Outpatient Volume Management of Heart Failure May Reduce Hospitalization, Mortality Risks

Ambulatory, or outpatient, intravenous (IV) diuretic treatment for volume management in decompensated heart failure can increase urine output, promote weight loss, and improve dyspnea. However, few comparative data exist on its effectiveness vs in-hospital observation, until now.

A recent study in Rhode Island Medical Journal shows that ambulatory IV diuretic treatment for heart failure led to a 61% reduction in the risk of hospitalization or death over 180 days (6 months) of follow-up (HR, 0.39; 95% CI, 0.19-0.83) compared with patients who underwent standard observation. There were also reductions in all-cause rehospitalization.

“This strategy may provide an alternative to hospitalization for the management of heart failure patients,” the authors noted.

Using data on 90 patients from the Providence Veterans Affairs Medical Center (PVAMC), their retrospective cohort study investigated outcomes in the group between January 1, 2014, and June 30, 2016. Patients were included if they were discharged from PVAMC with a primary diagnosis of decompensated heart failure or had at least 1 visit to an ambulatory IV diuretic clinic (n = 27) or a subsequent observational hospitalization shorter than 48 hours (n = 63).

Patients in the observation group were slightly older. Their mean (SD) age was 80.3 (11.0) years compared with 78.3 (8.3) years among the ambulatory IV diuretic group. The latter cohort received a median (interquartile range [IQR]) of 3 (IQR, 2-12) treatments, and their median urine output was 2525.0 mL (IQR, 1075-9830). With the same time periods being used for comparison, the hospitalized patients referred for subsequent treatment at an ambulatory IV diuretic clinic received a mean 12.3 (12.1) treatments during follow-up.

The diuresis group also had higher rates of the following conditions:

• Heart failure with reduced ejection fraction: 37.0% vs 28.6%
• Coronary artery disease: 81.5% vs 77.8%
• Chronic obstructive pulmonary disease (COPD): 51.9% vs 28.6%
• Type 2 diabetes: 55.6% vs 50.8%
• Obstructive sleep apnea (OSA): 59.3% vs 25.4%
• Pulmonary hypertension: 33.3% vs 15.9%
• Depression: 59.3% vs 31.8%

However, compared with those in the observational admission cohort, the diuresis group also had lower unadjusted and adjusted (for age, body mass index, a diagnosis of OSA or COPD, estimated glomerular filtration rate, loop diuretic use, left ventricular ejection fraction, hospice enrollment) HRs for any rehospitalization or death:

• Unadjusted: HR, 0.43 (95% CI, 0.23-0.81)
• Adjusted: HR, 0.43 (95% CI, 0.21-0.88)

Additionally, there were more median days to rehospitalization or death for the diuresis group vs the observational group: 38 (IQR, 21-87) vs 27 (IQR, 11-68) days.

“In patients with mild to moderate decompensated heart failure, ambulatory IV diuretic clinic was associated with risk reduction of any rehospitalization or death over 180 days of follow-up,” the authors concluded, “when compared to a strategy of observational hospitalization for less than 48 hours.”

In addition, they point out that these findings are especially timely in light of the Hospital Readmissions Reduction Program under which hospitals can be fined, in the form of reduced payments, from excessive heart failure readmissions. They also provide possible evidence that ambulatory diuretic treatment is a safe and feasible alternative to emergency department visits or in-hospital observation for patients with mild to moderate decompensated heart failure.

Reference

St. Amand A, Taveira TH, Henthorne KE, Wu W-C. Ambulatory intravenous diuretic clinic associated with short-term risk reduction in mortality and rehospitalizations in patients discharged with heart failure. R I Med J. 2020;103(9):16-21.