Unanticipated Consequences: Shorter Hospitalizations and More Readmissions

A JAMA article last week showed that shorter lengths of stays for congestive heart failure over the last decade and a half have been associated with higher levels of readmissions.  

The study is impressive.  In each time period there are close to a million fee for service Medicare members admitted, and data is presented both with risk adjustment and in raw form. (The numbers are so large that the risk adjustment doesn't matter so much).  The study was based on claims data only, and the press accounts I've read have emphasized that this data represents a failure of the health care delivery system

We can do better.  Studies have shown that a simple intervention like a post-discharge phone call can prevent  many readmissions  The good news is there is a real spotlight on hospital readmissions, since Medicare will start paying hospitals with high readmission less in 2014.

There is good news in this study that  has been largely overlooked. Mortality rates have tumbled dramatically.

What does this mean for readmissions?  Those surviving initial hospitalization are dramatically sicker.  (Indeed, 53% more are being discharged to nursing facilities). These patients with more serious underlying disease might in fact be more likely to be readmitted to the hospital regardless of length of stay.  It's also possible that the increase in discharge to nursing homes with vigilant professionals picks up more patient decompensation - so some who might have died at home are transferred for yet another hospitalization.

Society is getting a higher survival rate because health care for those with late-stage congestive heart failure has improved dramatically since the 1990s.  The additional quality adjusted life years we are gaining are not coming without cost.