Sankaranarayanan Rajiv, Rasoul Debar, Murphy Naomi, Kelly AnneMarie, Nyjo Siji, Jackson Carolyn, O'Connor Jane, Almond Peter, Jose Nisha, West Jenni, Kaur Rosie, Oguguo Chukwemeka, Douglas Homeyra, Lip Gregory Y H
Liverpool University Hospitals NHS Foundation Trust, Aintree Hospital, Liverpool, UK.
Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
ESC Heart Fail. 2024 Dec;11(6):4172-4184. doi: 10.1002/ehf2.15003. Epub 2024 Aug 13.
AIMS: The aim of this propensity score matched cohort study was to assess the outcomes of telehealth-guided outpatient management of acute heart failure (HF) in our virtual ward (HFVW) compared with hospitalized acute HF patients. METHODS AND RESULTS: This cohort study (May 2022-October 2023) assessed outcomes of telehealth-guided outpatient acute HF management using bolus intravenous furosemide in a HF-specialist VW. Propensity score matching (PSM) was performed using logistic regression to adjust for potential differences in baseline patient characteristics between HFVW and standard care [Get With The Guidelines-HF score, clinical frailty score (CFS), Charlson co-morbidity index (CCI), NT-proBNP, and ejection fraction]. Clinical outcomes (re-hospitalizations and mortality) were compared at 1, 3, 6, and 12 months versus standard care-SC (acute HF patients managed without telehealth in 2021). Five hundred fifty-four HFVW ADHF patients (age 73.1 ± 10.9 years; 46% female) were compared with 404 ADHF patients (74.2 ± 11.8; P = 0.15 and 49% female) in the standard care-SC cohort. After propensity score matching for baseline patient characteristics, re-hospitalizations were significantly lower in the HFVW compared with SC (1 month-HFVW 8.6% vs. SC-21.5%, P < 0.001; 3 months-21% vs. 30%, P = 0.003; 6 months-28% vs 41%, P < 0.001 and 12 months-47% vs. 57%, P = 0.005) and mortality was also lower at 1 month (5% vs. 13.7%; P < 0.001), 3 months (9.5% vs. 15%; P = 0.001), 6 months (15% vs. 21%; P = 0.03), and 12 months (20% vs. 26%; P = 0.04). Multivariate logistic regression analysis showed that compared with standard care, HFVW management was associated with lower odds of readmission (1-month odds ratio (OR) = 0.3 [95% Confidence Interval CI 0.2-0.5], P < 0.0001; 3 month OR = 0.15 [0.1-0.3], P < 0.0001; 6-month OR = 0.35 [0.2-0.6], P = 0.0002; 12-month OR = 0.25 [0.15-0.4], P ≤ 0.001 and mortality (1-month OR = 0.26 [0.14-0.48], P < 0.0001; 3-month OR = 0.11 [0.04-0.27], P < 0.0001; 6-month OR = 0.35, [0.2; 0.61], P = 0.0002; 12-month OR = 0.6 [0.48; 0.73], P = 0.03. Higher GWTG-HF score independently predicted increased odds of re-hospitalization (1-month OR = 1.2 [1.1-1.3], P < 0.001; 3-month OR = 1.5 [1.37; 1.64], P < 0.0001; 6-month OR = 1.3 [1.2-1.4], P < 0.0001; 12-month OR = 1.1 [1.05-1.2], P = 0.03) as well as mortality (1-month OR = 1.21 [1.1-1.3], P < 0.0001; 3-month OR = 1.3 [1.2-1.4], P < 0.0001; 6-month OR = 1.2 [1.1-1.3], P < 0.0001; 12-month OR = 1.3 [1.1-1.7], P = 0.02). Similarly higher CFS also independently predicted increased odds of re-hospitalizations (1-month OR = 1.9 [1.5-2.4], P < 0.0001; 3-month OR = 1.8 [1.3-2.4], P = 0.0003; 6-month OR = 1.4 [1.1-1.8], P = 0.015; 12-month OR 1.9 [1.2-3], P = 0.01]) and mortality (1-month OR = 2.1 [1.6-2.8], P < 0.0001; 3-month OR = 1.8 [1.2-2.6], P = 0.006; 6-month OR = 2.34 [1.51-5.6], P = 0.0001; 12-month OR = 2.6 [1.6-7], P = 0.02). Increased daily step count while on HFVW independently predicted reduced odds of re-hospitalizations (1-month OR = 0.85[0.7-0.9], P = 0.005), 3-month OR = 0.95 [0.93-0.98], P = 0.003 and 1-month mortality (OR = 0.85 [0.7-0.95], P = 0.01), whereas CCI predicted adverse 12-month outcomes (OR = 1.2 [1.1-1.4], P = 0.03). CONCLUSIONS: Telehealth-guided specialist HFVW management for ADHF may offer a safe and efficacious alternative to hospitalization in suitable patients. Daily step count in HFVW can help predict risk of short-term adverse clinical outcomes.
目的：本倾向评分匹配队列研究旨在评估在我们的虚拟病房（HFVW）中，远程医疗指导下的急性心力衰竭（HF）门诊管理与住院急性HF患者相比的结局。 方法与结果：本队列研究（2022年5月至2023年10月）评估了在HF专科虚拟病房中使用静脉推注速尿进行远程医疗指导的门诊急性HF管理的结局。使用逻辑回归进行倾向评分匹配（PSM），以调整HFVW与标准治疗[遵循指南-HF评分、临床衰弱评分（CFS）、Charlson合并症指数（CCI）、NT-proBNP和射血分数]之间基线患者特征的潜在差异。比较了1、3、6和12个月时的临床结局（再住院和死亡率）与标准治疗-SC（2021年未接受远程医疗管理的急性HF患者）。554例HFVW急性失代偿性HF患者（年龄73.1±10.9岁；46%为女性）与标准治疗-SC队列中的404例急性失代偿性HF患者（74.2±11.8；P = 0.15，49%为女性）进行比较。在对基线患者特征进行倾向评分匹配后，HFVW的再住院率显著低于SC（1个月-HFVW为8.6%，SC为21.5%，P < 0.001；3个月-21%对30%，P = 0.003；6个月-28%对41%，P < 0.001；12个月-47%对57%，P = 0.005），1个月时的死亡率也较低（5%对13.7%；P < 0.001），3个月时（9.5%对15%；P = 0.001），6个月时（15%对21%；P = 0.03），12个月时（20%对26%；P = 0.04）。多因素逻辑回归分析显示，与标准治疗相比，HFVW管理与再入院几率较低相关（1个月优势比（OR）= 0.3 [95%置信区间CI 0.2 - 0.5]，P < 0.0001；3个月OR = 0.15 [0.1 - 0.3]，P < 0.0001；6个月OR = 0.35 [0.2 - 0.6]，P = 0.0002；12个月OR = 0.25 [0.15 - 0.4]，P ≤ 0.001）和死亡率（1个月OR = 0.26 [0.14 - 0.48]，P < 0.0001；3个月OR = 0.11 [0.04 - 0.27]，P < 0.0001；6个月OR = 0.35，[0.2；0.61]，P = 0.0002；12个月OR = 0.6 [0.48；0.73]，P = 0.03）。较高的GWTG-HF评分独立预测再住院几率增加（1个月OR = 1.2 [1.1 - 1.3]，P < 0.001；3个月OR = 1.5 [1.37；1.64]，P < 0.0001；6个月OR = 1.3 [1.2 - 1.4]，P < 0.0001；12个月OR = 1.1 [1.05 - 1.2]，P = 0.03）以及死亡率（1个月OR = 1.21 [1.1 - 1.3]，P < 0.0001；3个月OR = 1.3 [1.2 - 1.4]，P < 0.0001；6个月OR = 1.2 [1.1 - 1.3]，P < 0.0001；12个月OR = 1.3 [1.1 - 1.7]，P = 0.02）。同样，较高的CFS也独立预测再住院几率增加（1个月OR = 1.9 [1.5 - 2.4]，P < 0.0001；3个月OR = 1.8 [1.3 - 2.4]，P = 0.0003；6个月OR = 1.4 [1.1 - 1.8]，P = 0.015；12个月OR = 1.9 [1.2 - 3]，P = 0.01]）和死亡率（1个月OR = 2.1 [1.6 - 2.8]，P < 0.0001；3个月OR = 1.8 [1.2 - 2.6]，P = 0.006；6个月OR = 2.34 [1.51 - 5.6]，P = 0.0001；12个月OR = 2.6 [1.6 - 7]，P = 0.02）。在HFVW期间每日步数增加独立预测再住院几率降低（1个月OR = 0.85[0.7 - 0.9]，P = 0.005），3个月OR = 0.95 [0.93 - 0.98]，P = 0.003和1个月死亡率（OR = 0.85 [0.7 - 0.95]，P = 0.01），而CCI预测12个月的不良结局（OR = 1.2 [1.1 - 1.4]，P = 0.03）。 结论：对于急性失代偿性HF，远程医疗指导的专科HFVW管理可能为合适的患者提供一种安全有效的替代住院治疗的方法。HFVW中的每日步数有助于预测短期不良临床结局的风险。
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