Vast majority of ED visits for acute heart failure become admissions

Nearly six of every seven patients presenting to U.S. emergency departments with acute heart failure are admitted. This means acute heart failure is "a major challenge" to emergency departments nationwide and consumes a sizeable portion of their resources.

"Strategies to reduce this clinical and economic burden are needed," said Dr. Alan B. Storrow of the department of emergency medicine, Vanderbilt University, Nashville, and his associates.

The investigators performed a retrospective cohort study to quantify the burden of acute heart failure on emergency medical care because "it is important ... to focus individual and health system strategies to address [these] challenges before they become overwhelming." To do so, they analyzed information from the Nationwide Emergency Department Sample, "the largest all-payer ED [emergency department] database in the United States," which contains 25-30 million records of ED visits for more than 950 hospitals.

For this study, the researchers assessed an average of 958,167 annual ED visits for acute heart failure over a 5-year period. They excluded patients with cardiogenic shock, unspecified shock, intubation, noninvasive ventilation, or acute myocardial infarction because such patients wouldn’t have been eligible for discharge from the ED, which was an important outcome for this analysis.

Overall, 83.7% of acute heart failure patients who presented to the ED were admitted for hospitalization. The median length of stay was 3.4 days. Median ED charges rose over time, from $1,075 to $1,558 per person (JACC Heart Failure 2014 April 30 [doi:10.1016/j.jchf.2014.01.006]).

Patients who presented to EDs at academic hospitals were 1.5 times more likely to be admitted than were those who presented to nonacademic hospitals.

Admission rates also varied with geographic location of the hospital. Patients who presented to EDs in the Northeast region of the country were the most likely to be admitted (90% admission rate), while those in the West were the least likely (79% admission rate).

Uninsured patients were admitted less often than insured patients, even though they were more likely to have significant comorbidities. However, uninsured patients who were admitted underwent more diagnostic and therapeutic procedures than did insured patients.

"These data strongly suggest the ED is increasingly being relied on to evaluate more complex patients, some of whom previously received care as outpatients, or were directly admitted from an outpatient setting. ... As a result, emergency physicians increasingly serve as the major decision makers for approximately one-half of all U.S. inpatient admissions," Dr. Storrow and his associates noted.

In addition, "Emergency physicians’ tolerance of ‘risk’ in relation to ED discharge decisions, especially for patients they do not have an ongoing relationship with, is likely lower than for other caregivers," they said.

Alternatives to admission must be considered, at least for a subset of patients who present to EDs with acute heart failure. For example, patients who are found not to have high-risk features could be managed for 24-48 hours in an observation unit or discharged home. "Exploring these alternative strategies is crucial because the prevalence of chronic heart failure, and ED presentations for acute heart failure, are expected to increase over the next decade," Dr. Storrow and his colleagues said.

They added that this study probably underestimated the burden of acute heart failure on EDs because some patients likely received primary diagnoses of pneumonia, chronic obstructive pulmonary disease, asthma, or pulmonary embolus, with acute heart failure listed only as a supporting diagnosis. Such patients wouldn’t have been included in the analysis.

This study was supported by the National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences. Dr. Storrow reported receiving grants from Abbott and Roche Diagnostics and is a consultant for Abbott, Astellas, and Novartis; his associates reported ties to numerous industry sources.

Nearly six of every seven patients presenting to U.S. emergency departments with acute heart failure are admitted. This means acute heart failure is "a major challenge" to emergency departments nationwide and consumes a sizeable portion of their resources.

"Strategies to reduce this clinical and economic burden are needed," said Dr. Alan B. Storrow of the department of emergency medicine, Vanderbilt University, Nashville, and his associates.

The investigators performed a retrospective cohort study to quantify the burden of acute heart failure on emergency medical care because "it is important ... to focus individual and health system strategies to address [these] challenges before they become overwhelming." To do so, they analyzed information from the Nationwide Emergency Department Sample, "the largest all-payer ED [emergency department] database in the United States," which contains 25-30 million records of ED visits for more than 950 hospitals.

For this study, the researchers assessed an average of 958,167 annual ED visits for acute heart failure over a 5-year period. They excluded patients with cardiogenic shock, unspecified shock, intubation, noninvasive ventilation, or acute myocardial infarction because such patients wouldn’t have been eligible for discharge from the ED, which was an important outcome for this analysis.

Overall, 83.7% of acute heart failure patients who presented to the ED were admitted for hospitalization. The median length of stay was 3.4 days. Median ED charges rose over time, from $1,075 to $1,558 per person (JACC Heart Failure 2014 April 30 [doi:10.1016/j.jchf.2014.01.006]).

Patients who presented to EDs at academic hospitals were 1.5 times more likely to be admitted than were those who presented to nonacademic hospitals.

Admission rates also varied with geographic location of the hospital. Patients who presented to EDs in the Northeast region of the country were the most likely to be admitted (90% admission rate), while those in the West were the least likely (79% admission rate).

Uninsured patients were admitted less often than insured patients, even though they were more likely to have significant comorbidities. However, uninsured patients who were admitted underwent more diagnostic and therapeutic procedures than did insured patients.

"These data strongly suggest the ED is increasingly being relied on to evaluate more complex patients, some of whom previously received care as outpatients, or were directly admitted from an outpatient setting. ... As a result, emergency physicians increasingly serve as the major decision makers for approximately one-half of all U.S. inpatient admissions," Dr. Storrow and his associates noted.

In addition, "Emergency physicians’ tolerance of ‘risk’ in relation to ED discharge decisions, especially for patients they do not have an ongoing relationship with, is likely lower than for other caregivers," they said.

Alternatives to admission must be considered, at least for a subset of patients who present to EDs with acute heart failure. For example, patients who are found not to have high-risk features could be managed for 24-48 hours in an observation unit or discharged home. "Exploring these alternative strategies is crucial because the prevalence of chronic heart failure, and ED presentations for acute heart failure, are expected to increase over the next decade," Dr. Storrow and his colleagues said.

They added that this study probably underestimated the burden of acute heart failure on EDs because some patients likely received primary diagnoses of pneumonia, chronic obstructive pulmonary disease, asthma, or pulmonary embolus, with acute heart failure listed only as a supporting diagnosis. Such patients wouldn’t have been included in the analysis.

This study was supported by the National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences. Dr. Storrow reported receiving grants from Abbott and Roche Diagnostics and is a consultant for Abbott, Astellas, and Novartis; his associates reported ties to numerous industry sources.

Nearly six of every seven patients presenting to U.S. emergency departments with acute heart failure are admitted. This means acute heart failure is "a major challenge" to emergency departments nationwide and consumes a sizeable portion of their resources.

"Strategies to reduce this clinical and economic burden are needed," said Dr. Alan B. Storrow of the department of emergency medicine, Vanderbilt University, Nashville, and his associates.

The investigators performed a retrospective cohort study to quantify the burden of acute heart failure on emergency medical care because "it is important ... to focus individual and health system strategies to address [these] challenges before they become overwhelming." To do so, they analyzed information from the Nationwide Emergency Department Sample, "the largest all-payer ED [emergency department] database in the United States," which contains 25-30 million records of ED visits for more than 950 hospitals.

For this study, the researchers assessed an average of 958,167 annual ED visits for acute heart failure over a 5-year period. They excluded patients with cardiogenic shock, unspecified shock, intubation, noninvasive ventilation, or acute myocardial infarction because such patients wouldn’t have been eligible for discharge from the ED, which was an important outcome for this analysis.

Overall, 83.7% of acute heart failure patients who presented to the ED were admitted for hospitalization. The median length of stay was 3.4 days. Median ED charges rose over time, from $1,075 to $1,558 per person (JACC Heart Failure 2014 April 30 [doi:10.1016/j.jchf.2014.01.006]).

Patients who presented to EDs at academic hospitals were 1.5 times more likely to be admitted than were those who presented to nonacademic hospitals.

Admission rates also varied with geographic location of the hospital. Patients who presented to EDs in the Northeast region of the country were the most likely to be admitted (90% admission rate), while those in the West were the least likely (79% admission rate).

Uninsured patients were admitted less often than insured patients, even though they were more likely to have significant comorbidities. However, uninsured patients who were admitted underwent more diagnostic and therapeutic procedures than did insured patients.

"These data strongly suggest the ED is increasingly being relied on to evaluate more complex patients, some of whom previously received care as outpatients, or were directly admitted from an outpatient setting. ... As a result, emergency physicians increasingly serve as the major decision makers for approximately one-half of all U.S. inpatient admissions," Dr. Storrow and his associates noted.

In addition, "Emergency physicians’ tolerance of ‘risk’ in relation to ED discharge decisions, especially for patients they do not have an ongoing relationship with, is likely lower than for other caregivers," they said.

Alternatives to admission must be considered, at least for a subset of patients who present to EDs with acute heart failure. For example, patients who are found not to have high-risk features could be managed for 24-48 hours in an observation unit or discharged home. "Exploring these alternative strategies is crucial because the prevalence of chronic heart failure, and ED presentations for acute heart failure, are expected to increase over the next decade," Dr. Storrow and his colleagues said.

They added that this study probably underestimated the burden of acute heart failure on EDs because some patients likely received primary diagnoses of pneumonia, chronic obstructive pulmonary disease, asthma, or pulmonary embolus, with acute heart failure listed only as a supporting diagnosis. Such patients wouldn’t have been included in the analysis.

This study was supported by the National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences. Dr. Storrow reported receiving grants from Abbott and Roche Diagnostics and is a consultant for Abbott, Astellas, and Novartis; his associates reported ties to numerous industry sources.