June 1, 2010--An analysis of Medicare data from 1993 through 2006 for older patients hospitalized for heart failure indicates that along with a decrease in hospital length of stay, the rate of in-hospital and 30-day mortality has decreased, while the rate of hospital readmission and discharge to skilled nursing facilities has increased, according to a study in the June 2 issue of JAMA.
"During the last decade, the most prominent change in the acute care of patients with heart failure (HF) was a decreasing length of stay in hospitals," the authors write. Whether this decrease may be associated with changes in outcomes is not known.
Hector Bueno, M.D., Ph.D., of Hospital General Universitario Gregorio Maranon, Madrid, Spain, and colleagues conducted a study to determine if during a period of decreasing length of hospital stay for heart failure, there were changes in short-term mortality, readmission and discharge to skilled nursing facilities, using data from Medicare. The analysis included 6,955,461 Medicare fee-for-service hospitalizations for heart failure between 1993 and 2006, with a 30-day follow-up.
Between 1993 and 2006, average length of stay decreased from 8.8 days to 6.3 days. The researchers found that in-hospital mortality decreased from 8.5 percent in 1993 to 4.3 percent in 2006, a 49 percent relative reduction; and the 30-day mortality rate decreased by 2.1 percent, from 12.8 percent to 10.7 percent. There was an increase in postdischarge mortality (from discharge to the 30th day after admission), from 4.3 percent in 1993 to 6.4 percent in 2006.
In 1993, a total of 74.0 percent of HF patients were discharged to home or under home care service, compared to 66.9 percent of patients in 2006. Thirteen percent of patients were discharged to skilled nursing facilities in 1993; in 2006, that figure was 19.9 percent, a relative increase of 53 percent. Thirty-day readmission rates increased from 17.2 percent to 20.1 percent.
"The most striking finding is that the period was associated with an increase in 30-day readmission rate. Although we cannot demonstrate that the shortened hospital stay caused these changes, it is certainly plausible that the effort to discharge patients quickly has led to transfers to nonacute institutional settings and occasionally sent patients out of the hospital before they were fully treated," the authors write.
The researchers add that from the patient perspective, it is not clear that care in 2006 was markedly better than it was in 1993. "The outcome of patients hospitalized for HF measured by short-term mortality has improved, which may be a result of better quality of care. However, because length of stay has substantially decreased, improvement is less than what might be suggested by in-hospital mortality. In contrast with that improvement, rates of readmission and discharge to skilled nursing facilities have increased, suggesting that patient outcomes, although better, have not improved in all areas."
"The current model of care for older patients with HF in the United States may benefit from more attention to the care and outcomes in the early transition period after hospital discharge and routine surveillance of how changes in practice affect patient outcomes."
(JAMA. 2010;303:2141-2147. Available pre-embargo to the media at www.jamamedia.org)
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