Trends in HF hospitalization outcomes: A mixed bag

June 01, 2010

Chicago,IL - Patients hospitalized for heart failure in recent years are discharged a lot sooner than they used to be, and their in-hospital mortality is way down, suggests an analysis based on Medicare data from 1993 to 2006 that would be seen as a triumph but for a few other findings[1]. It saw discharges to skilled nursing facilities shoot up by half and rehospitalizations within 30 days climb about 17%.

In-hospital mortality was cut by about 50% during that period, but 30-day mortality, which includes the in-hospital phase, declined only 16%, report Dr H<éctor Bueno (Hospital General Universitario Gregorio Marañón, Madrid, Spain) and colleagues in the June 2, 2010 issue of the Journal of the American Medical Association. "Hospital deaths were found, to some extent, to be shifting to outside the hospital."

Clinical studies and registry analyses in this area often focus on in-hospital outcomes; had the current study done that, "you would say we've shortened length of stay and reduced mortality, and you would claim victory," senior author Dr Harlan M Krumholz (Yale University, New Haven, CT) said to heartwire .

But the analysis underscores the importance of both the in-hospital and postdischarge phases. When the follow-up is extended to 30 days, Krumholz observed, "the net result is sort of a mixed bag for the patients." They care about the entire episode of care, not just in-hospital outcomes, and some found that "you can win the first lap but lose the race."

The gains for in-hospital outcomes and slippage in some 30-day outcomes were seen in 6 955 461 Medicare fee-for-service hospitalizations for heart failure from 1993 and 2006 for which there was 30-day follow-up.

Trends in hospital length of stay and short-term outcomes in patients hospitalized for heart failure

End point 1993 - 19 94 2005 - 20 06
Mean length of stay (d) 8.6 6.4
In-hospital mortality (%) 8.2 4.5
30-day mortality (%) 12.6 10.8
All-cause 30-day readmission (%) 17.3 20.1
Discharge to nursing or intermediate-care facility (%) 13.2 19.6
All differences p<0.001

Risk-adjusted outcomes were consistent with the unadjusted findings. Compared with 1993-1994, the 2005-2006 risk ratio for 30-day mortality was 0.92 (95% CI 0.91-0.93) and for 30-day readmission was 1.11 (95% CI 1.10-1.11) after controlling for age, sex, and comorbidities.

Whether the reduction in hospital length of stay over the 14 years actually contributed to the higher readmission rate can't be determined from the data, the group writes. Still, "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."

That makes some intuitive sense, but it's probably the wrong message, according to Krumholz. Shorter lengths of stay were followed by more readmissions but didn't necessarily put patients at higher risk. His take, he said, is that "we just haven't done a very good job with the transition period."

Obviously, minimizing time in the hospital is a good idea, "but we need to put in place sophisticated transition programs, and we need to develop some standards for when patients are ready to go home and when they need further support," according to Krumholz. There aren't formal guidelines for that, and criteria probably vary a lot among doctors and institutions.

"At the ends of the spectrum, it's easy," he said. "But there's a large intermediate zone where people will have disparate opinions about whether someone's ready [for discharge] yet. We need to start testing some strategies to see whether or not the use of tools for properly stratifying patients for risk at the time they go home . . . can provide an overall net benefit at the end of the day."

As the report notes, it's possible "that shorter lengths of stay in a system that supports the transition to outpatient status might not be associated with a higher readmission rate."

Bueno reports receiving consulting fees from Almirall, Bayer, Bristol-Myers Squibb, and Sanofi-Aventis and research grants from AstraZeneca, Bristol-Myers Squibb, and Pfizer. Krumholz reports that he develops and maintains performance measures under contract with the Centers for Medicare & Medicaid Services and chairs a scientific advisory board for United Healthcare. Disclosures for the other authors are listed in the paper .

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