Correlation of the Agency for Health Care Policy and Research congestive heart failure admission guideline with mortality: Peer Review Organization Voluntary Hospital Association Initiative to Decrease Events (PROVIDE) for congestive heart failure

Study objective: We quantify patient risk as related to the presence or abs ence of the Agency for Health Care Policy and Research (AHCPR) congestive h eart failure (CHF) hospital admission criteria. Methods: This was a retrospective observational cohort study at 12 acute ca re hospitals examining consecutive patients with the final primary diagnosi s of CHF. Trained record abstractors blinded to outcome extracted 386 data elements, including 6 AHCPR admission criteria: (1) pulmonary edema (determ ined by radiograph) or severe respiratory distress (respiration >40 breaths /min), (2) hypoxia (oxygen saturation <90%) not caused by pulmonary disease , (3) significant edema (greater than or equal to+2) or anasarca, (4) sympt omatic hypotension (<90 mm Hg systolic blood pressure) or syncope, (5) CHF of recent onset, and (6) clinical evidence (chest pain) of myocardial ische mia. The association between admission criteria and mortality rate (30 days , 6 months, and 1 year) was quantified and risk adjusted by stepwise logist ic regression analysis. Results: Of the 1,674 patients with CHF, 1,340 (80%) were admitted to the h ospital. Patients not admitted had a lower mortality rate than admitted pat ients (30-day mortality rate, 2.1% [95% confidence interval [CI] 0.6 to 3.6 ] versus 11.5% [95% CI 9.8 to 13.2]; odds ratio 0.20 [95% CI 0.09 to 0.45]) . Two of the admission criteria did not correlate with a higher mortality r ate: CHF of recent onset and myocardial ischemia. Excluding those 2 criteri a, the number of admission criteria present correlated with the patient's p robability of hospital admission (P < .001), length of hospital stay (P = . 014), and 30-day mortality rate (P < .0001). When zero or 1 admission crite ria was present, physician clinical judgment did distinguish patients less likely to die in the subsequent 30 days (1.5% [95% Cl 0.2 to 2.8] sent home Versus 10.2% [95% CI 8.5 to 11.9] admitted). When 2 or more admission crit eria were present, physician clinical judgment did not distinguish patients less likely to die in the subsequent 30 days (18.2% [95% CI 0 to 42.0] sen t home versus 19.4% [95% CI 13.6 to 25.2] admitted). Conclusion: Selected criteria of the AHCPR CHF admission guideline correlat e with mortality rate. Combined with physician clinical judgment, they may be useful in the risk stratification of patients with CHF. Selected low-ris k patients with CHF identified by the admission criteria who are presently managed in the acute care hospital may be candidates for outpatient managem ent.