Is hospital admission for heart failure always justified?

Heart failure is one of the commonest reasons for admission to acute care hospitals. Some such admissions are low-risk and could be managed in subacute facilities with substantial cost savings.

Butler et al reviewed all admissions for heart failure at Vanderbilt University Medical Center between 1993 and 1995: 52% fell into the low-risk category. Most were admitted because of dyspnea and rales reported on physical examination. However, over 90% had no x-ray evidence of interstitial or alveolar pulmonary edema, and none were hypoxic. The remaining patients had only mild interstitial edema with adequate arterial blood oxygen saturation and no evidence of alveolar edema. This low-risk group also had average normal blood pressure, heart rates, and laboratory values on admission.

Outcomes in this group were consistent with a low-risk grading. Less than 5% of low-risk patients had adverse cardiovascular outcomes, mainly symptomatic supraventricular arrhythmia responding to medical therapy. One patient developed pulmonary edema in hospital. In all cases, these complications followed a period of gradual worsening extending over more than 12 hours, suggesting that the patient could initially have been managed in the nonacute care setting.

Theoretically, low-risk patients could be managed at home either by adjusting their medication or by involving home nursing. A more attractive approach may be admission to a subacute care unit for rapid symptom relief, usually readily achieved by repeated doses of intravenous diuretics. Such a setting also identifies the small group of patients who fail to respond promptly to therapy or who develop complications and can therefore be rapidly transferred to an acute care facility.

Patients with poor access to outpatient services are more likely to be hospitalized with low-risk disease because of concerns that they will be unable to obtain adequate outpatient follow-up or monitoring. The decision to admit patients with low-risk disease may be subject to physician discretion and could in some cases represent inappropriate use of hospital resources. Many of these patients could have been safely managed without hospitalization, an assertion supported by their very low in-hospital mortality rates, particularly in the first 4 days of hospitalization. Since hospitalization has uncertain benefits in low-risk patients, efforts to decrease variability (embodied in explicit hospital admission guidelines, decision aids to identify low-risk patients, and improved access to ambulatory services and home healthcare) could be expected to improve the cost-effectiveness of care.

Keywords

management; hospitalization; cost-effectiveness; acute care unit


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