Heart failure stays and readmissions

Summaries from ACP Hospitalist Weekly.

Short and long heart failure stays associated with more readmissions

For hospitalized heart failure patients, short length of stay was associated with increased risk of readmission for heart failure or other cardiovascular causes, but not noncardiovascular causes, a recent Canadian study found.

The multicenter study included 58,230 patients over age 65 years who were hospitalized with a primary diagnosis of heart failure in Ontario, Canada, between April 1, 2003, and March 31, 2012. In their index heart failure admission, all of the patients were admitted through the ED, were discharged home, and had a length of stay less than 14 days. Results were published online by JACC: Heart Failure on May 10.

The study found a U-shaped association between length of stay and 30-day readmissions for heart failure or cardiovascular causes. Compared to a five- to six-day stay, lengths of stay of one to two days or nine to 14 days were associated with similarly increased risks of heart failure readmission (adjusted hazard ratios [HRs], 1.15 [95% CI, 1.04 to 1.27] and 1.14 [95% CI, 1.04 to 1.25], respectively) and cardiovascular readmission (adjusted HRs, 1.12 [95% CI, 1.04 to 1.21] and 1.11 [95% CI, 1.04 to 1.19], respectively). The risk of 30-day readmissions for noncardiovascular causes was more linear, increasing with longer length of stay. All-cause and cardiovascular mortality increased when the length of stay exceeded eight days.

The observed association between long length of stay and readmission and mortality is concordant with two prior studies, but this study newly identified risk of readmission among patients with short length of stay, the authors said. Although the study cannot prove a causal link between length of stay and outcomes for heart failure and cardiovascular readmissions, possible explanations for the association include persistent congestion not being apparent prior to discharge and insufficient optimization of medications and transitions.

The study was conducted in an environment without financial pressures to reduce length of stay, and the findings may have limited generalizability, the authors noted. The results do not challenge the value of strategies to reduce length of stay but do highlight potential additional approaches to improve care, including rapid cardiology follow-up after a short stay and multidisciplinary follow-up, both general and cardiology-specific, after a long admission, they said.

According to an accompanying editorial, the results lend support to the impression that some heart failure patients are discharged from the hospital prematurely. However, short stays for heart failure likely relate to many factors, including less complex or sick patients, patients' eagerness for discharge, and systemic pressures on clinicians to discharge sooner. Penalties for readmissions are unable to control for all these factors, according to the editorialists. “Readmissions should not be the sole focus of our prevention efforts, rather the prevention of the initial and all hospitalizations should be the goal,” they wrote.