EMHRG30 algorithm + RAPID-HF clinic improves outcome in acute HF patients: The COACH trial

19 Jan 2023

In the American Heart Association (AHA) Scientific Sessions 2022, Dr. Douglas S. Lee from the University of Toronto, Canada, presented the results of his group’s study on the comparisons of outcomes with regard to access to care for heart failure (HF).1 

Patients with indications of HF are frequently hospitalized and sent to the emergency department (ED).1 It is essential that clinicians make a timely decision on whether to admit or release these patients based on the severity of their conditions.1 Clinicians' subjective judgments might sometimes result in erroneous consequences, such as admitting a low-risk patient and discharging a high-risk patient, leading to adverse outcomes like death.1 

A pragmatic randomized trial evaluated the effectiveness of using EMHRG30-ST, a computer-based risk algorithm, to aid the ED clinicians in determining if an HF patient is actually at high risk for hospitalization or low risk for discharging home.1 In combination with a rapid outpatient follow-up (RAPID-HF) clinic for the low-risk discharged patients, this trial assessed if this intervention would improve outcomes in HF patients.1 

This trial termed the COACH trial as a stepped wedge, cluster randomized trial, which was conducted in 10 hospitals in 5 sequences, involving 6 periods with each step length of 4 months.1 In this trial, hospitals were randomized to the timing of crossover to intervention and blinded to allocation sequence until 4 months prior to the intervention to prepare for implementation and crossover to active intervention.1 Adult patients presenting to the ED with acute HF were determined by the clinical diagnosis, ED diagnosis, and Framingham criteria.1 Patients with a B-type natriuretic peptide (BNP) <100pg/mL or N-terminal-pro hormone BNP (NT-proBNP) <300pg/mL were excluded. Additionally, patients with end-stage kidney disease (ESKD) or palliative, as well as those who were unable to visit an outpatient clinic, or be linked to administrative databases were excluded from the study.1 

The EMHRG30-ST algorithm was used for the intervention, which could predict a patient’s 7-day and 30-day mortality risk, in addition to categorizing acute HF patients based on their likelihood of death.1 The second component of the trial was the RAPID HF clinic, a transitional rapid ambulatory care clinic that provides transitional care to patients, including all diagnostic testing, medication up-titration and laboratory investigation for up to 30 days post-discharge.1 In the intervention phase, patients categorized as low-risk using this algorithm were released within 3 days and received care at the RAPID-HF clinic, while high-risk patients required hospitalization.1 The control group had no access to either the EMHRG30-ST algorithm or the RAPID-HF clinic.1 Hospitals were blinded to allocation, until 4 months prior to switching to the intervention group.1 There were 2 co-primary endpoints for the study, including death from any cause or cardiovascular (CV) hospitalization within 30 days and 20 months after presentation, respectively.1 The secondary endpoints included CV hospitalization, HF hospitalization and mortality.1 All endpoints were determined by linking clinically obtained data to administrative databases.1 

Out of the 10,596 patients screened, 4,659 and 5,937 were eligible for the intervention and control, respectively.1 Finally, a total of 2,480 and 2,972 patients were included in the intervention and control arms, respectively, after the exclusion criteria were applied.1 The baseline characteristics were similar between the 2 groups.1 In the early primary outcome of 30 days, there was a 12% reduction in the primary outcome in the intervention group compared with the control group (HR=0.88; 95% CI: 0.78-0.99; p=0.036).1 In the 20-month extended period, there was a 5% reduction of the primary outcome in the intervention group compared with the control group (HR=0.95; 95% CI: 0.93-0.99; p=0.007).1 Similarly, with regard to CV hospitalization, which was one of the secondary outcomes, there was a significant reduction of 16% in the intervention group vs. the control group (HR=0.84; 95% CI: 0.76-0.93; p=0.001).1 There was also a significant reduction in HF hospitalization in the intervention group (HR=0.80; 95% CI: 0.65-0.98; p=0.028). However, there was no significant difference in mortality between the 2 arms.1 

In conclusion, using the EMHRG30-ST algorithm in conjunction with the RAPID-HF clinic improved clinical outcomes in acute HF patients, as it significantly decreased the risk of CV death and hospitalizations within 30 days and 20 months.1 Adoption of this strategy might result in early discharge of low-risk patients and helps improve patient outcomes.

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