Good treatment outcomes after acute heart failure (AHF) are largely dependent on the organizational structure surrounding patient care.1,2 Patient management organization is especially important in view of the failure of new treatment proposals for this syndrome3–5 and the essentially unaltered prognosis of AHF patients over the past several decades.6 Prominent among proposed organizational approaches is the transfer of care during decompensation episodes, and many Spanish hospitals have devised specific multidisciplinary protocols, many of them based in heart failure units (HFU).2,7

In addition to these specific intervention programs, AHF patient outcomes can also be affected by the inherent characteristics of the hospital and emergency department (ED). Key hospital characteristics include hospital type (high-technology or community) or whether the hospital has a short-stay unit (SSU), a home hospitalization (HH) service, or an HFU. Some hospitals are rapidly introducing the latest forms of telemedicine as a useful way to manage AHF patients during convalescence and even during the stabilization period between decompensations.8 The other key organizational element of patient care is the ED, since more than 90% of AHF patients are first treated there9 and 15%-35% of them are discharged from the ED without hospital admission.10 Patient outcomes can be affected by ED patient inflow, the availability of a specific observation unit for treatment-response monitoring, and the frequency of discharge directly from the ED (DDED) without hospital admission. Until now these organizational features have received very little attention in the Spanish health system. We hypothesized that all of these structural/organizational features will affect AHF outcomes and that each will have a specific outcome. The goal of the present study was thus to investigate the effect of these hospital and ED structural/organizational characteristics on AHF outcomes.

Of the 18 370 AHF episodes in the EAHFE Registry, we analyzed 17 974 (97.8%) episodes recorded at 40 EDs, corresponding to 130 independent period-by-center groups (figure 1). Mean patient age was 82 years, 55.6% were women, and the sample presented many comorbidities. Other baseline and event characteristics are presented in table 1. Of the study population, 14 482 (80.6%) were treated in high-technology hospitals, 11 154 (62.1%) in hospitals with an SSU, 13 148 (73.2%) in hospitals with HH, 9853 (54.8%) at hospitals with an HFU, 14 482 (82.3%) at hospitals with a high-inflow ED, and 15 653 (87.1%) at hospitals with an ED observation unit.

Figure 1.

Patient inclusion flowchart. ED, emergency department; HFU, heart failure unit; HH, home hospitalization; SSU, short-stay unit.

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In-hospital mortality was 7.4%, 22.4% of patients had prolonged stays, and 30-day all-cause mortality was 10.3%. Among the 16 546 index event survivors, the rates of AHF-related reconsultation, hospitalization, mortality, and the combined event were 29.5%, 20.7%, 5.0%, and 31.2%, respectively.

The univariate analysis showed a significant association between structural/organizational characteristics and some of the outcome measures (table 2). The progressive adjustment models revealed a center effect on all outcome measures (table 1 of the supplementary data), and we therefore studied the effect of hospital and ED structural/organizational characteristics on all outcomes in a model adjusted for the inclusion period, the patient variables, and the structural/organizational characteristics. This analysis revealed the following results: high-technology hospitals had lower in-hospital mortality (OR, 0.78; 95%CI, 0.65-0.94) and fewer prolonged stays (OR, 0.84; 95%CI, 0.74-0.94); hospitals with an SSU had more 30-day postdischarge hospitalizations (OR, 1.19; 95%CI, 1.02-1.38); hospitals with HH had fewer prolonged stays (OR, 0.81; 95%CI, 0.73-0.89); hospitals with an HFU had more prolonged stays (OR, 1.14; 95%CI, 1.05-1.24) but fewer 30-day postdischarge ED reconsultations, hospitalizations, and combined events (OR, 0.83; 95%CI, 0.76-0.91; OR, 0.85; 95%CI=0.75-0.97, and OR, 0.84, 95%CI, 0.77-0.92); hospitals with a high-inflow ED had fewer prolonged stays (OR, 0.72; 95%CI, 0.63-0.82) as well as fewer 30-day postdischarge deaths (OR, 0.73; 95%CI, 0.56-0.96) and combined events (OR, 0.87; 95%CI, 0.77-0.92); and hospitals with an ED observation unit had more prolonged stays (OR, 1.45; 95%CI, 1.27-1.66) (figure 2).

Figure 2.

Adjusted odds ratios for the investigated outcomes according to hospital characteristics. The adjusted model included the inclusion period, patient characteristics, and hospital characteristics. Statistically significant results (P<.05) are highlighted in bold. 95%CI, 95% confidence interval; ED, emergency department.

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In most cases, the sensitivity analyses generated estimates showing the same trends (increased or decreased risk) as the principal analysis. However, these analyses included fewer patients (17 974 in the principal analysis vs 13 347, 8615, 3828, and 3427 in sensitivity analysis A, B, C, and D, respectively), and therefore the 95%CIs were wider and many included the value 1 (figure 3). In contrast, LVEF mostly showed no interactions with the statistically significant associations in the principal analysis; the exceptions were the association between high-technology hospitals and fewer prolonged stays, which was more evident in patients with LVEF ≥ 50% (OR, 0.89; 95%CI, 0.55-1.44) than in those with LVEF<50% (OR, 1.43; 95%CI, 0.96-2.13; interaction, P=.032), and the association between hospitals with an SSU and more 30-day postdischarge hospitalizations, which was more evident in patients with LVEF<50% (OR, 1.39; 95%CI, 0.89-2.17) than in those with LVEF ≥ 50% (OR, 0.86; 95%CI, 0.50-1.45; interaction, P=.035).

Figure 3.

Sensitivity analysis of associations between hospital characteristics and acute heart failure patient outcomes that were statistically significant in the adjusted principal analysis. Statistically significant results (P<.05) are highlighted in bold. Sensitivity analysis A exclusively included the 13 347 patients admitted to hospital for AHF (excluding patients discharged directly from the ED). Sensitivity analysis B exclusively included the 8615 patients whose AHF was confirmed by natriuretic-peptide assay. Sensitivity analysis C limited multiple imputation to variables with <10% of missing patient variables, corresponding to a total of 3828 patients. Sensitivity analysis D was performed without multitple imputation of missing values, limiting the analysis to 3427 patients. 95%CI, 95% confidence interval; ED, emergency department.

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The higher the percentage of DDED, the fewer the prolonged stays (R2=0.109; P<.001), but the DDED rate showed no significant association with the other outcomes (figure 4). In the stratified analysis according to hospital and ED structural/organizational characteristics, DDED showed significant interaction with 6 of the 42 relationships analyzed (table 2 of the supplementary data), grouped as follows: a) hospital type for prolonged stay (a more intense decrease in community hospitals, P=.015) and for 30-day postdischarge mortality (decreasing in high-technology hospitals and increasing in community hospitals, P=.047); b) the presence of an HH service for prolonged stay (a more intense decrease if there was no HH, P=.04); and c) the presence of an SSU for 30-day postdischarge ED reconsultations, hospitalizations, and combined events (declining if there was an SSU and increasing if there was not; P=.01, P=.003, and P=.041, respectively) (figure 5).

Figure 4.

Relationship between the percentage of DDED and the outcomes of acute heart failure patients treated in emergency departments. DDED, discharge directly from the ED; ED, emergency department.

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Figure 5.

Stratified analyses showing significant interaction between the DDED–outcome relationship and the investigated structural/organizational characteristics. DDED, discharge directly from the ED; ED, emergency department; HH, home hospitalization; SSU, short-stay unit.

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The present study shows that hospitals and ED structural and organizational characteristics significantly impact the short-term outcomes of patients diagnosed with AHF in the ED, irrespective of the inclusion period or the profile of patients attending each ED. Indeed, adjustment for these factors did not substantially alter the nonadjusted calculations. This may indicate a similar distribution of AHF patients between inclusion periods and participating centers, which would be consistent with the high prevalence of AHF and the fact that most patients are treated at their nearest hospital, with few patients transferred to a higher level of care. It may also be that between-center differences in the distribution of some patient characteristics had opposing effects on outcomes that largely canceled each other out. Taken together, the main findings discussed below provide a useful framework for planning selected organizational features of AHF patient management.

The first notable finding is that prolonged stays related to the index event were less frequent at high-technology hospitals and hospitals with an HH service or a high-inflow ED. The good performance of high-technology hospitals may reflect an ability to carry out certain examinations more rapidly, especially if the patient is admitted; however, this possibility was not investigated in the present study. Probably the most important factor limiting prolonged stays after the index event is the high caseload and greater experience of high-inflow EDs, which results in more decisions to discharge directly from the ED. These results also confirm the effectiveness of structures specifically aimed at limiting length of stay, such as HH, at least in the case of AHF. On the other hand, the number of prolonged stays was increased by the presence of an HFU or an ED observation unit. The presence of these facilities might suggest more conservative management of AHF patients, whereas hospitals lacking an HFU tend to favor more symptom-focused care and to discharge patients without completing diagnostic and therapeutic procedures. Our study was not designed to explore these questions, and they should therefore be tested in specifically designed studies in the future.

Uniquely among hospital and ED structural/organizational characteristics, high-technology was associated with significantly lower in-hospital mortality. However, this advantage of high-technology hospitals was not seen for 30-day mortality or 30-day postdischarge mortality, suggesting that the lower in-hospital mortality may reflect differential management of patients showing good progress versus those who are dependent or in a terminal condition. Differential patient management of this type is common practice with AHF patients,14,15 and high-technology hospitals may as a consequence have more structured extrahospital care programs that increase the proportion deaths occurring after discharge.

The presence of an HFU shows a clear relationship with better postdischarge outcomes. While this important finding has been described in previous reports,7,16 the present results demonstrate that the association is independent of other characteristics that may be present in the same hospital and could also influence prognosis. In light of our results, we believe that HFUs should be established more extensively within the Spanish health system because, beyond their benefits for patients with complex forms of HF during the stabilization period, these specialist units provide a clear benefit to patients with acute decompensated HF.

A high DDED rate correlated with fewer prolonged stays. Although a more aggressive patient management might be expected to result in worse postdischarge outcomes, this expectation is not supported by the 30-day postdischarge data. Some hospital or ED structural/organizational features may even have minimized this potential negative effect. For example, our data indicate that the presence of an SSU allows for safer discharge from the ED, which may also be a benefit of high-technology hospitals. AHF patients are currently not risk-stratified before the decision on discharge or hospital admission from the ED; our findings suggest that systematic risk stratification would contribute to improved selection of patients for discharge while maintaining the rate of DDED.11,17–19

The short-term outcomes of AHF patients are strongly affected by hospital and ED structural and organizational characteristics and by the aggressiveness of ED management, indexed by the percentage of DDED. Although the present study did not include all examinations and treatments during hospitalization, we believe that health care managers should use these findings to strengthen measures to improve AHF patient prognosis. Among these measures, the presence of an HFU is of particular interest.

None.