Does Diuretic Dose at Discharge Influence Readmission Rate in ADHF Patients?
Increasing loop diuretic dosages at discharge may reduce the rate of 30-day readmission for patients with acute decompensated heart failure (ADHF) with a low ejection fraction and evidence of fluid overload, a new study has found.
By analyzing a cohort of patients admitted to Buffalo Medical Center and Millard Fillmore Gates Hospital in 2012, researchers were able to identify 131 ADHF patients. Of these, 50 patients were discharged with an increased loop diuretic dose while 81 patients were discharged with the same or a decreased dose.
The median furosemide equivalent dose on preadmission was 40mg (IQR=20-60), and for the 50 patients with increased dosages on discharge the median furosemide equivalent dose was 80mg (IQR=80-160).
Results showed that the patients who had their dosage increased had a 20% 30-day readmission rate compared to 38.3% for those with the same or decreased dose (P=0.0285). Compared with patients who did not get an increase in dosage, patients who did get the increase had 68% lower odds of hospital readmission within 30 days (OR=0.320; 95% CI=0.117-0.873). In the increased-dose group, many of the patients were switched from furosemide prior to admission to bumetanide at discharge, however this was not tied to all-cause reduction in 30-day readmission.
The results will interest hospitals, who under the Affordable Care Act, are penalized by the Centers for Medicare and Medicaid Services (CMS) if they have higher 30-day readmission rates than the national average.
The authors claim their findings emphasize a need for greater diuresis at discharge to help the transition to home. “The most optimal way to do this may be to switch a patient from furosemide to a more potent loop diuretic such as torsemide or bumetanide, which have bioavailabilities of 80% compared with ~50% for furosemide,” they write.
The study cites mitigating strategies that can the lower risks associated with long-term diuretics, such as optimization beta-blocker, ACE inhibitor, and aldosterone antagonist dosage.
The authors conclude by acknowledging the need for further studies to assess the links between patient outcomes and loop diuretics.
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