JAMA: For HF, risk of in-hospital death decreases, readmission increases

An analysis of Medicare data from 1993 through 2006 for older patients hospitalized for heart failure (HF) 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 Journal of the American Medical Association.

“During the last decade, the most prominent change in the acute care of patients with HF was a decreasing length of stay in hospi­tals,” the authors wrote, adding that it is unknown whether this decrease may be associated with changes in outcomes.

Hector Bueno, MD, PhD, of Hospital General Universitario Gregorio Maranon in Madrid, Spain, and colleagues conducted a study to determine if during a period of de­creasing length of hospital stay for HF, there were changes in short-term mortality, readmission and discharge to skilled nurs­ing facilities, using data from Medicare.

The analysis included approximately 6.96 million Medi­care fee-for-service hospitalizations for HF 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.

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 post-discharge mortality (from dis­charge to day 30 after admis­sion), from 4.3 percent in 1993 to 6.4 percent in 2006.

In 1993, a total of 74 percent of HF patients were dis­charged to home or under home care service, compared to 66.9 percent of patients in 2006. According to Bueno and colleagues, 13 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,” the authors wrote. “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 non-acute institu­tional settings and occasionally sent pa­tients out of the hospital before they were fully treated.”

Bueno and colleagues added 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,” the authors wrote.

“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,” they continued.

Bueno and colleagues concluded that the current model of care for older patients with HF in the U.S. “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.”