischarge was similar between randomly assigned SSU and hospitalized groups (Kansas City Cardiomyopathy Questionnaire summary score average 51.3 vs 45.8 points, P=0.19).

Days alive and out of hospital at 30 days did favor SSU patients (26.9 vs 25.4, P=0.02), according to researchers led by Peter Pang, MD, of Indiana University School of Medicine in Indianapolis, who noted that this had been the original primary endpoint of their trial before it was amended and ultimately terminated early because of the COVID-19 pandemic.

In light of the multicenter trial being underpowered for the primary analysis, the “findings of lower healthcare utilization with the SSU strategy need to be definitively tested in an adequately powered study,” the group urged in JAMA Network Open.

“Our findings build on past work where SSU as an alternative to hospitalization from the ED appeared to be a safe option in lower-risk patients with AHF seen in the ED. Prior to this study, only observational data combined with expert consensus supported SSU management of AHF,” the investigators wrote.

The trial’s SSU protocol prioritized relief of heart failure symptoms and signs, decongestion and correction of any electrolyte imbalances, hemodynamic improvement, and guideline-recommended therapy at discharge. Pang’s group targeted lower-risk patients for the trial and excluded those with de novo heart failure, direct admissions, and acute comorbid conditions, among other criteria.

Even so, they found that the SSU patients in their trial still needed hospitalization in 41.9% of cases, namely after they had an acute event and were not ready for discharge after SSU management. This high rate “suggests that further refinement of SSU eligibility criteria, SSU management procedures, or both may strengthen the SSU strategy,” the authors wrote.

SSU’s appeal as an alternative to routine hospitalization comes as the U.S. faces rising healthcare utilization costs for heart failure. Hospitalization for AHF is the biggest contributor to costs of heart failure, estimated to reach $69.8 billion in 2030, Pang and colleagues noted.

Safety is the main concern of the SSU route. In the trial, there was no increase in 30-day or 90-day death or rehospitalization in the SSU group. There was an adverse event rate of approximately 16% for the two groups.

“To maximize the potential of SSU management, there is a need for improved evidence-based ED risk stratification criteria and innovative decongestion strategies,” wrote Andrew Ambrosy, MD, of Kaiser Permanente Northern California in Oakland, and two co-authors in an accompanying editorial.

“The fear of overdiuresis often leads to relative underdosing of diuretics, which may result in delays in therapy and residual congestion after discharge,” they explained. “Thus, innovative decongestion strategies may improve the feasibility of timely, safe, and effective treatment of AHF in SSUs without the need for further hospitalization.”

SSU-AHF was a randomized clinical trial that included AHF patients in the ED assigned to SSU or hospital admission at 12 academic hospital sites in the U.S.

The study authors originally hoped for 534 participants, but only got 193 enrolled due to interruption by the COVID-19 pandemic.

This final cohort had a mean age of 64.8 years, 40.9% were women, and 56.3% were Black. Baseline characteristics were well-balanced between groups, though there were numerically more patients with a reduced left ventricular ejection fraction in the SSU arm.

Besides the trial’s early termination and small sample, the study authors noted the lower-than-expected completion of the quality-of-life survey and their inability to count deaths not recorded in the electronic health record.