In-hospital mortality and length of stay decreased in patients with HF between 1993 and 2006

Patients admitted for HF within a 14-year interval saw a reduction in both in-hospital mortality and length of stay, researchers from several US cities and Spain reported.

The observational study consisted of 6,955,461 Medicare fee-for-service patients hospitalized for HF between 1993 and 2006. All patients included in the study had 30-day follow-up. The primary outcome measures of interest were length of hospital stay; in-patient and 30-day mortality; and 30-day readmission rates.

From 1993-2006, mean length of stay decreased from 8.81 days (95% CI, 8.79-8.83) to 6.33 days (95% CI, 6.32-6.34). In-hospital mortality decreased from 8.5% (95% CI, 8.4%-8.6%) to 4.3% (95% CI, 4.2%-4.4%), and 30-day mortality decreased from 12.8% (95% CI, 12.8%-12.9%) to 10.7% (95% CI, 10.7%-10.8%). Home discharges or under home care service decreased from 74.0% to 66.9%, while discharges to skilled nursing facilities increased from 13.0% to 19.9%. Additionally, 30-day readmission rates increased from 17.2% (95% CI, 17.1%-17.3%) to 20.1% (95% CI, 20.0%-20.2%).

“Although the 30-day mortality rate has decreased, the increase in the readmission rates that paralleled the decrease in length of stay does raise concerns—as does the increase in the rates of discharge to nursing home facilities,” concluded the researchers. “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.”

Bueno H. JAMA. 2010; 303:2141-2147.

This analysis of the MEDPAR database for acute hospital admissions is an extraordinary tour de force resulting in an overview of almost seven million HF hospital admissions occurring over about a decade and a half. Clearly, we are getting better at managing these patients in the hospital with evidence of this being the decrease in hospital mortality. Also clear is the fact that we are getting more clever at moving patients out of the hospital more quickly, and this is probably multifactorial (eg, using more skilled nursing facilities after acute hospital discharge).

What is difficult for this study to answer precisely is whether or not the shortened length of stay translated into the increased readmission rate. It is tempting to speculate that if patients were held just a bit longer the hospital to perhaps effect more complete diuresis or even carry out more extensive education and rehabilitation efforts, fewer patients would return and require readmission down the road. The authors are to be congratulated on assembling an extraordinary compendium of data that will give great insight into the acutely decompensated patient with chronic HF.

– James B. Young, MD

Cardiology Today Section Editor

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