目的:本倾向评分匹配队列研究的目的是评估我们虚拟病房(HFVW)中远程医疗指导门诊治疗急性心力衰竭(HF)的结果与住院急性HF患者的比较。
结果:这项队列研究(2022年5月至2023年10月)评估了在HF专科医生大众中使用静脉推注速尿进行远程医疗指导的门诊急性HF治疗的结果。使用逻辑回归进行倾向评分匹配(PSM),以调整HFVW和标准护理之间基线患者特征的潜在差异[获得指南-HF评分,临床虚弱评分(CFS),Charlson合并症指数(CCI),NT-proBNP,和射血分数]。比较了1、3、6和12个月时的临床结果(再住院和死亡率)与标准护理-SC(2021年无远程医疗管理的急性HF患者)。在标准护理-SC队列中,将550例HFVWADHF患者(年龄73.1±10.9岁;46%为女性)与404例ADHF患者(74.2±11.8;P=0.15和49%为女性)进行了比较。在倾向评分匹配基线患者特征后,与SC相比,HFVW的再住院率显着降低(1个月-HFVW8.6%vs.SC-21.5%,P<0.001;3个月-21%vs.30%,P=0.003;6个月-28%vs41%,P<0.001和12个月-47%vs.57%,P=0.005),死亡率在1个月时也较低(5%vs.13.7%;P<0.001),3个月(9.5%vs.15%;P=0.001),6个月(15%与21%;P=0.03),和12个月(20%与26%;P=0.04)。多因素Logistic回归分析显示,与标准护理相比,HFVW管理与较低的再入院几率相关(1个月比值比(OR)=0.3[95%置信区间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也独立预测了再次住院的可能性增加(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个月或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)。每日步数增加,而HFVW独立预测再住院的几率降低(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:远程医疗指导的ADHF专科HFVW管理可能为合适患者的住院治疗提供安全有效的替代方案。HFVW的每日步数可以帮助预测短期不良临床结局的风险。
OBJECTIVE: 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.
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.