Heart Failure Hospitalizations

Heart failure is a chronic disease which is the primary cause of many hospitalizations, especially among the Medicare population.  Consistent with a general effort to lower hospital length of stays, partly for cost reasons but also to avoid in-hospital adverse events, lengths of stay for Medicare heart failure admissions have been declining.  Researchers examined the consequences of this trend in research published in the Journal of the American Medical Association.  (JAMA Article)

The authors looked at Medicare heart failure admissions during the period from 1993 to 2006.  During that time there was a decrease in length of stay from 8.81 days to 6.33 days.  In-hospital mortality decreased from 8.5% of patients to 4.3% in 2006.  But readmissions within 30 days were up and mortality within 30 days of discharge also increased.  The authors suggest, and the general media reporting has picked up on the suggestion, that there is cause and effect at work here; in other words, people are being pushed out of the hospital too soon.  But other data collected by the researchers suggests this is unlikely to be the case.  The demographics and comorbidities of the hospitalized patients changed in ways that would indicate that sicker patients are being admitted.  The overall number of admissions actually delcined on a per capita basis, which is consistent with a general trend toward not hospitalizing people unless they really need it.  The percent of discharges to a skilled nursing facility increased, which again indicates that sicker patients were being admitted in the first place.

So the most likely explanation for the results would seem to be that only sicker patients were being admitted, and they were more likely to need readmission or to die after discharge.  Another possible cause for the results noted by the author is lack of good transition of care, particularly from the hospital to home.  Greater use of remote patient monitoring and readmission penalties may positively affect this problem.  In any event, the study is a good reminder that the popular impression that may be left by media reporting of research is often not accurate.