Outcomes of Heart Failure Admissions Under Observation Versus Short Inpatient Stay

Abstract

BackgroundPatients with heart failure (HF) are admitted either under observation (OBS) or inpatient stays; however, there is little data on whether this designation reflects the clinical status of a patient, with significant logistical and financial implications. We sought to compare the outcomes of patients with HF admitted OBS versus inpatient stay (≤2 days; INPT).Methods and ResultsFrom January 1, 2008 to September 30, 2015, our multisite health system saw 21 339 unique patients totaling 52 493 hospital admissions with a primary diagnosis of HF. Patients were excluded if they underwent cardiac surgery (n=611), heart transplantation (n=187), or left ventricular assist device insertion (n=198), or if they died during hospitalization (n=1839). Of the remaining 50 654 discharges, 2 groups were identified: INPT group and OBS group. Outcomes were HF readmission, all‐cause readmission, and all‐cause mortality within 1 year of discharge. Hazard ratios were computed using the Andersen‐Gill method in the Cox proportional‐hazards model. A total of 8709 admissions (17%) occurred in the INPT group and 2648 admissions (5%) occurred in the OBS group. HF readmission rate at 1 year was 55.3% in INPT versus 66.5% in OBS (hazard ratio, 0.75; 95% confidence interval, 0.71–0.80; P<0.01). All‐cause readmission rate at 1 year was 70.7% in INPT versus 82.5% in OBS (hazard ratio, 0.74; 95% confidence interval, 0.70–0.78; P<0.01). All‐cause mortality at 1 year occurred in 25.2% of INPT versus 24.2% of OBS (hazard ratio, 1.03; 95% confidence interval, 0.95–1.12; P=0.46).Conclusions HF admissions designated INPTs were associated with lower readmission rates and equivalent mortality to those designated OBS.

Observation Versus Inpatient Stay for Heart Failure: Is It Semantics?

“…However, at 90 days, both the readmission and mortality rates were similar between the 2 groups, suggesting that patients presenting with chest pain designated to observation status may portend a better prognosis than the short inpatient stay group, at least in the short-term. This is different from the results of the current study by Masri et al, 12 raising the question of whether it may be easier to prognosticate patients with chest pain and predetermine hospitalization status, compared with those with HF. Bellolio et al conducted a similar study, whereby the investigators compared observation status with short inpatient stay (<48 hours) in patients presenting with chest pain.…”

“…[8][9][10][11] In this context, the results of the interesting study by Masri et al, published in this issue of Journal of the American Heart Association (JAHA), add to the debate. 12 The investigators compared outcomes of 11 355 HF admissions under observation (n=2648) with short inpatient stay (ie, <2 midnights; n=8709) from January 2008 to September 2015 within a large healthcare system of 8 hospitals. They examined differences between the 2 groups in baseline characteristics and outcomes of readmission (including both inpatient and observation stays) at 1, 3, and 12 months and mortality at 1 year after discharge.…”

“…Although the study by Masri et al is relatively novel in comparing short inpatient admissions (<2 midnights) with observation stays for HF, 12 at least 2 similar studies evaluated this issue in patients presenting with chest pain. 14,15 Wright et al evaluated >110 000 hospitalizations with a primary diagnosis of chest pain at Veterans Affairs hospitals.…”

Assessment of Hospital Readmissions From the Emergency Department After Implementation of Medicare’s Hospital Readmissions Reduction Program

“…Such pathways may be intended to increase patient-centered care, but recent research suggests potential for increased morbidity and mortality. 45,46 For instance, a 2017 study by Sax et al 45 found that 1 in 3 patients with CHF discharged from the ED had a repeat ED visit, hospitalization, or death within 30 days after ED discharge. More research should examine this possibility.…”

The cost impact to Medicare of shifting treatment of worsening heart failure from inpatient to outpatient management settings

“…At a same-day access HF clinic launched by Duke University Hospital, a 10% reduction in 30-day readmissions was observed out of over 3,000 visits over the course of 3 years 26. On the other hand, a retrospective multicenter study found readmission rates higher for HF treatment in observation units compared to inpatient hospital treatment, suggesting the need for improvements in the process of determining which worsening HF patients are most appropriate for OP treatment 27…”