Death Rates Rise for Hip Fracture Patients Discharged Early

Diedtra Henderson

February 25, 2015

Older patients hospitalized for 10 days or less after hip fracture faced heightened risk of dying within 30 days of discharge, according to a nationwide cohort study.

Peter Nordström, MD, PhD, from the Department of Community Medicine and Rehabilitation, Geriatrics, Umeå University, Sweden, and colleagues report their findings in an article published online February 20 in the BMJ.

Although shorter hospital stays may seem to reduce costs of care, the authors caution that earlier discharges may exact their own cost in the form of increased complications, incomplete rehabilitation, and higher risk for death.

To test the hypothesis, they searched the Swedish National Patient Register for patients older than 50 years who had been hospitalized with a first hip fracture between 2006 and 2012. This segment of the population, patients older than 50 years, grew by 16% during the study period, whereas the number of hospital beds shrank by 8%.

The researchers identified 116,111 patients. Their mean age at the time of hip fracture was 82.2 years. The researchers excluded 5863 patients who died during their hospital stay.

The mean length of stay declined during the study period from 14.2 days in 2006 to 11.6 days in 2012, Dr Nordström and colleagues report.

Meanwhile, for patients with hospital stays of 10 or fewer days (n = 59,154), the 30-day risk for death increased by 8% for each day below 10 days in 2006 and by 16% for each day below 10 in 2012. For patients who stayed 11 days or longer, reducing the length of stay by a day had no effect on 30-day risk of death.

"[W]e found that patients with a length of stay of 1–5 days had twice the risk of death within 30 days of discharge compared with patients with a length of stay of ≥15 days," Dr Nordström and colleagues write.

"Our results suggest that the continuous efforts to decrease length of stay after major surgery in many countries is associated with higher mortality after hospital discharge."

Patients who were male, had trochanteric fractures, and suffered from such conditions as chronic obstructive pulmonary disease or cardiovascular disease were at the highest risk of dying, the authors found.

In an accompanying editorial, Peter Cram, MD, and Raphael Philip Rush, both from the Department of Medicine, University of Toronto, Ontario, Canada, said the study findings may serve as "further warning" against shortening hospitals stays lower than 10 days, which was an inflection point in the study data.

"One possible explanation [for the association] is that reductions in length of stay resulted in more complications occurring after discharge; complications that might have been quickly recognized and treated if the patient had remained in hospital," Dr Cram and Rush write. "A short initial admission may merely be the precursor to a longer, potentially deadly readmission to treat a complication that might have been recognized earlier."

The commentators suggest that policy makers weigh both the potential cost savings of rapid discharge and the "potential for unintended consequences."

The study authors and editorialists note wide variations in length of hospital stay across the globe. For example, the authors point to a 2012 study that showed that in the United States, patients with all medical conditions treated at 129 Veterans Affairs hospitals had a mean length of stay that declined from 5.4 days in 1997 to 4 days in 2010. However, readmission rates for these patients, whose mean age was 65 years, also dropped by 2.7% ( Ann Intern Med. 2012;157:837-845).

"In addition to evaluation of other diagnoses than hip fractures, further research should seek to gain a better understanding of the underlying cause of the increased risk of death after discharge in surgical patients, and evaluate whether early discharge to rehabilitation centers or nursing homes is associated with a worse outcome," Dr Nordström and coauthors conclude.

Financial support for the research study was provided by the Swedish research council. The study authors and the commentators have disclosed no relevant financial relationships.

BMJ. Published online February 20, 2015. Full text

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