Routine Indwelling Urethral Catheterization in Acute Heart Failure Patients Is Associated With Increased Urinary Tract Complications Without Improved Heart Failure Outcomes

Abstract

Background: Indwelling urethral catheters (IUC) are routinely inserted for the purpose of monitoring urine output in patients with acute heart failure (AHF). The benefit of IUC in patients capable of complying with urine collection protocols is unclear, and IUC carry multiple risks. This study describes the impact of IUC on AHF treatment.

Methods and Results: A total of 540 records were retrospectively analyzed. After exclusion criteria were applied, 316 patients were propensity matched to establish groups of 100 AHF patients who either did (IUC(+)) or did not receive an IUC (IUC(−)) upon admission. Hospital length of stay (9 vs. 7 days), in-hospital urinary complications (24 vs. 5%), and 1-year urinary tract infection rate (17 vs. 6%; HR, 3.145; 95% CI: 1.240–7.978) were significantly higher in the IUC(+) group (P<0.05 for all). There were no differences in 30-day rehospitalization (6 vs. 6%; HR, 0.981; 95% CI: 0.318–3.058; P=0.986) or major adverse cardiac/cerebrovascular events at 1 year (37 vs. 32%, HR, 1.070; 95% CI: 0.636–1.799; P=0.798).

Conclusions: Based on this retrospective analysis, the routine use of IUC may increase length of stay and UTI complications in AHF patients without reducing the risk for major cardiovascular and cerebrovascular events or 30-day rehospitalization rate.

Heart failure (HF) is a worldwide public health problem with high mortality, despite recent advances in treatment strategy.^1–3 For patients with acute HF (AHF), early initiation of treatment is critical to improve outcomes.^4,5 Diuretic therapy is a cornerstone in the management for AHF, and indwelling urethral catheters (IUC) are widely used to accurately monitor urine output.^6–8 IUC are frequently placed in alert patients capable of complying with urine output measurements. Although accurate accounting of urine output is important, the benefits and risks of IUC have not been analyzed in AHF patients. Herein, we retrospectively analyzed an AHF group with regard to the association between IUC placement and outcomes.

Editorial p 1505

Methods

Sample

This study was approved by the institutional ethics committee and complied with the Declaration of Helsinki (6th revision). We retrospectively analyzed medical records of AHF patients admitted through the emergency room (ER) to the general cardiology service at Gachon University Medical Center between 1 January 2011 and 31 December 2015. Inclusion criteria were: (1) ICD10 diagnosis of HF with either preserved or reduced ejection fraction; (2) alert mental state; (3) age ≥18 years; (4) presence of dyspnea with New York Heart Association (NYHA) class III/IV or IV/IV symptoms; (5) lung congestion defined as bilateral pulmonary edema or pleural effusion on chest X-ray; and (6) examination findings consistent with AHF including: jugular venous distension, auscultated crackles, and lower extremity edema. Exclusion criteria were: (1) active acute coronary syndrome; (2) indications justifying IUC insertion including: critical illness, impaired mental state, and acute or chronic urinary retention;⁹ and (3) N-terminal pro-brain natriuretic peptide (NT-proBNP) <400 pg/mL.⁶ Enrollment is illustrated in Figure 1.

Figure 1.

Patient enrollment. IUC, indwelling urethral catheter; NT-proBNP, N-terminal pro-brain natriuretic peptide.

Statistical Analysis

Statistical analysis was performed using IBM SPSS Statistics (IBM Release 2014; IBM SPSS Statistics for Windows, version 23.0; IBM, Armonk, NY, USA). Continuous normally distributed data are expressed as mean±SD, whereas continuous nonnormally distributed data are given as median (IQR). Student’s ttest and Mann-Whitney Utest were used to compare intergroup differences for normally distributed and non-normally distributed variables, respectively. Categorical variables were analyzed using Pearson chi-squared test. NTproBNP was log-transformed for analysis throughout due to positive skewness.

Propensity Matching

Given that significant imbalances between baseline IUC(+) and IUC(−) groups were observed, propensity scores for each IUC insertion/noninsertion were calculated using logistic regression. Twenty-seven variables including age, sex, hemoglobin, white blood cell count, platelets, sodium, potassium, protein, albumin, total bilirubin, aspartate aminotransferase (AST), blood urea nitrogen (BUN), creatine kinase myoglobin (CK-MB), troponin-I, uric acid, left ventricular ejection fraction (LVEF), LV enddiastolic dimension (LVEDD), log NT-proBNP, systolic blood pressure, diastolic blood pressure, heart rate, NYHA class, hypertension, diabetes mellitus (DM), chronic obstructive pulmonary disease, atrial fibrillation, and benign prostatic hyperplasia (BPH) were used to calculate propensity scores. Multivariate linear regression was performed to exclude variables with multicollinearity. On standard analysis, HF medication is not included in propensity matching, because it is given after the decision to insert an IUC has been made.^10,11

Both groups were then matched 1 to 1, using the nearest neighbor method at a caliper width of 0.20. Missing data were estimated and replaced using the multiple imputation method. Paired-sample ttest and McNemar’s test were utilized for continuous and categorical postmatched data, respectively.

Longitudinal data were analyzed with the Cox proportional hazards regression model. IUC insertion was tested for association with all prematched baseline characteristics. Parameters with statistically significant findings on univariate analysis were included for subsequent multivariate analysis. The postpropensity-matched data were analyzed on bivariate Cox regression modeling as well. Longitudinal data for 1-year outcomes were plotted using the Kaplan-Meier estimates with logrank test. For risk stratification of urinary complications, both univariate and multivariate logistic regression were utilized on unmatched data. To evaluate the independent effect of IUC duration on in-hospital composite urinary complications (IHCUC) and 1-year major adverse cardiac and cerebrovascular events (MACCE), we performed a multivariable-adjusted binary logistic regression analysis using IUC duration-based quartile groups, with the IUC(−) group as the reference.

AHF Management and Outcome Assessment

Patient management was assessed according to medication rate. The in-hospital length of stay, 30-day rehospitalization rate, and MACCE at 1 year were calculated. One-year MACCE was defined as the composite of mortality, stroke or unplanned rehospitalization for AHF at 1 year. All events were assessed on chart review or telephone contact. After discharge, each patient was examined in the cardiology outpatient clinic ≤1 month after discharge, and every 1–3 months afterwards.

IUC and Urinary Complications

IUC were inserted by the responsible hospital staff in the ER upon initiation of AHF treatment. IHCUC were categorized into infectious and noninfectious complications. Infectious complications were further defined as urinary tract infection (UTI).⁹ Noninfectious urinary complications were defined as newonset hematuria and post-IUC-removal lower urinary tract symptoms (LUTS).^12–14 One-year UTI included all UTI occurring between IUC insertion and 1-year follow-up. To be considered a true complication, non-infectious urinary complications required confirmation of diagnosis by a urologist during the index admission.¹⁴ BPH also required confirmation of diagnosis by a urologist.¹⁵

Echocardiography

Two-dimensional transthoracic echocardiography was performed at ≤24 h after presentation. LVEF was calculated using the modified Simpson’s method and LVEDD was evaluated. Left atrial volume index (LAVI) was obtained by dividing the left atrial (LA) volume by body surface area, with the LA volume measured using the biplane arealength method. A 1–2-mm pulsed Doppler sample volume was located at the tip of mitral valve, where velocities were measured from the apical window. Peak early diastolic filling velocity (E) was then divided by early diastolic mitral annulus velocity (E’) measured on Doppler tissue imaging at the mitral annulus for E/E’ calculation. All echocardiography was performed by 2 highly trained echocardiographers unaware of the patient clinical information.

Results

Baseline Characteristics

All patients were Korean. Table 1 lists the pre and postpropensity matched groups with or without IUC. In the prematched analysis, the IUC(+) group had a higher percentage of women and higher uric acid, AST, BUN, CK-MB (although still within normal limits) and NTproBNP. Propensity-score matching (PSM) was performed to balance possible confounders between groups. After matching, no baseline inter-group characteristics differed significantly between the IUC(+) and IUC(−) group. All baseline characteristics at initial presentation and intergroup comparisons for MACCE(+) and MACCE(−) are listed in Table S1. Time to MACCE was 88±100 days (median, 48 days; IQR, 0–365 days). IUC insertion rate was higher in the MACCE(+) group, but the difference did not reach statistical significance (P=0.051).

Table 1. Subject Baseline Characteristics vs. IUC and PSM Status

	Before PSM			After PSM
	IUC(+) (n=195)	IUC(−) (n=121)	P-value	IUC(+) (n=100)	IUC(−) (n=100)	P-value
Demographic findings
Age (years)	73±12	71±15	0.108	73±13	73±13	0.644
Men	74 (38)	60 (50)	0.042*	40 (41)	42 (43)	0.772
NYHA class IV	118 (97)	114 (94)	0.405	94 (94)	94 (94)	1.000
DM	62 (32)	34 (28)	0.487	32 (33)	29 (30)	0.643
Hypertension	85 (44)	61 (50)	0.237	43 (44)	49 (50)	0.390
BPH	11 (6)	8 (7)	0.724	5 (5)	6 (6)	0.756
AF	6 (3)	8 (7)	0.138	4 (4)	3 (3)	0.700
SBP (mmHg)	131±29	129±29	0.424	129±30	129±30	1.000
DBP (mmHg)	73±17	71±14	0.139	72±18	72±15	0.973
Heart rate (beats/min)	99±96	84±24	0.077	93±31	88±27	0.304
Laboratory data (reference range)
Hemoglobin (13–17 g/dL)	12±2	12±2	0.618	12±2	12±2	0.899
Sodium (135–145 mEq/L)	135±9	137±6	0.065	135±8	137±6	0.161
Potassium (3.5–5.5 mEq/L)	4.5±0.7	4.4±0.9	0.140	4.5±0.7	4.4±0.9	0.607
Uric acid (2.5–8.3 mg/dL)	7.5±2.8	6.9±2.8	0.038*	7.5±2.6	7.1±2.9	0.853
AST (10–40 U/L)	108±452	42±65	0.015*	38±26	38±42	0.903
ALT (5–40 U/L)	59±180	37±79	0.100	26±18	29±33	0.440
BUN (8–22 mg/dL)	33±22	28±19	0.037*	29±20	28±20	0.825
Creatinine (0.5–1.2 mg/dL)	1.6±1.3	1.5±1.4	0.566	1.5±1.3	1.5±1.3	0.855
CK MB (0–5 ng/mL)	4.6±7	2.8±2.7	0.004*	3.6±4.1	2.9±2.8	0.202
Troponin I (0–0.78 ng/mL)	0.3±0.9	0.3±1.0	0.554	0.3±1.2	0.3±0.8	0.686
NT proBNP (0–263 pg/mL)	11,381 (2,003–10,736)	8,294 (2,719–16,593)	0.008*,†	7,964 (2,103–9874)	8,085 (4,757–10,824)	0.564†
Log-transformed NT proBNP (0–2.42 log pg/mL)	3.8±0.5	3.6±0.6	0.003*	6.6±2.5	6.6±2.4	0.900
Echocardiography
LVEF (%)	47±19	47±17	0.970	50±18	47±17	0.338
E/E’	20±10	20±11	0.938	21±10	20±10	0.752
LVEDD (mm)	53±9	53±9	0.757	53±10	53±9	0.910
LAVI (mL/m2)	51±30	52±33	0.796	55±36	50±24	0.385

Data given as mean±SD, n (%) or median (IQR). *P<0.05. ^†Mann-Whitney U-test. AF, atrial fibrillation; ALT, alanine transaminase; AST, aspartate transaminase; BPH, benign prostatic hyperplasia; BUN, blood urea nitrogen; CK-MB, creatine kinase myoglobin; DBP, diastolic blood pressure; DM, diabetes mellitus; E/E’, the ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral annulus; IUC, indwelling urethral catheter; LAVI, left atrial volume index; LVEDD, left ventricular end-diastolic dimension; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-brain natriuretic peptide; NYHA, New York Heart Association; PSM, propensity-score matching; SBP, systolic blood pressure.

In-Hospital Outcome Analysis

With regard to in-hospital outcomes in the pre-matched population, the IUC(+) group had longer length of stay and higher rate of IHCUC (Table 2). The statistical significance of the IHCUC rate was driven by LUTS and in-hospital UTI. After PSM, IHCUC and hospital stay length remained significantly higher in the IUC(+) group.

Table 2. In Hospital and 1 Year Outcome vs. IUC and PSM Status

	Before PSM			After PSM
	IUC(+) (n=195)	IUC(−) (n=121)	P-value	IUC(+) (n=100)	IUC(−) (n=100)	P-value
In-hospital outcome
In-hospital mortality	15 (8)	5 (4)	0.206	5 (5)	5 (5)	1.000
In-hospital stay (days)	9 (7–14)	7 (4.5–10)	<0.0001*,†	9 (7–13)	7 (5–11)	0.006*,†
IHCUC	32 (16)	3 (2)	<0.001*	24 (24)	5 (5)	<0.001*
Hematuria	6 (3)	0 (0)	0.051	2 (2)	0 (0)	0.497
LUTS	13 (7)	2 (2)	0.042*	13 (13)	3 (3)	0.016*
In-hospital UTI	13 (7)	1 (0)	0.014*	8 (8)	1 (1)	0.017*
Thirty-day outcome
Thirty-day rehospitalization	12 (6)	7 (6)	1.000	6 (6)	6 (6)	1.000
One-year outcomes
One-year MACE	74 (38)	33 (27)	0.051	37 (37)	32 (32)	0.552
One-year rehospitalization	38 (19)	22 (18)	0.774	19 (19)	21 (21)	0.860
One-year stroke	11 (6)	7 (6)	0.957	5 (5)	7 (7)	0.767
One-year mortality	31 (16)	12 (10)	0.132	15 (15)	12 (12)	0.680
One-year UTI	26 (13)	7 (6)	0.033*	17 (17)	6 (6)	0.025*

Data given as n (%) or median (IQR). *P<0.05. ^†Mann-Whitney U-test. IHCUC, in-hospital composite urinary complications; LUTS, lower urinary tract symptoms; MACE, major adverse cardiac events; UTI, urinary tract infection. Other abbreviations as in Table 1.

Thirty-Day Rehospitalization and 1-Year Outcome Analysis

On post-discharge outcome analysis, 30-day rehospitalization and 1-year MACCE were not significantly different between the IUC(+) and IUC(−) groups, while the rate of UTI was significantly higher in both the pre and postmatched IUC(+) group (Table 2). On pre-matched unadjusted/multivariable adjusted and post-matched Cox regression analysis, IUC were associated with higher UTI rate, but not with 30-day-rehospitalization or 1-year MACCE and its subcategories (Table 3). On Kaplan-Meier analysis of 1-year outcomes according to IUC status (Figure 2), higher occurrence of UTI is noted in the IUC(+) group (Figure 2D), while other clinical outcomes did not differ significantly (Figure 2A–C).

Table 3. Cox Proportional Hazards Regression Analysis of 1 Year Outcome

	Events, n (%)		HR (95% CI)	P-value
	IUC(+) (n=195)	IUC(−) (n=121)
One-year UTI
Pre-matched unadjusted	27 (14)	7 (6)	2.601 (1.132–5.972)	0.032*
Multivariable adjusted†	–	–	2.330 (1.004–5.405)	0.049*
Propensity matched	17 (17)	6 (6)	3.145 (1.240–7.978)	0.010*
Thirty-day rehospitalization
Pre-matched unadjusted	12 (6)	7 (6)	0.928 (0.365–2.358)	0.876
Multivariable adjusted‡	–	–	0.947 (0.353–2.542)	0.913
Propensity matched	6 (6)	6 (6)	0.981 (0.318–3.058)	0.986
One-year MACE
Pre-matched unadjusted	74 (38)	33 (27)	1.481 (0.982–2.232)	0.061
Multivariable adjusted§	–	–	1.200 (0.786–1.833)	0.399
Propensity matched	37 (37)	32 (32)	1.171 (0.729–1.880)	0.513
One-year rehospitalization
Pre-matched unadjusted	38 (20)	22 (18)	1.088 (0.643–1.839)	0.754
Multivariable adjusted¶	–	–	1.102 (1.041–1.167)	0.844
Propensity matched	19 (19)	21 (21)	0.901 (0.484–1.676)	0.742
One-year stroke
Pre-matched unadjusted	11 (6)	7 (6)	0.976 (0.376–2.519)	0.961
Multivariable adjusted††	–	–	1.050 (0.398–2.770)	0.922
Propensity matched	5 (5)	7 (7)	0.706 (0.224–2.225)	0.553
One-year mortality
Pre-matched unadjusted	31 (16)	12 (10)	1.612 (0.828–3.138)	0.160
Multivariable adjusted‡‡	–	–	1.415 (0.712–2.813)	0.322
Propensity matched	15 (15)	12 (12)	1.238 (0.579–2.645)	0.581

*P<0.05. ^†Adjusted for WBC and LVEF; ^‡adjusted for sodium, log-transformed NT-proBNP, LVEF, and AF; ^§adjusted for age, WBC, protein, total bilirubin, BUN, creatinine, uric acid, creatine kinase myoglobin, LVEF, and LVEDD; ^¶adjusted for age, WBC, albumin, log-transformed NT-proBNP, LVEF, E/E’, LVEDD, and LAVI; ^††adjusted for hemoglobin, WBC, creatinine, and AF; ^‡‡adjusted for age, albumin, BUN, creatinine, CK-MB, and LVEF. MACCE, major adverse cardiac and cerebrovascular events; WBC, white blood cells. Other abbreviations as in Tables 1,2.

Figure 2.

Kaplan-Meier plot of propensity-matched (A) 1-year major adverse cardiac and cerebrovascular events (MACCE), (B) time to readmission, (C) all-cause mortality, and (D) time to urinary tract infection (UTI) according to indwelling urethral catheter (IUC) status.

Risk Factor Assessment for Urinary Complications

Presence of IUC, DM, and BPH correlated with IHCUC. On subgroup analysis, IUC was the only variable associated with nosocomial UTI, while both IUC and BPH were associated with post-IUC-removal LUTS (Table 4). On 1-year UTI assessment, IUC was the only meaningful risk factor. Longer duration of IUC placement produced an added increase in OR of IHCUC for longer placements compared with the IUC(−) group, while MACCE rate did not (Table 5; Figure 3). The risk of IHCUC increased 5-fold in the indwelling IUC quartile >6 days.

Table 4. Indicators of Overall In-Hospital Urinary Complications and 1-Year UTI

	Univariate		Multivariate
	OR (95% CI)	P-value	OR (95% CI)	P-value
IHCUC
Sex (male)	1.038 (0.545–1.974)	0.911	0.995 (0.473–2.097)	0.995
IUC	4.639 (1.897–11.342)	0.001*	5.018 (1.995–12.621)	0.001*
DM	2.398 (1.254–4.587)	0.008*	2.488 (1.265–4.897)	0.008*
BPH	3.146 (1.128–8.772)	0.028*	3.967 (1.209–13.017)	0.023*
In-hospital UTI
Sex (male)	0.402 (0.156–1.036)	0.059	0.361 (0.118–1.104)	0.074
IUC	3.530 (1.181–10.548)	0.024*	3.288 (1.086–9.950)	0.035*
DM	2.275 (0.997–5.188)	0.051	2.115 (0.912–4.905)	0.081
BPH	1.402 (0.305–6.445)	0.665	3.293 (0.547–19.830)	0.193
In-hospital post-IUC-removal LUTS
Sex (male)	2.855 (0.952–8.557)	0.061	2.043 (0.565–7.393)	0.276
IUC	4.250 (0.942–19.172)	0.060	5.846 (1.178–29.008)	0.031*
DM	2.084 (0.734–5.921)	0.168	2.569 (0.830–7.950)	0.102
BPH	10.250 (3.087–34.034)	<0.001*	9.045 (2.151–38.036)	0.003*
One-year UTI
Sex (male)	0.715 (0.341–1.502)	0.376	0.792 (0.356–1.763)	0.568
IUC	2.617 (1.102–6.214)	0.029*	2.525 (1.057–6.029)	0.037*
DM	1.707 (0.823–3.542)	0.151	1.634 (0.780–3.423)	0.193
BPH	0.974 (0.215–4.412)	0.973	1.205 (0.239–6.064)	0.821

*P<0.05. Abbreviations as in Tables 1,2.

Table 5. Independent Effect of IUC Duration on IHCUC and 1-Year MACCE

IUC / Duration quartile		IUC duration (days) mean±SD	IHCUC events (%)	IHCUC† OR (95% CI)	P-value	1-year MACCE events (%)	1-year MACCE‡ OR (95% CI)	P-value
(−)
	–	0	5.0	Ref.		27.3	Ref.
(+)
	1st	0.59±0.50	9.3	2.097 (0.589–7.461)	0.253	35.2	1.004 (0.456–2.212)	0.992
	2nd	2.41±0.50	16.7	3.996 (1.284–12.436)	0.017*	40.0	1.936 (0.922–4.067)	0.081
	3rd	4.74±0.83	17.5	6.901 (1.917–24.845)	0.003*	32.5	0.716 (0.272–1.885)	0.499
	4th	23.06±43.84	26.5	8.893 (3.105–25.467)	<0.0001*	41.2	2.134 (0.985–4.623)	0.055

*P<0.05. ^†Adjusted for sex, DM, and BPH and compared with the IUC (−) group; ^‡adjusted for age, WBC, protein, total bilirubin, BUN, creatinine, uric acid, creatine kinase myoglobin, LVEF, and LVEDD. Abbreviations as in Tables 1–3.

Figure 3.

Odds ratio (OR) vs. indwelling urethral catheter (IUC) duration quartiles for (●) in-hospital composite urinary complications (IHCUC; ^†adjusted for sex, diabetes mellitus, and benign prostatic hyperplasia) and (■) 1-year major adverse cardiac and cerebrovascular events (MACCE; ^‡adjusted for age, white blood cell count, protein, total bilirubin, blood urea nitrogen, creatinine, uric acid, creatine kinase myoglobin, left ventricular [LV] ejection fraction, and LV end-diastolic dimension). OR were adjusted on multivariable analysis and compared with the IUC(−) groups.

Discussion

Principal Findings

The IUC facilitates urine output monitoring, which has theoretical benefits in the management of HF patients with acute volume overload and pulmonary edema. Routine IUC placement, however, has been associated with unintended consequences of less frequent physical examinations by physicians,¹⁶ less face-to-face time between physicians and patients, and increased rates of UTI.¹⁷ Herein, we present data further bringing into question the risk : benefit ratio of routine IUC placement. In this study, we found that routine use of IUC was associated with (1) higher rates of urinary complications during and after hospitalization; (2) longer hospitalization; and (3) similar 30-day rehospitalization and 1-year HF outcomes in the general AHF population.

Overuse of Well-Intentioned IUC

It has been shown that a very high percentage of IUC are placed in the ER and not by admitting physicians.¹⁷ These same data suggest that as many as 65% of all Foley catheter insertions may be avoidable. Also, the physicians responsible for admitted patients are frequently unaware that IUC have been placed in their patients and often do not use the urine output data generated from catheter monitoring.¹⁸ Although IUC placement is well-intentioned, the aforementioned observations bring into question the possibility of overuse of IUC in modern care. The present results highlight a similar theme in the management of AHF patients. Most of the present patients lacked a clear indication for catheter placement, and, after propensity matching, we failed to find an association between IUC placement and improved HF outcomes. While acknowledging the potential benefit of accurate urine output monitoring in AHF patients, routine use of IUC may be unnecessary in AHF management.

The potential explanations for overuse of IUC are numerous. Modern electronic medical records use order sets, which often bundle orders frequently used for a specific diagnosis.¹⁹ Additionally, improved inter-specialty education has led to ER physicians often attempting to facilitate good patient care by initiating orders appropriate for inpatients in the ER.²⁰ Although this ER practice creates measurable improvements in patient outcomes for some diagnoses, opportunities for over-utilization of other care modalities arise. IUC may be such an example. Studies on the use of IUC routinely demonstrate overuse in modern care and high rates of UTI and LUTS that persist well beyond the time of catheter placement.¹⁷

IUC Associated With Increased Length of Hospitalization and Complication Rate

Although urinary complications were manageable in most cases, some patients had irreversible complications: 2 patients had catheter-associated UTI leading to sepsis and 5 other patients eventually underwent permanent catheterization. Urology consultation also lengthened hospital stay for additional evaluation and management. Approximately 16% of IUC patients had some type of urinary complication and had urology consultation (Table 2). Given the significant complication rate increase after approximately 1 day of catheterization, early IUC removal should be considered (Table 5).

Possible Solutions

Routine IUC placement in AHF patients should be scrutinized. Given the high rate of placement, reduction in IUC utilization may have important cost implications for health systems and may facilitate reduction of urinary complications in an already ill patient population.¹⁷ Simple solutions such as flagging of patients with IUC in the electrical medical record have been shown to reduce IUC use and subsequent side-effects.²¹ Straightforward solutions, such as electronic flags, could lead to rapid and profound improvements in the care of AHF patients.

Study Limitations

AHF patients with the highest propensity scores represent patients with the highest tendency to have an IUC. Also, the highest propensity scores may reflect alert AHF patients with the highest severity of heart failure, who are most likely to benefit from IUC instrumentation. PSM, however, is designed to exclude entities with both lower and higher extreme propensity scores and compare populations with moderate scores. This may have resulted in those likely to benefit from IUC being excluded from the matched study (Figure S1) and explain why we were not able to identify any benefits of IUC placement.

Conclusions

Routine ER IUC insertion in AHF patients was not associated with a better 30-day or 1-year clinical outcome, while having higher urinary complication rates and longer hospitalization. Given the elevated urinary complication rates in patients comorbid with DM and BPH, IUC placement should be scrutinized in these patient groups. Avoiding unnecessary IUC placement in alert patients with voluntary voiding control may not only lower urinary complications but reduce length of hospitalization, ultimately leading to a better quality of care.

Acknowledgments

We would like to express our deepest gratitude to Professor Kwangpil Ko for statistical support.

Sources of Funding

This research was partly supported by the Gachon University Gil Medical Center (grant no.: 2015-02) and the Next-generation Medical Device Development Program for Newly-Created Market of the National Research Foundation (NRF) funded by the Korean government, MSIP (No. 2015M3D5A1066043).

Disclosures

The authors declare no conflicts of interest.

Supplementary Files

Supplementary File 1

Figure S1. Distribution of propensity score in patients excluded from the propensity score matching.

Table S1. Baseline characteristics at presentation and vs. MACCE status

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-17-1113

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