Overutilization of the Observation Unit for Decompensated Heart Failure
Mashiba M, Lawler S, Mendiratta V, Lipari V, Georgie F, Nona P, and Gibbs J. Overutilization of the observation unit for decompensated heart failure. J Gen Intern Med 2017; 32(2):S260.
J Gen Intern Med
BACKGROUND: Acutely decompensated heart failure (ADHF) remains a significant health burden in the United States, with high mortality and cost. To promote quality care, the Centers for Medicare and Medicaid Services have decreased reimbursement for hospital systems with high readmission rates. Observation Units (OU) are a less-costly option for treatment of ADHF, however outcome data beyond 30 days is sparse. We sought to evaluate long-term outcomes and utilization for patients treated in the OU for ADHF.
METHODS: We performed a retrospective cohort study with patients admitted from the Emergency Department (ED) with ADHF. Patients with heart transplant, ventricular-assist device, or end-stage renal disease were excluded. Demographic and 12-month outcomes were collected. Patients discharged from the OU were compared with those admitted using Chi-Square Analysis, Fisher Exact Test, and Two-Sample T-Test. OU patients later admitted were also compared with those admitted from the ED.
RESULTS: Of the 535 patients included in the study, 427 were triaged to OU. Of these, 156 (37%) had LOS > 48 hours and required admission. The mean age was 71.4 years (standard deviation, 14.9 years) and 52% were female. OU patients converted to admission had higher Charlson Comorbidity Index (4.5 vs 3.9, p = 0.012) and higher 12-month mortality (17.3% vs 9.2%, p = 0.014) compared to those discharged. When converted patients were compared to those admitted from the ED, mortality (17.3% vs 10.3%, p = 0.210) and Charlson (4.3 vs 4.5, p = 0.552) were comparable. Patients triaged to OU showed no difference in readmissions, downstream OU visits, or adverse cardiac events. However, OU patients later admitted had shorter time to death compared to patients triaged directly to inpatient units (137.3 vs 257.9 days, p = 0.023). Patients cared for in the OU were more likely to follow-up outpatient (41.0% vs 25.9%, p = 0.041).
CONCLUSIONS: The OU is a venue for high-quality care for ADHF. Our study showed over utilization of the OU, commonly defined as over 15% conversion. A possible difference in time to death exists due to suboptimal triage, but multivariate analysis is needed to confirm. Enhanced risk stratification for patient triage is needed.