New study confirms accuracy of Kaiser Permanente tool to identify lower risk patients with heart failure who may not need hospitalization
A risk tool developed by Kaiser Permanente safely identified heart failure patients seen in the emergency department with new or worsening symptoms who were at low risk of experiencing a heart attack, another serious problem, or dying, and could potentially be cared for outside the hospital, new research shows.
The new study, published in the Journal of the American College of Cardiology: Heart Failure, prospectively validated the risk tool, and piloted its use in 2 emergency departments in Kaiser Permanente Northern California (KPNC). The findings validate a retrospective study conducted by the same research team in 2022, that evaluated the tool’s effectiveness, and set the stage for further implementation and assessment of the risk tool.
“It took us 10 years to go from identifying the need to better differentiate low- and high-risk patients to optimize their care to implementing a novel KPNC-derived risk tool that provides accurate, personalized risk estimates at the point of care to help guide physician decision-making,” said lead author Dana R. Sax, MD, MPH, a research scientist with the Kaiser Permanente Division of Research and an emergency medicine physician with The Permanente Medical Group. “We had to develop and test the tool and build it into our electronic health record. We also collaborated with clinical leads in emergency medicine, cardiology, heart failure, and hospital-based specialists to develop care pathways necessary to bring the tool into the hospital setting.”
Prospective and real-time validation
For the prospective study, researchers had the risk tool — called STRIDE-HF (Systematic Tool for Risk Identification and Decision-making in Emergency Heart Failure) — assess in real time all 13,274 patients with acute heart failure seen in KPNC’s 21 emergency departments from January through December 2023. The risk tool classified 11.4% of these patients as very low risk; within this group fewer than 1% died over the next 30 days. In addition, 24.8% of the patients were identified as low risk; within this group, the study showed, fewer than 2% died.
“This study was designed to evaluate the tool’s effectiveness in a different contemporary population than the retrospective study,” said Sax. “The findings not only validate the previous study but confirm we have developed a tool that is consistently effective across people of different ages, sexes, race and ethnicities.”
The pilot study evaluated use of the tool by physicians in 2 KPNC emergency departments. The emergency medicine physicians at these sites received training on how the tool gathered information from the medical record and test results and what they would see in real time when the tool generated a risk score. Once the risk score is calculated, physicians can choose to simply view the risk category or open a report that provides more comprehensive decision support.
Among the 845 patients in the clinical pilot, the risk tool assessed 12% (102) as very low risk. Of these, 47 were discharged from the ED and 11 were discharged from an observation unit. Among the 211 low-risk patients, 83 were discharged from the ED and 15 from an observation unit. There were no serious adverse events s or deaths among the ED or observation unit discharged very-low-risk patients over the next 30 days.
“The clinical pilot allowed us to validate the tool as well as learn how our physicians interact with it,” said Sax. “Physicians told us they found it helpful to share the risk assessment with patients to explain their recommendations. We also found that the report, which includes the risk score as well as comprehensive clinical data and medication recommendations, was valuable to help streamline care. This report is also available to all providers in the hospital — which is an additional benefit.”
A leading cause of hospitalization
Heart failure occurs when the heart is unable to pump as much blood as the body needs. The condition, which can get continually worse over time, can cause damage to the kidneys and other organs and lead to fluid buildup in the lungs. Acute heart failure occurs when a person suddenly starts to have new or worsening signs or symptoms of heart failure, such as shortness of breath, weakness, fatigue, an irregular or fast heartbeat, or coughing and wheezing — leading many to seek care in the emergency department.
Heart failure is a leading cause of hospitalization in the U.S., with more than 1 million admissions and readmissions each year. People who are experiencing acute heart failure symptoms will often go to the emergency department for care. Across the U.S., about 80% to 85% of these patients are admitted to the hospital.
The risk tool assesses a patient’s 30-day risk of experiencing a life-threatening medical event based on sociodemographic and clinical variables, including prior visit history, how they arrived at the emergency department, test results, and need for ventilator support.
In January 2025, the risk tool became available to providers at all 21 KPNC hospitals.
“The work behind this research is an ideal example of how physicians can be curious about how to improve their own practice, get involved with research, and then design a tool that can help themselves, their colleagues, and their patients,” said senior author Mary Reed, DrPH, a DOR research scientist. “It is not a trivial thing to take something from a research project and make it into a tool used in real-world clinical practice to help patients, and to cross that bridge is exciting.”
The project was funded by The Permanente Medical Group Delivery Science and Applied Research program.
Co-authors include Jie Huang, PhD, of the Division of Research, and Dustin G. Mark, MD, Jamal S. Rana, MD, PhD, Matthew S. Solomon, MD, PhD, and Robert P. Norris, MD, of The Permanente Medical Group.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. KPDOR seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 720-plus staff, including 73 research and staff scientists, are working on nearly 630 epidemiological and health services research projects. For more information, visit divisionofresearch.kp.org or follow us @KPDOR.
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