Early Ambulation May Benefit Patients With HF

The findings of a retrospective study indicate that early ambulation may be associated with improved outcomes in patients with heart failure (HF).

Lisa M. Fleming, MD, of the Beth Israel Deaconess Hospital and Medical Center, presented the results of the study at the Scientific Sessions of the American Heart Association (AHA) held November 12 to 16, 2016, in New Orleans, LA. Adrian F. Hernandez, MD, and Adam DeVore, MD, of Duke, were coinvestigators on the study.

HF accounts for more than 1 million hospitalizations and is associated with annual costs of $30 billion. Among all conditions, HF is associated with the highest rate of hospital readmissions within 30 days (~23%).

Fleming noted that the data on early ambulation and HF are not clear, but that some studies have shown that exercise may improve quality of life and reduce the readmission rate among outpatients with HF. She and her colleagues sought to determine the effect of early ambulation on patient outcomes, including length of stay, discharge to home, and 30-day rates of readmission and mortality.

They reviewed data on 285,653 inpatients with HF at 369 hospitals enrolled in the AHA’s Get With The Guidelines-Heart Failure program from 2009 to 2015. These data were linked to Centers for Medicare & Medicaid Services data. Early ambulation was defined as mobilization within 2 days after hospitalization. Overall, 187,189 patients (65.5%) ambulated by hospitalization day 2.

After adjustment, the researchers found that adherence to the early ambulation performance measure was associated with improvement in all outcomes. The adjusted length of stay decreased by approximately 24%. Compared with no early ambulation, patients with early ambulation were 3.7 times more likely to be discharged to home (Table).

Table. Discharge to Home and LOS

Outcome Unadjusted Adjusted
OR (95% CI) P Value OR (95% CI) P Value
Discharge to home 4.102 (3.881-4.335) < .0001 3.658 (3.464-3.862) < .0001
LOS > 4 d 0.483 (0.462-0.505) < .0001 0.475 (0.452-0.498) < .0001

CI = confidence interval, LOS = length of stay, OR = odds ratio.

Early ambulation was also associated with significantly lower rates of 30-day readmission (hazard ratio [HR] 0.788; 95% confidence interval [CI], 0.755-0.822; P < .0001) and 30-day mortality (HR 0.389; 95% CI, 0.360-0.420; P < .0001).

The researchers used multivariate logistic regression analysis to evaluate several patient-level predictors of early ambulation, including demographic variables (age, sex), presence of comorbidities (chronic obstructive pulmonary disease, asthma, peripheral vascular disease, stroke), and markers of HF severity (anemia, renal insufficiency), as well as third-party payment (private insurance, Medicare coverage). They also analyzed hospital-level predictors, such as US geographic region (Midwest, South, West, Northeast), heart transplant facility, hospital type (academic, nonacademic), setting (rural, urban), and number of beds.

Predictors of early ambulation included age, sex, and hospital location outside of the northeastern United States (P < .01 for all).

Fleming noted that the influence of patient frailty on ambulation has been difficult to evaluate in retrospective studies. To address this issue, she and her coinvestigators also analyzed hospital-level data.

When the researchers stratified hospitals into quartiles based on rates of early ambulation, the hospitals with the highest rates of early ambulation had the shortest lengths of stay. In addition, the 30-day readmission rate was significantly lower in hospitals in quartile 1 compared with quartile 4 (HR 0.857; 95% CI, 0.816-0.938; P = .0002).

The 30-day mortality rate did not significantly differ between any of the quartiles.

“Hospital-level analysis can help to overcome confounding of patient-level factors,” said Fleming, adding that more studies are needed to determine the effect of early ambulation in this population.

Source: Fleming LM, Zhao X, Devore, AD, et al. Early ambulation among hospitalized heart failure patients is associated with decreased length of stay and higher rates of discharge to home. Presented at: American Heart Association Scientific Sessions 2016; November 12-16, 2016; New Orleans, LA. Abstract 546.