Outpatient Diuresis Clinic - A Patient Centered and Cost Saving Approach to Heart Failure Management

Background Heart failure (HF) remains one of the leading causes of hospital admissions, representing annual healthcare costs exceeding $30 billion in the United States. In an effort to reduce hospitalizations and transition to a value-based care model, Medicare's Hospital Readmission Reduction Program penalizes hospitals that have above average 30 day readmission rates, withholding 3% of all Medicare reimbursement for these hospitals. While the national average for HF readmissions is currently at 22%, the 30 day readmission rate for HF at the University of North Carolina (UNC) is 23.9%. Fiscal incentives to reduce the burden of hospital admissions have fueled interest in ambulatory strategies that can better manage HF, including clinic-based administration of IV diuretics. Methods The aim of this study was to assess the impact of an outpatient diuresis clinic on HF hospitalizations and resultant cost savings. The clinic is staffed by an advanced practice provider and a registered nurse with cardiologist oversight. There is also multidisciplinary support by pharmacy, nutrition, and social work. Data were collected retrospectively from 445 patient encounters between August 2017 and February 2019. Primary endpoints included observation stays, inpatient hospitalizations, and cost to payers. Results As of February 2019, 162 unique patients had been treated in the diuresis clinic, totaling 445 encounters. Based on our FY2016 data, 90% of patients presenting to the emergency department with a diagnosis of HF are admitted for either an observation or inpatient stay. For patients admitted to UNC who require less than a 48 hour hospitalization, the total cost to payers was approximately $3.5 million. These 445 encounters would have resulted in a total payer cost of $1,184,145 for observation stays and $4,040,155 for inpatient admissions (less than 48 hours). In comparison, the cost to payer for each diuresis clinic visit is $276, resulting in a total cost of $122,820. In addition, assuming that each outpatient diuresis encounter substitutes for at least a 36 hour hospital stay (median length of stay in observation unit), this would, at minimum, result in 668 hospital bed days saved. Though transient electrolyte abnormalities and rare but reversible episodes of acute kidney injury were noted during clinic visits, there were no significant adverse events requiring hospitalizations during the study period. Conclusions For stable patients with decompensated heart failure, the outpatient IV diuresis clinic is a patient-centered, safe, and cost savings alternative to hospital admission.