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Introduction Acute heart failure (AHF) hospitalisation is typically lengthy, costly and associated with 10% mortality. Outpatient based management (OPM) of AHF appeared effective in observational studies. We conducted a pilot randomised controlled trial (RCT) comparing OPM with standard inpatient care (IPM). Hopelessness independently predicted mortality in patients with risk factors of ischaemic heart disease. We hypothesize that patients randomised to OPM may be more hopeful and have better mental well-being, with better quality of life, patient and carer satisfaction. Methods We randomised patients with AHF, considered to need IV diuretic treatment for >2 days, to IPM or OPM. We recorded all-cause mortality (index-episode), and the number of full days alive and out-of-hospital (DAOH) within 60 days after randomisation. Quality of life (EQ5D-VAS), mental well-being [Short Warwick-Edinburgh Mental Wellbeing scale] and hope (Adult State Hope Scale) scores which have been validated as accurate in detecting fluctuations in hope were assessed up to 60 days follow-up. We calculated mean NHS cost savings and 95% central range (CR) from bootstrap analysis. Results Eleven patients were randomised to IPM and thirteen to OPM. There was no statistically significant difference in all-cause mortality during the index episode (1/11 vs 0/13) and up to 60 days follow-up (2/11 vs 2/13) [log rank p=0.86]. (Figure 1). Patients randomised to IPM accrued a median of 47 [IQR 36, 51] vs 59 [41, 60] DAOH in OPM (p=0.13). 2 patients randomised to IPM (vs 6 OPM) were readmitted within 60 days [p=0.31]. Hope scores increased more with OPM within 30 days after randomisation but by 60 days, dropped to lower levels compared with the group allocated to IPM (not statistically significant). (Table 1). In-patients’ mental well-being score was higher at baseline but more out-patients had increased total well-being scores by the 60-day follow-up visit (p=0.04). (Table 2). 100% patients in both arms were satisfied according to the ‘NHS Family and Friends Test’ but interestingly 100% would choose OPM again whilst only 90% would choose Inpatient care again. Similarly, 100% carers were satisfied in the OPM arm whilst 60% only were satisfied if the patient was randomised to inpatient care. 100% carers would choose OPM again, vs 60% IPM carers.OPM was associated with mean cost savings of £2,658 (95% CR 460 - 4,857) per patient during the index episode. Conclusions Patients with acute HF randomised to OPM accrued more DAOH (albeit not statistically significant in this small pilot RCT). There was no increase in mortality but there was a higher risk of readmissions (not statistically significant). OPM was associated with improved mental well-being. But the initial increase in hope diminished within 60 days, possibly as a result of increased readmissions. The pilot RCT generated important hypotheses that need further testing in a large multicentre RCT. Conflict of Interest none

Introduction Outpatient based management of heart failure is gaining popularity in the UK. Observation data and a small pilot randomised controlled trial suggested it is safe and clinically effective. However, the cost-effectiveness of this novel treatment approach is not known. Patient level costing is thought to be more accurate providing extra granularity when reviewing the cost of patient pathways. Methods We used the Trust’s patient level costing models from financial years 2018/19 and 2019/20 to calculate total treatment costs for the patients in the pilot prospective trial which randomised acute heart failure patients to receive inpatient vs outpatient based therapy. Patient level costing for inpatients would include hospital bed, nursing cost, consultant /ward doctor cost, non-pay costs (pharmacy including iv drugs, diagnostics e.g. pathology, radiology, ECG, echocardiography). Where patient level costs are unavailable, for example Community contacts, we have used a national average cost. Community centre visit - HRG code of N29AF 2018/19 National average cost £71 Home visit - HRG code of N29AF 2018/19 National average cost £71 GP visit - National average cost of £30 [1] All other costs used are from the Trust costing model. We also tested the feasibility of collecting quality of life data using EQ5D-5L and the visual analogue scale (VAS) where 100 means the ‘best health you can imagine’ and 0 is the worst. EQ-5D-5L 5 items each with a different domain: mobility, self-care, activities, pain and depression. Each is scored from 1-5 where 5 is the worst (severe limitation/unable to do). Value sets are used to transform the health profile into an index value that can be interpreted as a health utility; these range from -0.594 to 1.000 where a value below zero is taken to describe a health state whose quality is ‘worse than death’. Results 24 patients were randomised to 13 outpatients and 11 inpatients between July 2018 and June 2019: Inpatients received 5.8 ± 2.8 days of treatment, outpatients received 8.5 ± 5.2 (p=0.12). No patient was in CCU, HDU or ITU or received dialysis/haemofiltration. 1 patient randomised to inpatient care died during the index episode, but none died in the outpatient group. There was one extra AE Outpatients costed £31435 (£2418 on average). Therefore total average saving was £2663 per patient. Treatment groups varied little in their quality of life. EQ-5D-5L VAS scores are significantly higher for outpatient. [Figure 1] Indeed a linear mixed model confirms that treatment arm is significantly associated with higher VAS scores; an outpatient reports a VAS score 13 points higher on average than an inpatient, and there is evidence that the score increases slightly over time (0.18 points per day, equivalent to ≈ 11 points over the 60 day period) for all patients. [Table 1] This is not true of EQ-5D utility indices; estimates for treatment and time are non-significant (p=0.78 and p=0.88 respectively). Conclusion Outpatient based AHF management appears cost-effective. Total average saving was £2663 per patient. Treatment groups varied little in their quality of life. EQ-5D-5L VAS scores are significantly higher for outpatient. Conflict of Interest No conflict of interest

Introduction Worsening heart failure (HF) leading to hospital admission is common and associated with substantial morbidity and mortality. For many patients, the preferred place of care, including end-of-life care, is at home or in the community, but this is often thwarted by the need for intravenous (IV) diuretic therapy. Alternative models of ambulatory care exist but safety and efficacy should be compared to standard care in randomised controlled trials (RCT). Methods We randomised patients with pulmonary or peripheral oedema who no longer required supplementary oxygen and who were considered to need at least two more days of IV diuretic treatment. A left ventricular ejection fraction 100pg/mL within the previous two years were also required. Patients who were admitted to hospital as well as those seen in the emergency department or out-patient clinic could be enrolled. Patients were randomised to be admitted (conventional care) or for out-patient care (at home, in the community centre, or in a hospital ‘Furosemide lounge’. The primary safety outcome was all-cause mortality during the index episode and primary effectiveness outcome was the number of full days alive and out of hospital (which did not include day-care in the Furosemide lounge) within 30 days after randomisation. Statistical analysis was based on ‘intention to treat’. Results Of 24 patients enrolled, eleven were randomised to in-patient and thirteen to out-patient care. There was no statistically significant difference in all-cause mortality. Only one patient, who was randomised to inpatient care, died. Patients randomised to in-patient care accrued 16 [IQR 12.5 to 20.5] days alive out of hospital compared to 29 [IQR 20.5 to 29] days for those assigned to out-patient care (p=0.015). Two patients randomised to in-patient care required readmission within 30-days compared to five assigned to out-patient care. Using these data, we calculate that a trial using this primary endpoint would require 92 patients to show, compared to standard in-patient care, that outpatient care leads to at least two more days alive and out of hospital with 90% power. Conclusion In this feasibility RCT, out-patient intravenous diuretic treatment was associated with a favourable outcome compared to standard inpatient care which might also be a cost-effective and an approach to care preferred by many patients. Conflict of Interest No conflict of interest