In this large, national study, we find that over a 16-year period of reduction in hospital length of stay and increased use of skilled nursing facilities after discharge for Medicare patients with heart failure, 30-day mortality was reduced but post-hospital readmission and mortality risk increased. From the patient perspective, it is not clear that care in 2008 is markedly better than it was in 1993. The outcome of patients hospitalized for heart failure, as measured by short-term mortality, has improved, which may be a result of better treatment. However, because length of stay has substantially decreased, improvement based on in-hospital mortality is misleading. In contrast, rates of readmission and discharge to skilled nursing facilities have also increased, suggesting that patient outcomes, while better, have not improved substantially.
The Medicare fee-for-service system provided an incentive for shortening length of stay without penalty for potential unfavorable later outcomes such as increased readmission or mortality rates. This policy has been considered responsible for the progressive reduction in length of stay observed in patients with heart failure in the United States.9
However, despite the main objective of reducing hospital costs, it is possible that when the hospital and short-term non-hospital post-discharge costs are considered, this policy failed to reduce healthcare expenses. It is unknown whether the increased use of non-acute settings or the increase in short-term readmission risk are the best options for the system, or whether they have been aligned with patient preferences and resulted in increased patient satisfaction.
Several studies have addressed the secular trends of various aspects related to the care and outcomes of patients with heart failure in the United States, such as incidence, hospitalization rate, hospital stay, therapy, mortality, discharge destination, and readmission risk.1, 6, 7, 9–12, 17–24, Ross J
The present study is the most comprehensive examination of recent short-term post-hospital management of heart failure and its consequences in the United States.
Our study also indicates the importance of examining an episode of acute care over a standardized period of assessment rather than merely focusing on the hospitalization. The approach of using a standardized period of assessment, particularly 30-day mortality, and readmission rates was endorsed for performance measures by the American College of Cardiology and the American Heart Association.13
Current payments are recognized as a major limitation of the Medicare fee-for-service payment system contributing to poor coordination of care across settings, and the Medicare Payment Advisory Commission has recommended that Medicare adopt episode-based payments including care provided during and post-hospitalization. In this study, had we focused solely on the period of hospitalization, we would have reached different conclusions, perhaps finding that hospital stay could be shortened and that there was a remarkable reduction in mortality. Only with the study of the peri-hospitalization period are we able to see the full change in outcomes for patients.
We found that hospital deaths were, to some extent, being shifted outside the hospital. The marked reduction in in-hospital deaths was accompanied by an increase in early post-discharge deaths. We cannot determine if these deaths were expected or whether the place of death imposed a burden on patients and their families or was consistent with their preferences. We also cannot determine if the shorter hospital stay contributed to some of the deaths. Nevertheless, we did find that the period did not have the magnitude of improvement in mortality that was suggested by the in-hospital experience alone.
The most striking finding is that the period was associated with an increase in 30-day readmission rate. While we cannot demonstrate that the shortened hospital stay caused these changes, it is certainly plausible that the effort to discharge patients quickly has led to transfers to non-acute institutional settings and occasionally sent patients out of the hospital before they are fully treated. Moreover, there is a paucity of studies that test criteria for readiness for discharge, adding to uncertainty about what constitutes appropriate hospital treatment for the condition.
Our findings are consistent with those of most studies and at odds with some others. Our findings concur with previous studies regarding reduction in the length of stay7, 9–12
and in the proportion of patients discharged to home, as well as an improvement in in-hospital1, 6, 9, 11, 12, 20
and 30-day mortality rates.6, 9, 10, 18, 20, 21
During the 1990s, a progressive increase in 30-day readmission rates for patients with heart failure was reported in the United States7, 9
while more recent reports did not find such an increase in the 2000s in the Medicare population.6, Ross
Our study demonstrates that during an observation period of 16 years, spanning most of the time during which the previous studies were performed, there has been a slow but steady increase in 30-day all-cause readmissions.
Our study has several limitations. First, the use of administrative data precludes the consideration of some clinically relevant prognostic factors as well as the evaluation of the quality of care. For instance, there is no information about changes in treatment during the study period. However, the reported trends towards an increase in the use of angiotensin-converting enzyme inhibitors and beta-adrenergic blockers, and a decrease in the use of inotropic agents in the United States12, 19, 23
as well as the modest effect of these therapies on short-term outcomes make it unlikely that therapeutic changes accounted for the increase in post-discharge outcomes. The inability to evaluate the quality of hospital care precludes the evaluation of the rate of premature discharge, as well as the identification of length of stay reduction as the causal factor for the increase in early post-discharge outcomes. Potential alternative explanations for our findings deserve consideration. For instance, a decrease in the threshold for admission of sicker heart failure patients would likely increase the rate of early outcomes. In addition, Medicare payments for hospital and skilled nursing care have undergone further changes over the study period. Our study focused on length of stay, discharge status, readmission and mortality, not on other important dimensions of patient outcomes, such as functional status or quality of life. Also, we were limited in our ability to determine if patients switched into managed care before the index hospitalization. This period was used to determine the comorbidities, but the results were similar to the crude analysis and would not be expected to affect the results. Finally, the study of fee-for-service beneficiaries may be associated with the selection of sicker patients, and an underestimation in outcomes and their time changes.Shimada
In conclusion, the pattern of care during hospitalization and immediately after for older patients with heart failure has changed substantially in the United States during the last 16 years. On the positive side, the 30-day mortality rate has decreased. However, the increase in the readmission rates which paralleled the decrease in length of stay does raise concerns – as does the increase in the discharge to nursing home facilities. The current model of care for older patients with heart failure in the United States may benefit from more attention to the care and outcomes in the early transition period after hospital discharge.