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Rationale and design of the Comparison of Outcomes and Access to Care for Heart failure (COACH) trial: a stepped wedge cluster randomized trial

Lee DS, Straus SE, Austin PC, Mohamed S, Taljaard M, Chong A, Fang J, Prasad T, Farkouh ME, Schull MJ, Mak S, Ross HJ. Am Heart J. 2021; 240:1-10. Epub 2021 May 10. DOI: https://doi.org/10.1016/j.ahj.2021.05.003


Background — Heart failure (HF) is an ambulatory care sensitive condition and a leading reason for emergency department (ED) visits and hospitalizations. Improved decision-making and care may enhance safety and efficiency for patients presenting to the ED with acute HF.

Objectives — We will evaluate an intervention comprised of two complementary components: i) the Emergency Heart Failure Mortality Risk Grade simultaneous 7- and 30-day (EHMRG30-ST) risk scores, which will inform admission-discharge decisions, and ii) a rapid outpatient follow-up (RAPID-HF) clinic for low-to-intermediate risk patients on cardiovascular readmissions or death.

Study Design — Stepped wedge cluster randomized trial with cross-sectional measurement at 10 acute care hospitals in Ontario, Canada. Patients presenting during control and intervention periods are eligible if they have a primary ED diagnosis of HF. In the intervention periods, access to the EHMRG30-ST web calculator will become available to hospitals' internet protocol (IP) addresses, and referral to the RAPID-HF clinic will be facilitated by a study nurse navigator. Patients with a high risk EHMRG30-ST score will be admitted to hospital. The RAPID-HF clinic will accept referrals for patients: a) with low risk 7- and 30-day EHMRG30-ST scores who are discharged directly from the ED, or b) intermediate risk patients with hospital length of stay < 72 hours. The RAPID-HF clinic, staffed by a nurse-clinician and cardiologist, will provide care during the 30-day transition after hospital separation.

Conclusion — This trial will determine whether novel risk stratification coupled with rapid ambulatory care achieves better outcomes than conventional decision-making and care for patients with HF.

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