Francisco Javier Martín-Sánchez, Ana Suero Roiz, María Suárez Cadenas, Patricia Parra Esquivel, Begoña Espinosa, María Pilar López Díez, Rodolfo Romero Pareja, Miguel Alberto Rizzi Bordigoni, Carlos Bibiano, Javier Jacob, Enrique Martín Mojarro, Alfons Aguirre, Pere Llorens, Pablo Herrero, Esther Rodríguez Adrada, Cristina Bermejo Boixareu, Xavier Rosselló, Òscar Miró, DEED-Frail Trial Study Group
In older patients with geriatric vulnerability and AHF discharged home from the ED or related units, MGDP did not demonstrate a statistically significant reduction in 30-day adverse outcomes.
OBJECTIVE: To evaluate the impact of the multilevel-guided discharge plan (MGDP) on clinical outcomes in older patients with geriatric vulnerability and acute heart failure (AHF) discharged from the ED.
METHODOLOGY: DESIGN: Open-label, multicenter, cluster-randomized trial comparing patients with and without an intervention. Hospitals were matched by complexity for the cluster randomized procedure.
MAIN INCLUSION CRITERIA: Age≥70 years, geriatric vulnerability (ISAR≥2 points), NT-proBNP >1800pg/mL, discharged <96 h after ED arrival.
INTERVENTION: MGDP at patient discharge consisted of: 1) multidimensional checklist for clinical recommendations and activation of resources where needed; 2) early visit with the specialist scheduled; 3) information to primary care team transmitted; and 4) written instruction sheet to the patient/caregiver provided.
PRIMARY OUTCOME: 30-day composite of AHF-related ED visit, hospitalization, or cardiovascular-related death.
RESULTS: Twenty-three hospitals (intervention:11, control:12) included 472 patients (mean age:84 years; 57% women; intervention:231, control:241). Adherence to the mandatory core components of MGDP was high, although implementation of deficit-specific interventions varied across geriatric domains. The primary endpoint was observed in 30 and 41 patients in the intervention and control group, respectively (13.0%vs17.0%; OR:0.73, 95%CI:0.44-1.22). Interaction tests did not suggest heterogeneity across prespecified subgroups. The intervention was associated with higher patient/caregiver satisfaction with transition of care (67.2%vs47.3%; OR:2.28, 95%CI:1.50-3.47), although no significant differences were observed for other secondary clinical or patient-centered outcomes. Mixed-effects models yielded consistent findings.
CONCLUSIONS: In older patients with geriatric vulnerability and AHF discharged home from the ED or related units, MGDP did not demonstrate a statistically significant reduction in 30-day adverse outcomes.