Telehealth-aided outpatient management of acute heart failure in a specialist virtual ward compared to standard care
Authors: Rasoul D , Sankaranarayanan R , Murphy N , Kelly A M , Nyjo S , Jackson C , O'connor J , Almond P , Jose N , West J , Kaur R , Oguguo C , Douglas H , Lip G Y H 
Published: October 2024

Abstract

Background/Introduction
Acute decompensated heart failure (ADHF) leads to hospitalisations, frequent re-hospitalisations and mortality. The safety and efficacy of telehealth-guided outpatient ADHF management (virtual ward-VW) as an alternative to hospitalisation has not been assessed previously.

Aim
The aim of this study was to assess the safety and outcomes of our acute heart failure virtual ward (HFVW) pathway (Figure 1) when compared to hospitalised ADHF patients.

Methods
This cohort study (May 2022-October 2023) assessed the outcomes of telehealth-guided outpatient ADHF management using bolus intravenous furosemide in a HF-specialist VW. We compared baseline patient characteristics, NTproBNP, ejection fraction, NYHA Class, clinical risk score (Get With the Guidelines-Heart Failure-GWTG-HF), comorbidities (Charlson Co-morbidity Index-CCI), frailty (Rockwood Clinical Frailty Score-CFS), HF therapies and measured clinical outcomes at 1, 3, 6 and 12 months (re-hospitalisations, mortality) in the HFVW cohort versus standard care (ADHF patients managed without telehealth in 2021).

Results
554 HFVW ADHF patients (age 73.1±10.9 years; 46% female) were compared with 402 ADHF patients (74.2±11.8; p=0.15 and 49% female) in the standard care cohort (SC). Despite similar baseline patient characteristics, GWTG-HF score, CCI and CFS, re-hospitalisations were significantly lower in the HFVW compared to standard care (1 month - 11.6% vs. 21%, p=0.002; 3 months - 20.4% vs. 30%, p=0.001; 6 months -29.3% vs 41%, p=0.02 and 12 months-48% vs. 57%,p=0.03) whereas mortality was lower at 1 month (6% vs. 14%; p&lt;0.001), 3 months (10.5% vs. 15%; p=0.02) and 6 months (15.5% vs. 21%; p=0.04) (Figure 2). Multivariate logistic regression analysis showed that an increased daily step count whilst on HFVW independently predicted reduced odds of re-hospitalisations at 1 month (OR 0.85; 95% CI 0.7-0.9; p=0.005), 3 months [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]. Higher GWTG-HF score independently predicted increased odds of re-hospitalisation [1-month OR 1.2 (1.1-1.3), p=0.01; 12-month OR 1.1, 1.05-1.2, p=0.03) as well as mortality [1-month OR 1.2 (1.1-1.4), p=0.01; 12-month OR 1.3 (1.1-1.7), p=0.02]. Similarly higher CFS also independently predicted increased odds of re-hospitalisations [1-month OR 1.5 (1.1-2.2), p=0.03; 12-month OR 1.9 (1.2-3, p=0.01] and mortality [1-month OR 2 (1.1-3.5), p=0.02; 12-month OR 2.6 (1.6-10); p=0.02] throughout the follow-up period.

Conclusions
A telehealth-guided specialist HFVW management strategy for ADHF may offer a safe and efficacious alternative to hospitalisation in suitable patients. Daily step count, GWTG, CCI and CFS can play a vital role in assessing suitability for VW and in predicting risk of adverse clinical outcomes.Heart Failure Virtual Ward PathwayMortality & Re-hospitalisations outcomes