Delay In Door-to-diuretic Time Is Associated With Greater Odds Of 30-day Readmission And Mortality

Abstract

Introduction Achieving a prompt euvolemic state in heart failure (HF) using diuretics is associated with better outcomes. While current guidelines advocate for the timely initiation of diuretics, existing literature on the concept of “door-to-diuretic” time is controversial. Hypothesis The hypothesis was that longer door-to-diuretic time was associated with greater odds of 30-day hospital readmission and death among hospitalized HF patients. Methods This ongoing study is prospectively collecting data from the electronic medical records of admitted HF patients since April 2020 at an academic medical center. Inclusion criteria were admitting diagnosis of HF (ICD-10 code I50), and positive Framingham Heart Failure Diagnostic Criteria. Data collected included demographics, echocardiographic results, patient symptoms and exam findings, and medication administration. HF was classified using NYHA functional classification. Comorbidities were quantified using the Charleston Comorbidity Index. Door-to-diuretic time was defined as the time interval between patient hospital arrival and the first diuretic administration. Door-to-diuretic time was right-skewed and corrected with a log10 transformation. The endpoints were 30-day death or readmission, defined as hospital admission within 30 days of prior hospitalization for HF. Descriptive and between-group statistics were used to analyze the sample, and multivariate logistic regression was used to evaluate the odds associated with door-to-diuretic time. Results In this analysis, 110 patients (age 68±15 years, 59% n=65 male; 73% n=80 white, 78% n=86 NYHA class 3-4) were included. Within 30 days of hospitalization, 33% n=47 were readmitted for HF and 10% n=11 died. In terms of diuresis, most (88%, n=97) received intravenous furosemide bolus (dose 47±2.4 milligrams) with a median time of administration 241 minutes (interquartile range 150-388 minutes). Only 6% (n=7) received intravenous furosemide bolus within 60 minutes of admission. Door-to-diuretic time was a univariate predictor (odds ratio=2.6, 95% 1.1-6.3) of 30-day readmission and death and remained significant (odds ratio=4.3, 95% 1.1-16.8) after adjustment for age, sex, race, pack-years smoking, Charleston Comorbidity Index, NYHA class, and ejection fraction. Conclusion Door-to-diuretic time among hospitalized HF patients was associated with greater odds of 30-day readmission and death. Door-to-diuretic time may be a quality of care measure for HF, and conditional on the speed of HF evaluation and diagnosis. Future work aims to improve HF diagnosis to improve door-to-diuretic time by utilizing machine learning and electrocardiography. Achieving a prompt euvolemic state in heart failure (HF) using diuretics is associated with better outcomes. While current guidelines advocate for the timely initiation of diuretics, existing literature on the concept of “door-to-diuretic” time is controversial. The hypothesis was that longer door-to-diuretic time was associated with greater odds of 30-day hospital readmission and death among hospitalized HF patients. This ongoing study is prospectively collecting data from the electronic medical records of admitted HF patients since April 2020 at an academic medical center. Inclusion criteria were admitting diagnosis of HF (ICD-10 code I50), and positive Framingham Heart Failure Diagnostic Criteria. Data collected included demographics, echocardiographic results, patient symptoms and exam findings, and medication administration. HF was classified using NYHA functional classification. Comorbidities were quantified using the Charleston Comorbidity Index. Door-to-diuretic time was defined as the time interval between patient hospital arrival and the first diuretic administration. Door-to-diuretic time was right-skewed and corrected with a log10 transformation. The endpoints were 30-day death or readmission, defined as hospital admission within 30 days of prior hospitalization for HF. Descriptive and between-group statistics were used to analyze the sample, and multivariate logistic regression was used to evaluate the odds associated with door-to-diuretic time. In this analysis, 110 patients (age 68±15 years, 59% n=65 male; 73% n=80 white, 78% n=86 NYHA class 3-4) were included. Within 30 days of hospitalization, 33% n=47 were readmitted for HF and 10% n=11 died. In terms of diuresis, most (88%, n=97) received intravenous furosemide bolus (dose 47±2.4 milligrams) with a median time of administration 241 minutes (interquartile range 150-388 minutes). Only 6% (n=7) received intravenous furosemide bolus within 60 minutes of admission. Door-to-diuretic time was a univariate predictor (odds ratio=2.6, 95% 1.1-6.3) of 30-day readmission and death and remained significant (odds ratio=4.3, 95% 1.1-16.8) after adjustment for age, sex, race, pack-years smoking, Charleston Comorbidity Index, NYHA class, and ejection fraction. Door-to-diuretic time among hospitalized HF patients was associated with greater odds of 30-day readmission and death. Door-to-diuretic time may be a quality of care measure for HF, and conditional on the speed of HF evaluation and diagnosis. Future work aims to improve HF diagnosis to improve door-to-diuretic time by utilizing machine learning and electrocardiography.