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Original Research |

IMPROVING PATIENT CARE

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

Peter J. Kaboli, MD, MS; Jorge T. Go, MD, MS; Jason Hockenberry, PhD; Justin M. Glasgow, BS, MS; Skyler R. Johnson, BS, MS; Gary E. Rosenthal, MD; Michael P. Jones, PhD; and Mary Vaughan-Sarrazin, PhD
[+] Article and Author Information

From Veterans Rural Health Resource Center–Central Region, Iowa City Veterans Affairs Medical Center, Center for Comprehensive Access & Delivery Research and Evaluation at the Iowa City Veterans Affairs Healthcare System, University of Iowa Carver College of Medicine, and University of Iowa College of Public Health, Iowa City, Iowa.

Presented in part at the annual meeting of the Society of Hospital Medicine, Washington, DC, 14 May 2009.

Disclaimer: The authors had full access to and take full responsibility for the integrity of the data. The views expressed in this article are those of the authors and do not necessarily represent the views of the U.S. Department of Veterans Affairs.

Grant Support: By the Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs, Veterans Rural Health Resource Center–Central Region, and the Center for Comprehensive Access & Delivery Research and Evaluation at the Iowa City Veterans Affairs Healthcare System (HFP 04-149). Dr. Go was supported by the Veterans Affairs Quality Scholars Fellowship Program, Veterans Affairs Office of Academic Affiliations.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1365.

Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Kaboli (e-mail, peter.kaboli@va.gov). Data set: Not available.

Requests for Single Reprints: Peter J. Kaboli, MD, MS, Iowa City Veterans Affairs Healthcare System, Comprehensive Access & Delivery Research and Evaluation Center, Mailstop 152, 601 Highway 6 West, Iowa City, IA 52246; e-mail, peter.kaboli@va.gov.

Current Author Addresses: Dr. Kaboli: Iowa City Veterans Affairs Healthcare System, Comprehensive Access & Delivery Research and Evaluation Center, Mailstop 152, 601 Highway 6 West, Iowa City, IA 52246.

Dr. Go: Department of Internal Medicine, Division of Gastroenterology, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242.

Dr. Hockenberry: Department of Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30329.

Mr. Glasgow, Ms. Johnson, and Drs. Rosenthal and Vaughan-Sarrazin: Iowa City Veterans Affairs Healthcare System, 601 Highway 6 West, Iowa City, IA 52246.

Dr. Jones: Department of Biostatistics, University of Iowa College of Public Health, 105 River Street, Iowa City, IA 52245.

Author Contributions: Conception and design: P.J. Kaboli, J.T. Go, J. Hockenberry, J.M. Glasgow, G.E. Rosenthal, M. Vaughan-Sarrazin.

Analysis and interpretation of the data: P.J. Kaboli, J.T. Go, J. Hockenberry, J.M. Glasgow, S.R. Johnson, M.P. Jones, M. Vaughan-Sarrazin.

Drafting of the article: P.J. Kaboli, J.T. Go, J.M. Glasgow, M. Vaughan-Sarrazin.

Critical revision of the article for important intellectual content: P.J. Kaboli, J.T. Go, J. Hockenberry, J.M. Glasgow, G.E. Rosenthal, M. Vaughan-Sarrazin.

Final approval of the article: P.J. Kaboli, J. Hockenberry, J.M. Glasgow, S.R. Johnson, G.E. Rosenthal, M. Vaughan-Sarrazin.

Provision of study materials or patients: P.J. Kaboli.

Statistical expertise: J.T. Go, S.R. Johnson, M.P. Jones, M. Vaughan-Sarrazin.

Obtaining of funding: P.J. Kaboli.

Administrative, technical, or logistic support: P.J. Kaboli.

Collection and assembly of data: P.J. Kaboli, S.R. Johnson, M. Vaughan-Sarrazin.


Ann Intern Med. 2012;157(12):837-845. doi:10.7326/0003-4819-157-12-201212180-00003
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Chinese translation

Background: 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.

Objective: 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.

Design: Observational study from 1997 to 2010.

Setting: All 129 acute care Veterans Affairs hospitals in the United States.

Patients: 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).

Measurements: Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals.

Results: 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).

Limitations: This study is limited to the Veterans Health Administration system; non–Veterans Affairs admissions were not available. No measure of readmission preventability was used.

Conclusion: 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.

Primary Funding Source: Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.

Figures

Grahic Jump Location
Figure.

Study flow diagram.

AMI = acute myocardial infarction; CAP = community-acquired pneumonia; COPD = chronic obstructive pulmonary disease; GIH = gastrointestinal hemorrhage; HF = heart failure; LOS = length of stay.

Grahic Jump Location

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Reducing Readmission Rates
Posted on December 19, 2012
Beril Cakir
Carolinas Hospitalist Group, Carolinas Medical Center, Charlotte, NC
Conflict of Interest: None Declared

I have read Kaboli et al.’s article with great interest (1). The study revealed that improved length of stay (LOS) did not increase the readmission rates. On the contrary, a previous study on Medicare beneficiaries with congestive heart failure concluded that reduction of LOS was associated with higher readmission rates (2). This difference may definitely be related to the variation in patient population and/or risk adjustment methods. This study is noteworthy for demonstrating the potential of the large Veterans Affairs (VA) patient population as a data source for future studies. As with every readmission study, once again, we are questioning: 1. Is readmission rate, the right quality indicator to use? 2. Do we know the root causes of readmissions and can we control them all? 3. How low is low enough for readmission rates? 4. What are the potential future interventions to prevent readmissions? In the light of previously detected risk factors for readmissions, peri-discharge interventions including use of a care bundle, centered on patient education, discharge planning, and medication reconciliation decreased the readmission rates within 30 days from 38% to 10%, while decreasing the cost (3,4). Most of the published prevention studies are from academic centers containing intense protocols, requiring dedicated time and manpower (3,4,5). Here is another study with impressive sample size, showing decreased readmission rates. Unfortunately, despite the availability of data, the study was not designed to determine the factors, which facilitated the improvement. The article talks about the increased use of hospitalist services in VA hospitals and the initiation of extensive medication reconciliation, which may have contributed to the decreased readmission rates. However, the intention of the study was not to assess the above association. At this point, we may want to initiate additional prevention-based approaches for long-term solutions. Evaluating the readmissions not linked to the primary admitting diagnosis but linked to the presence of uncontrolled diabetes with complications or uncontrolled malignant hypertension may exhibit the extent of the iceberg below the waterline. I think VA patient population and present data set may be a valuable source for the study. That will prove us the importance of bridging the gap between public health and individual health care with emphasis on primary, secondary, and tertiary prevention. Improving the health literacy level and self-care behaviors in patients could be one of the goals of future interventions. Patient education and empowering them to control their disease symptoms will not only decrease the readmissions but also overall admissions in long-term.Recent launch of TransitionAdvantage by Vree Health(6), a post discharge service to help hospitals with improved transition care, raises the question whether transitional care will emerge as a new specialty between inpatient and outpatient care. Cost effectiveness of outsourcing for the hospitals and overall health care is yet to be seen. Last but not the least, we are to readdress the need for universal electronic medical records, which can eliminate the problems due to miscommunication and provide better continuity of care. It will also enable us capturing the readmissions to different facilities, which is a major limitation for most of the current studies. Health care organizations are complex systems and discharge process is a complex task. We need to use systems thinking approaches to implement a change. Even if we can identify the exact causes of readmissions, it will not be easy to control all of the determinants in the discharge period. Therefore, readmissions will be inevitable. Until the availability of further evidence, readmission rates will stay as a quality indicator.

References:

1. Kaboli PJ, Go JT, Hockenberry J, Glasgow JM, Johnson SR, Rosenthal G, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med. 2012;157:837-845.

2. Bueno H, Ross JS, Wang Y, Chen J, Vidan MT, Normand SLT, et al. Trends in LOS and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006. JAMA. 2010;303(21):2141-2147.

3. Koehler BE, Richter KM, Youngblood l, Cohen BA, Prengler ID, Cheng D, et al. Reduction of 30-day post-discharge hospital readmission or ED visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4:211-218.

4. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med. 2009;150:178-187.

5. Society of Hospital Medicine. BOOSTing Care Transitions Resource Room. Available at: http://www.hospitalmedicine.org. Accessed December, 2012.6. Vree Health Posts. Available at www.vreehealth.com Accessed December, 2012.

Reduced All-cause Mortality May Result Not From Reduced LOS But From Other Causes.
Posted on December 26, 2012
Ronald N. Levy, MD
Conflict of Interest: None Declared

Three questions are raised by the interesting report of Kaboli and colleagues "suggesting," in the words of the report, "that as LOS improved, hospital readmission did not increase."

1.  Kaboli states that "hospital readmission is being used as a quality indicator and may result in payment incentives."  Could these payment incentives have provided incentives not to readmit when it was a close call whether to readmit or not?

2.  Kaboli says "LOS improved" referring to length of stay.  Could seeing shorter LOS as "improved" increase hospital efforts to shorten LOS?

3.  Kaboli reports "all-cause mortality 90 days after admission was reduced by 3% annually."  Is it possible that this reduction resulted not from reduced LOS but from increased quantity and quality of post-discharge care?

"I'll never again eat turkey sandwiches" a patient may say following chemotherapy during which the patient had turkey sandwiches and later lost hair.  But just as alopecia may result not from eating turkey but from a different cause, reduced all-cause mortality in the Kaboli study may result not from reduced LOS but from other causes.

 

Hospital Length-of-Stay
Posted on January 16, 2013
John Glaser
(Unaffiliated)
Conflict of Interest: None Declared

To the Editor:

Dr. Kaboli and colleagues have shown that during the past 14 years when hospital length-of-stay has decreased, the hospital readmission rate (for all diseases combined) also has decreased (1). However, for particular diseases, readmission rates have increased: For drug abuse, readmission rose from 12.4% in 1997 to 15.4% in 2010. For alcohol abuse, readmission rose from 14.6% to 15.7%. And for peripheral vascular disease (PAD), readmission rose from 18.1% to 24.6%. Together these three diseases accounted for 20% of the readmissions in 2010.

If we consider that smoking is a primary risk factor for PAD, then patients with any of these diseases – drug abuse, alcohol abuse, and PAD – can be helped by the resources available in the hospital (physicians, nurses, pharmacists, and behavioral psychologists) to reduce cravings and support them through the withdrawal stage. But this help may have been less effective when the length-of-stay was decreased.

Because hospital readmission is being used as a quality indicator and may affect payments to hospitals from Medicare, it might be to their advantage (and to the patients’ advantage) for hospitals to allow a longer length-of-stay for the three diseases noted above.

John H. Glaser

Lexington, MA

E-mail: jhgstat@aol.com

Reference

1. Kaboli PJ, Go JT, Hockenberry J, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 veterans affairs hospitals. Ann Intern Med.2012;157:837-845.

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