Associations Between Reduced Hospital Length of Stay and 30-Day Readmission Rate and Mortality: 14-Year Experience in 129 Veterans Affairs Hospitals

Annals of internal medicine (Impact Factor: 17.81). 12/2012; 157(12):837-45. DOI: 10.7326/0003-4819-157-12-201212180-00003
Source: PubMed


Chinese translation
Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions.
To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration.
Observational study from 1997 to 2010.
All 129 acute care Veterans Affairs hospitals in the United States.
4 124 907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage).
Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals.
For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected).
This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used.
Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission.
Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.

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    • "However, after adjusting for the case-mix and service-mix (not shown here), the relation tends to be negative (about 7.3% increase for each in-hospital day lower than expected), which implies that shorter individual LOS is generally connected with higher risk of readmission. Therefore, consistent with (Kaboli et al., 2012), we observe that significant reduction in LOS, without simultaneously improving inpatient care, is more likely to result in premature discharge and rehospitalization. Further, enrollment priority turns out to be highly linked with odds of readmission in all conditions, especially when it comes to catastrophically disabled veterans (increases of .2% in AMI to 10.9% in HF). "
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    ABSTRACT: Hospital readmission has become a critical metric of quality and cost of healthcare. Medicare anticipates that nearly $17 billion is paid out on the 20% of patients who are readmitted within 30 days of discharge. Although several interventions such as transition care management and discharge reengineering have been practiced in recent years, the effectiveness and sustainability depends on how well they can identify and target patients at high risk of rehospitalization. Based on the literature, most current risk prediction models fail to reach an acceptable accuracy level; none of them considers patient's history of readmission and impacts of patient attribute changes over time; and they often do not discriminate between planned and unnecessary readmissions. Moreover, the effect of different time intervals that defines readmissions has not been looked at before. In this study, we tackle such drawbacks by developing and validating a predictive analytics framework for avoidable readmissions. We further assert that the government endorsed 30 day time window that is used to count and report readmissions is not appropriate for chronic conditions such as chronic obstructive pulmonary disease. The proposed methods and tools are demonstrated with real world datasets from four hospitals of the Veterans Health Administration system.
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    • "The Veterans Health Administration (VHA) is the largest integrated health care system in the USA and serves 8.3 million veterans annually. Patients are characterized by male predominance, advanced age, and a large burden of chronic cardiopulmonary diseases [9]. For example, the number of veterans ≥85 years treated by the VHA has tripled from 2000 to 2011. "
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    ABSTRACT: Accurate determination of left ventricular filling pressure is essential for differentiation of pre-capillary pulmonary hypertension (PH) from pulmonary venous hypertension (PVH). Previous data suggest only a poor correlation between left ventricular end-diastolic pressure (LVEDP) and its commonly used surrogate, the pulmonary capillary wedge pressure (PCWP). However, no data exist on the diagnostic accuracy of PCWP in veterans. Furthermore, the effects of age and comorbidities on the PCWP-LVEDP relationship remain unknown. We investigated the PCWP-LVEDP relationship in 101 patients undergoing simultaneous right and left heart catherization at a large VA hospital. PCWP performance was evaluated using correlation and Bland-Altman analyses. Area under Receiver Operating Characteristics curves (AUROC) for PCWP were determined. PCWP-LVEDP correlation was moderate (r = 0.57). PCWP-LVEDP calibration was poor (Bland-Altman limits of agreement -17.2 to 11.4 mmHg; mean bias -2.87 mmHg). 59 patients (58.4%) had pulmonary hypertension; 15 (25.4%) of those met pre-capillary PH criteria based on PCWP. However, if LVEDP was used instead of PCWP, 7/15 patients (46.6%) met criteria for PVH rather than pre-capillary PH. When restricting analysis to patients with a mean pulmonary artery pressure of ≥25 mmHg and pulmonary vascular resistance of >3 Wood units (n = 22), 10 patients (45.4%) were classified as pre-capillary PH based on PCWP ≤15 mmHg. However, if LVEDP was used, 4/10 patients (40%) were reclassified as PVH. Among patients with any type of pulmonary hypertension, PCWP discriminated moderately between high and normal LVEDP (AUROC, 0.81; 95%CI 0.69-0.94). PCWP-LVEDP correlation was particularly poor in patients with COPD or obesity. Reliance on PCWP rather than LVEDP results in misclassification of veterans as having pre-capillary PH rather than PVH in almost 50% of cases. This is clinically relevant, as misclassification may lead to inappropriate therapies and adverse events.
    PLoS ONE 01/2014; 9(1):e87304. DOI:10.1371/journal.pone.0087304 · 3.23 Impact Factor
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    • "9 leading to additional readmissions, or differences in baseline health of patients, are unclear (Andraws, 2012). However, other recent work suggesting long term reductions in length of stay in the US Veterans Affairs system was not associated with higher readmission would argue for the latter (Kaboli et al., 2012). "
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    ABSTRACT: All-cause readmission to inpatient care is of wide policy interest in the United States and a number of other countries (Centers for Medicare and Medicaid Services, in the United Kingdom by the National Centre for Health Outcomes Development, and in Australia by the Australian Institute of Health and Welfare). Contemporary policy efforts, including high powered incentives embedded in the current US Hospital Readmission Reduction Program, and the organizationally complex interventions derived in anticipation of this policy, have been touted based on potential cost savings. Strong incentives and resulting interventions may not enjoy the support of a strong theoretical model or the empirical research base that are typical of strong incentive schemes. We examine the historical broad literature on the issue, lay out a 'full' conceptual organizational model of patient transitions as they relate to the hospital, and discuss the strengths and weaknesses of previous and proposed policies. We use this to set out a research and policy agenda on this critical issue rather than attempt to conduct a comprehensive structured literature review. We assert that researchers and policy makers should consider more fundamental societal issues related to health, social support and health literacy if progress is going to be made in reducing readmissions.
    Health Economics Policy and Law 08/2013; 9(2):1-21. DOI:10.1017/S1744133113000340 · 1.33 Impact Factor
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