Inpatient versus outpatient intravenous diuresis for the acute exacerbation of chronic heart failure

Abstract

Background We established an IV outpatient diuresis (IVOiD) clinic and conducted a quality improvement project to evaluate safety, effectiveness and costs associated with outpatient versus inpatient diuresis for patients presenting with acute decompensated heart failure (ADHF) to the emergency department (ED). Methods Patients who were clinically diagnosed with ADHF in the ED, but did not have high-risk features, were either diuresed in the hospital or in the outpatient IVOiD clinic. The dose of IV diuretic was based on their home maintenance diuretic dose. The outcomes measured were the effects of diuresis (urine output, weight, hemodynamic and laboratory abnormalities), 30–90 day readmissions, 30–90 day death and costs. Results In total, 36 patients (22 inpatients and 14 outpatients) were studied. There were no significant differences in the baseline demographics between groups. The average inpatient stay was six days and the average IVOiD clinic days were 1.2. There was no significant difference in diuresis per day of treatment (1159 vs. 944 ml, p = 0.46). There was no significant difference in adverse outcomes, 30–90 day readmissions or 30–90 day deaths. There was a significantly lower cost in the IVOiD group compared to the inpatient group ($839.4 vs. $9895.7, p=<0.001). Conclusions Outpatient IVOiD clinic diuresis may be a viable alternative to accepted clinical practice of inpatient diuresis for ADHF. Further studies are needed to validate this in a larger cohort and in different sites.

Outpatient intravenous diuresis in a rural setting: safety, efficacy, and outcomes

“…Our 60-day readmission rates increased to 33%. Although our clinic and other urban centers did not significantly affect 30-day hospitalizations ( Figure 2 ), the 30-day mortality rate for our clinic and urban OP IV centers were significantly lower compared to DHMC FY21 and national mean (1.7% vs. 2.5% vs. 12.3% vs. 10.7%, respectively; p < 0.001) ( 4 – 7 ).…”

“…One strategy to augment HF care and reduce readmission costs is the implementation of outpatient intravenous (OP IV) diuresis to address decompensated HF in outpatient clinics, infusion centers, and more recently, home-based IV diuresis care. While preliminary studies have demonstrated promising results in urban settings, additional research is necessary to assess the efficacy in rural communities (3)(4)(5)(6)(7)(8)(9)(10).…”

Systems of care for ambulatory management of decompensated heart failure

“…While there have been transformational trials yielding dramatically improved prognosis associated with the use of GDMT and other areas of HF care, significant work is needed to improve access to these therapies and reduce disparities in HF care. Cost, insurance approval, disparities in accessing care related to other social determinants of health, as well as logistics of navigating the healthcare system present barriers to utilization of GDMT, IV FCM, outpatient IV diuretics, and exercise training for patients with HFpEF, despite their potential to improve care and reduce the burden of disease ( 9 , 38 , 53 , 56 , 69 , 70 , 73 ). Addressing these factors is of utmost importance given the growing body of evidence demonstrating the impact of socioeconomic status and social determinants of health on cardiovascular outcomes in general and HF outcomes specifically ( 68 – 70 ).…”

Diuretic resistance in patients with chronic heart failure: mechanisms, prevention, and treatment

“…Такая тактика приводит к снижению числа госпитализаций в связи с декомпенсацией сердечной деятельности за счет предупреждения развития устойчивости к пероральным формам петлевых диуретиков. В частности, у пациентов с умеренно выраженной декомпенсацией для достижения эуволемии может потребоваться всего одна или две дозы внутривенного диуретика [64][65][66][67].…”