Analysis of How Emergency Physicians’ Decisions to Hospitalize or Discharge Patients With Acute Heart Failure Match the Clinical Risk Categories of the MEESSI-AHF Scale

The Multiple Estimation of Risk Based on the Emergency Department Spanish Score in Patients With Acute Heart Failure (MEESSI-AHF) is a validated clinical decision tool that characterizes risk of mortality in emergency department (ED) acute heart failure patients. The objective of this study is to co...

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Bibliographic Details
Published in:	Annals of emergency medicine Vol. 74; no. 2; pp. 204 - 215
Main Authors:	Miró, Òscar, Rossello, Xavier, Gil, Víctor, Martín-Sánchez, Francisco J., Llorens, Pere, Herrero-Puente, Pablo, Jacob, Javier, Piñera, Pascual, Mojarro, Enrique M., Lucas-Imbernón, Francisco J., Llauger, Lluís, Agüera, Carmen, López-Díez, María P., Valero, Amparo, Bueno, Héctor, Pocock, Stuart J., Gil, Marta Fuentes, Salvo, Eva, Escoda, Rosa, Aguiló, Sira, Xipell, Carolina, Sánchez, Carolina, Gaytan, Josep M., Noval, Antonio, Torres, José M., Aguirre, Alfons, Pedragosa, María Àngels, Torres-Gárate, Raquel, Alonso, María Isabel, Ruiz, Francisco, Franco, José Miguel, Sánchez, Susana, Alquézar, Aitor, Rizzi, Miguel Alberto, Herrera, Sergio, Cabello, Irene, Roset, Álex, Alonso, Héctor, Adrada, Esther Rodríguez, García, Guillermo Llopis, Álvarez Pérez, José María, Mecina, Ana Belén, Álvarez, Joaquín Vázquez, González, Marta Sánchez, Prieto, Belén, García, María García, Marquina, Víctor, Jiménez, Inmaculada, Javaloyes, Patricia, Hernández, Néstor, Brouzet, Benjamin, López, Ana, Andueza, Juan Antonio, Romero, Rodolfo, Calvache, Roberto, Lorca, María Teresa, Calderón, Luis, Arriaga, Beatriz Amores, Sierra, Beatriz, Sánchez Nicolás, José Andrés, Mojarro, Enrique Martín, Bécquer, Lisette Travería, García, Lluís Llauger, La Salle, Gerard Corominas, Urbano, Carmen Agüera, Ferrer, Ester Soy
Format:	Journal Article
Language:	English
Published:	United States Elsevier Inc 01-08-2019
Subjects:	Acute Disease Aged Aged, 80 and over Clinical Decision-Making - methods Emergency Service, Hospital - standards Female Heart Failure - diagnosis Heart Failure - epidemiology Heart Failure - mortality Hospital Mortality - trends Hospitalization - statistics & numerical data Humans Male Observational Studies as Topic Patient Discharge - statistics & numerical data Physicians - statistics & numerical data Practice Patterns, Physicians' - standards Prospective Studies Retrospective Studies Risk Assessment - methods Risk Factors Sensitivity and Specificity
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Summary:	The Multiple Estimation of Risk Based on the Emergency Department Spanish Score in Patients With Acute Heart Failure (MEESSI-AHF) is a validated clinical decision tool that characterizes risk of mortality in emergency department (ED) acute heart failure patients. The objective of this study is to compare the distribution of risk categories between hospitalized and discharged ED patients with acute heart failure. We included consecutive acute heart failure patients from 34 Spanish EDs. Patients were retrospectively classified according to MEESSI-AHF risk categories. We calculated the odds of hospitalization (versus direct discharge from the ED) across MEESSI-AHF risk categories. Next, we assessed the following 30-day postdischarge outcomes: ED revisit, hospitalization, death, and their combination. We used Cox hazards models to determine the adjusted association between ED disposition decision and the outcomes among patients who were stratified into low- and increased-risk categories. We included 7,930 patients (80.5 years [SD 10.1 years]; women 54.7%; hospitalized 75.3%). Compared with that for low-risk MEESSI-AHF patients, odds ratios for hospitalization of patients in intermediate-, high-, and very-high-risk categories were 1.83 (95% confidence interval [CI] 1.64 to 2.05), 3.05 (95% CI 2.48 to 3.76), and 3.98 (95% CI 3.13 to 5.05), respectively. However, almost half (47.6%) of all discharged patients were categorized as being at increased risk by MEESSI-AHF, and 19.0% of all the increased-risk patients were discharged from the ED. Among the low-risk MEESSI-AHF patients, the 30-day postdischarge mortality did not differ by ED disposition (hazard ratio [HR] for discharged patients with respect to hospitalized ones 0.65; 95% CI 0.70 to 1.11), nor did it differ in the increased-risk group (HR 0.88; 95% CI 0.63 to 1.23). The discharged low-risk MEESSI-AHF patients had higher risks of 30-day ED revisit and hospitalization (HR 1.86, 95% CI 1.57 to 2.20; and HR 1.92, 95% CI 1.54 to 2.40, respectively) compared with the admitted patients, as did the discharged patients in the increased-risk group (HR 1.62, 95% CI 1.39 to 1.89; and HR 1.40, 95% CI 1.16 to 1.68, respectively), with similar results for the combined endpoint. The disposition decisions made in current clinical practice for ED acute heart failure patients calibrate with MEESSI-AHF risk categories, but nearly half of the patients currently discharged from the ED fall into increased-risk MEESSI-AHF categories.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	0196-0644 1097-6760
DOI:	10.1016/j.annemergmed.2019.03.010