Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006

Abstract

Context: Whether decreases in the length of stay during the past decade for patients with heart failure (HF) may be associated with changes in outcomes is unknown.

Objective: To describe the temporal changes in length of stay, discharge disposition, and short-term outcomes among older patients hospitalized for HF.

Design, setting, and participants: An observational study of 6,955,461 Medicare fee-for-service hospitalizations for HF between 1993 and 2006, with a 30-day follow-up.

Main outcome measures: Length of hospital stay, in-patient and 30-day mortality, and 30-day readmission rates.

Results: Between 1993 and 2006, mean length of stay decreased from 8.81 days (95% confidence interval [CI], 8.79-8.83 days) to 6.33 days (95% CI, 6.32-6.34 days). In-hospital mortality decreased from 8.5% (95% CI, 8.4%-8.6%) in 1993 to 4.3% (95% CI, 4.2%-4.4%) in 2006, whereas 30-day mortality decreased from 12.8% (95% CI, 12.8%-12.9%) to 10.7% (95% CI, 10.7%-10.8%). Discharges to home or under home care service decreased from 74.0% to 66.9% and discharges to skilled nursing facilities increased from 13.0% to 19.9%. Thirty-day readmission rates increased from 17.2% (95% CI, 17.1%-17.3%) to 20.1% (95% CI, 20.0%-20.2%; all P < .001). Consistent with the unadjusted analyses, the 2005-2006 risk-adjusted 30-day mortality risk ratio was 0.92 (95% CI, 0.91-0.93) compared with 1993-1994, and the 30-day readmission risk ratio was 1.11 (95% CI, 1.10-1.11).

Conclusion: For patients admitted with HF during the past 14 years, reductions in length of stay and in-hospital mortality, less marked reductions in 30-day mortality, and changes in discharge disposition accompanied by increases in 30-day readmission rates were observed.

Figure 1

Secular trends for length of stay, in-hospital and early post-discharge outcomes in Medicare fee-for-service patients hospitalized for heart failure, 1993–2008. The 95% confidence intervals lie within the size of the symbols 1A. Length of stay 1B. Unadjusted 30-day all-cause readmission rate 1C. Discharge disposition 1D. In-hospital (green line), post-discharge (red line), and 30-day (black line) unadjusted mortality rates.

Figure 2

Risk-adjusted survival curves of 30-day all-cause mortality (2A) and all-cause readmission (2B) rates (1993–1994 vs. 2007–2008).