Trying to Stay Afloat: Reducing Heart Failure Hospitalizations Among Heart Failure with Preserved Ejection Fraction Patients by Utilization of an Outpatient Heart Failure Bridge Clinic

Abstract

Background Heart failure with preserved ejection fraction (HFpEF) constitutes half of heart failure (HF) hospitalizations today, and is expected to be the prevalent form of hospitalized HF by the year 2020. There is limited data to date on the utilization of outpatient, nurse practitioner-managed diuresis clinics in the chronic outpatient management of the HFpEF patient population. Methods This was an observational study of HFpEF patients seen in the Johns Hopkins HF Bridge Clinic (HFBC) for intravenous (IV) furosemide administration from May 2014 to July 2016. Results Over the study period, 90 unique patients with HFpEF were seen in the HFBC for IV diuresis, 55 (61%) of whom were initially referred after a HF hospitalization ( Table 1 ). Among the 90 patients, there were a total of 664 visits including 197 visits at which IV furosemide was given. The number of visits per patient was highly variable, ranging from a single visit to 57 visits, with a mean of 14 (SD 14) visits per patient. The median percent of visits in which patients received IV diuresis was 29% (IQR 30%). Mean IV furosemide dose was 125 mg (SD 43 mg). Additionally, there were 24 (12%) visits at which metolazone was given, 132 (67%) visits at which potassium was given, and 103 (52%) visits at which magnesium was given. There were 101 (51%) oral diuretic dose titrations made during the diuretic clinic visits. The mean post IV diuretic urine output was 675 ± 412 mL and weight decreased by 0.68 ± 0.60 kg. There was no significant change reported in blood pressure, renal function, or electrolytes post-diuresis. Of the 197 IV diuresis visits, 12 (6%) resulted in need for further management with an emergency department visit or direct admission from clinic and 142 (72%) remained out of the hospital for over 30 days following the IV diuresis visit. Conclusion We describe successful outpatient management of HFpEF patients via a comprehensive, nurse practitioner-managed diuresis clinic. HFpEF patients constitute a growing proportion of hospitalized HF, and strategies to successfully manage their HF in the outpatient setting may have significant implications in reduction of healthcare utilization.