Clinical and Financial Implications of Inpatient and Outpatient Management of Worsening Heart Failure

AIMS: Little is known regarding the clinical and financial implications of varying inpatient and outpatient management strategies for worsening heart failure (WHF). This analysis aimed to compare clinical outcomes, home-time, and healthcare expenditure following various types of inpatient and outpatient WHF events in US clinical practice. METHODS AND RESULTS: We examined US Medicare beneficiaries 65 years and older discharged from a hospitalization for heart failure (HF) in the Get With The Guidelines-Heart Failure registry from 2010 to 2018. Patients developing subsequent WHF within 12 months were divided into four mutually exclusive groups by type of first event: HF hospitalization, emergency department (ED) visit with ED discharge, observation stay, and outpatient intravenous (IV) diuretic clinic visit. Following each type of WHF event, mortality, home-time (days alive and out of any healthcare institution), and healthcare costs were compared over the subsequent 12 months. Among 181 827 eligible patients discharged alive from a HF hospitalization across 553 US hospitals, 61 159 (33.6%) patients had a subsequent WHF event within 12 months. Of these, 48 612 were managed with HF hospitalization (79.5%), 8139 (13.3%) with an ED visit, 1767 (2.9%) with an observation stay, and 2641 (4.3%) with an outpatient IV diuretic visit. Rates of 12-month mortality were highest following HF hospitalization (cumulative incidence rate [IR] 48.8; 95% confidence interval [CI] 48.3-49.3), lowest following observation unit stay (IR 29.9; 95% CI 27.7-32.0), and intermediate following ED discharge (IR 41.2; 95% CI 40.1-42.3) and outpatient IV diuretic visit (IR 39.3; 95% CI 37.4-41.2). Median (25th-75th) 12-month home-time was lowest following HF hospitalization (251 [47-351] days) and highest following observation unit stays (354 [206-365] days). For the index WHF event itself, median total per-patient costs were highest for HF hospitalization (US$11 335) and lowest for outpatient IV diuretic visit (US$259). Over the 12 months following the WHF event, when accounting for costs of all patients including those who died within 12 months, the median total per-patient costs were highest following outpatient IV diuretic visits (US$29 173). Among patients surviving 12 months after WHF, median total per-patient costs following an outpatient IV diuretic visit (US$29 931) versus HF hospitalization (US$30 971) were similarly high. CONCLUSIONS: In this nationwide analysis of older US adults, high rates of death and substantial reductions in home-time occurred following WHF regardless of inpatient or outpatient management, but were worse following HF hospitalization. Outpatient IV diuretic administration was the least expensive initial management strategy, but over the subsequent 12 months, associated costs were similar or higher than costs following HF hospitalization.