June 3rd, 2010

What are the Dangers of Shorter Hospital Stays for HF Patients?

CardioExchange welcomes Dr. Héctor Bueno to answer questions about his recent paper in JAMA, which found that shorter hospital stays for heart-failure patients have resulted in fewer deaths in the hospital, but at the cost of more readmissions, leading researchers to speculate that “because length of stay has substantially decreased, improvement is less than what might be suggested by in-hospital mortality.”  Bueno and colleagues (including senior author Harlan Krumholz, editor-in-chief of CardioExchange) analyzed Medicare data from nearly 7 million heart-failure hospitalizations from 1993 until 2006. They conclude that heart-failure patients “may benefit from more attention to the care and outcomes in the early transition period after hospital discharge.” We invite members to ask  their own questions in the comments section.

Your study highlights the tension between reducing the cost of care while providing quality care and you suggest that premature hospital discharge is a large factor contributing to the higher readmission and post-discharge mortality rates. What would you recommend to CMS as a policy change to improve the quality of care? Would you:

(A) increase the DRG for heart failure so that patients can be treated more optimally in the hospital
(B) increase the penalty for 30-day readmission rates
(C) do both?

(B) I am not a big fan of using penalties for improving quality, but in this particular case I think it would help managers and physicians to understand that the management of heart failure is a continuous process in which hospitals are just one step that must be very well coordinated with other levels of health-care delivery. The real problem is not that the quality of hospital care may have been reduced due to pressure to shorten the length of stay, it is the disconnection between hospitals and other health providers after discharge. I do not know if the DRG is appropriate for the real cost of the hospital management of heart failure, but I am skeptical that increasing its value would have a big impact on improving quality. I´d rather recommend that CMS incorporate incentives for increasing communication and cooperation between hospitals and primary care for heart-failure patients to improve transitional care which, in my view, should be the main target.

Do you have any information on other factors that might influence readmission rates such as (1) time from discharge to first follow-up visit, and (2) availability/timing of heart-failure nurse contact?

The transition between hospital discharge and resumption of usual care is a period of high vulnerability for chronic patients in general and for heart-failure patients in particular. There is evidence to suggest that early readmissions may be more strongly related to the failure of transitional care than to the quality of hospital care. Patients, families, caregivers, and health-care providers may have difficulty learning or understanding changes in lifestyle and medical treatments, or identifying secondary effects or new complications that require special attention before they become important enough to require a new hospitalization. Therefore, early interventions to educate patients and caregivers on new therapeutic measures, signs of alert, potential complications, and how to respond would be helpful. Discharge plans shared by the hospital team and GPs, medicine reconciliation, early follow-up visits, and contact persons for problem solving are measures that can help reduce readmissions.

Can patients be safely discharged earlier if they receive the best care? Or, alternatively, are there measures that can be taken that will reduce the risk of readmission following early discharge?

I think patients may be discharged earlier and receive the best care, but this is not easy, and perhaps not possible, in the type of hospital-centered, health-care systems that we currently have. Only with a fluid coordination between all levels of care that ensures continuity of care across different settings and disease stages could this be possible. A sophisticated interaction between the different care settings — hospitals, day hospitals, outpatient specialized care, heart-failure offices, heart-failure nurses,  and GPs that took into consideration all the measures that I mentioned previously — would be needed to reduce days in the hospital with high-quality care.

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