The rate of cardiovascular or heart failure (HF) readmission may increase in patients hospitalized for HF despite the length of their stay, according to a study published May 10 in JACC: Heart Failure.

Maneesh Sud, MD, et al., used the Canadian Institute for Health Information Discharge Abstract Database to identify 58,230 elderly patients residing in Ontario, Canada who were hospitalized for HF between April 1, 2003 and March 31, 2012, and whose length of stay ranged from one to 14 days.

The authors found that when length of stay was modeled as a continuous variable, its association with risk of cardiovascular or HF readmissions was non-linear and U-shaped. Yet, when analyzed as a categorical variable, there was a higher rate of readmission for a length of stay shorter and longer than 5-6 days (cardiovascular readmission: 1-2 days; adjusted hazard ratio [HR] 1.12, 95 percent CI; 1.04-1.21, p=0.003 and 9-14 days; adjusted HR 1.11, 95 percent CI; 1.04-1.19, p=0.002 vs. HF readmission: HR 1.15, 95 percent CI; 1.04-1.27, P=0.006 and HR 1.14, 95 percent CI; 1.04-1.25, p=0.004). 

In comparison, the risk of non-cardiovascular readmission decreased with shorter lengths of stay and increased with longer lengths of stay (HR 0.87, 95 percent CI; 0.79-0.96, p=0.006 vs. HR 1.17, 95 percent CI; 1.07-1.129, p<0.001). The risk of cardiovascular and non-cardiovascular mortality was highest for patients whose length of stay exceeded eight days (HR 1.28, 95 percent CI, 1.14-1.43, p<0.001).

The authors explain that they did not find a causal link between length of stay and readmission or mortality. They also did not directly challenge strategies aimed at reducing length of stay, which have been adopted by facilities to reduce costs and avoid financial penalties for failing to meet expected rates of readmission.

"Our data underscore the need for further examination of short and long length of stay patients with the aim of developing targeted approaches to mitigate readmission risk," the authors conclude. They also suggest evaluating the impact of post-discharge strategies, including early physician follow-up and transitional care.

In a related editorial comment, Gregg C. Fonarow, MD, FACC, and Boback Ziaeian, MD, PhD, FACC, note that "highlighting 30-day readmissions as both an outcome, measurable metric, and basis for financial penalties is rife with conceptual difficulties." They add that "Much of the relationship between [length of stay] and outcomes relates to patient complexity and factors unmeasured in administrative or clinical data." Moving forward, they explain that "readmissions should not be the sole focus of our prevention efforts, rather the prevention of the initial and all hospitalizations should be the goal."

Keywords: Aged, Follow-Up Studies, Heart Failure, Hospitalization, Length of Stay, Ontario, Patient Discharge, Patient Readmission, Proportional Hazards Models

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