A tertiary care ambulatory heart failure pathway managing one-third of all admissions including older patients with similar quality to inpatient management

Amy Thomson-Anderson; Nicola Fawcett; Saniya Naseer; Anurup Kumar; Barbara Onen; Helen Nolte; Rebecca Bone; Jordan Bowen; James Gamble

doi:10.7861/clinmed.22-4-s59

Introduction

Heart failure (HF) is the commonest cause of adult hospital admissions in the over 65s, accounting for over 67,000 admissions in England and Wales per year 1.¹ The average hospital stay lasts 13 days and costs around £3,800.² The increased use of same day emergency care (SDEC) services provide opportunity for novel HF management pathways while still achieving quality and best practice tariff targets³ in this setting.

Methods

An ambulatory HF pathway was established in a ‘medical’ SDEC unit supported by a specialist HF team and a Hospital At Home service providing intravenous diuretic therapy, clinical assessment and point-of-care diagnostics. Data were collected on every index HF admission as part of the National Heart Failure Audit, and as a service evaluation.

Results

From August 2019 to January 2021, 598/1,919 (31%) HF admissions were managed on an ambulatory pathway. Factors associated with inpatient management were hypotension, higher New York Heart Association Classification (NYHA) class, faster heart rate, higher N-terminal-pro-brain natriuretic peptide (BNP), lower haemoglobin, and living alone. Age was not associated with inpatient management. Patients managed via the ambulatory pathway were more likely to be referred to heart failure nurses and cardiology follow-up on discharge. There was no difference in the proportion seen by the specialist team within 24 hours, or having an echocardiography. Independent and comorbidity-corrected 30-day mortality was lower for ambulatory patients. Savings of approximately 5,000 bed-days are estimated.

Discussion

A third of heart failure management can be achieved via an ambulatory pathway irrespective of age without a clear difference in outcomes when compared with inpatient care. A large saving in inpatient bed usage can be achieved, despite cost of outreach teams. Mortality differences demonstrated are confounded by patient selection. Further evaluation of ambulatory pathways is needed to understand which patients benefit from ambulatory management, and better develop these services.

View this table:

Table 1.

Patient characteristics and mortality for heart failure index admissions

References

↵
1. National Institute for Health and Care Excellence
. Acute heart failure: diagnosis and management: Clinical guideline [CG187]. NICE, 2021. www.nice.org.uk/guidance/cg187 [Accessed 10 February 2022].
↵
1. British Heart Foundation
. An integrated approach to managing heart failure in the community. BHF, 2015.
↵
1. NHS England
. 2021/22 national tariff payment system. NHSE, 2021. www.england.nhs.uk/wp-content/uploads/2020/11/21-22-National-tariff-payment-system.pdf [Accessed 10 February 2022].