June 1, 2010 -- The average hospital stay for heart failure has declined from almost nine days to just over six days in a little over a decade, but there is new evidence patients may be being sent home too soon.
The current Medicare fee-for-service system rewards hospitals for discharging patients sooner, rather than later, but the impact of shorter hospitalizations on patient outcomes has not been fully understood.
An analysis of close to 7 million heart failure hospitalizations among Medicare recipients found that the average time in the hospital declined by almost three days between 1993 and 2006.
Death rates during initial hospitalization also dropped, but deaths after discharge increased, as did hospital readmissions within 30 days of discharge and discharges to nursing facilities instead of home.
The study is published in the June 2 issue of The Journal of the American Medical Association.
Study co-author Harlan M. Krumholz, MD, of Yale University, says the findings suggest that many patients are discharged before they are ready without the medical support they need to transition from hospital to home.
"This system has worked well for everyone but the patient and society," he tells WebMD. "The hospitals made more money with shorter initial stays and readmissions, and nursing facilities have more patients."
Heart Failure Hospitalization Trends
Krumholz credits advances in the treatment of heart failure over the 14-year period studied for the drop in deaths during initial hospitalization.
Between 1993 and 2006, the in-hospital death rate declined by almost 50%, from 8.5% to 4.3%.
But during the same period, deaths in the 30 days following hospital discharge increased from around 4% to 6%.
Among the other findings:
- One in 3 patients was discharged to other health care facilities instead of home in 2006, compared to one in four in 1993.
- There was a 53% increase in discharges to skilled nursing facilities, from 13% to 20%.
- Hospital readmissions within 30 days of discharge increased by 20%, from 17% to 20% during the 14-year period.
"Most people would not consider it progress to get out of the hospital sooner when that is coupled with a 20% increase in readmissions and a 53% increase in nursing home admissions," Krumholz says.
Longer Stays Not the Answer
But that doesn't mean patients are better off when they are hospitalized longer, he adds.
"Hospitals can be dangerous places, especially for older patients who are most at risk for life-threatening infections," he says. "People should be hospitalized only as long as they need to be, but there has to be a plan for treating them after discharge."
Philadelphia heart failure specialist Alfred A. Bove, MD, who is immediate past president of the American College of Cardiology (ACC), agrees that the lack of continuity of care following hospitalization is a bigger contributor to poor outcomes than shorter hospital stays.
"Heart failure patients can certainly be managed outside the hospital, but it requires a level of care that they have not been getting," he says.
These days, he says, most patients are discharged with no plan for follow-up care.
The ACC recently launched a nationwide program to address this problem that includes 725 institutions. The goal, he says, is to reduce unnecessary hospital readmissions by 20% by 2013.
Health Care Reform May Help
A provision of the new health care reform law set to go into effect in 2012 has provisions that are designed to penalize hospitals with high readmission rates.
Krumholz says the details are still being worked out, but the idea is to give hospitals an economic incentive to provide care after discharge.
A billion dollars in last year's federal economic stimulus plan has also been earmarked for tracking the influence of in-hospital practices, such as length of stay, on patient outcomes, San Francisco public health director Mitchell Katz, MD, tells WebMD.
"The impact of shorter or longer hospital stays on quality of life hasn't been well understood, but that may soon change," he says.