Clinical question

Does decreased length of stay result in increased risk of 30-day readmission for hospitalized patients with acute medical illness?

Bottom line

Reduction in length of stay (LOS) is not associated with increased risk of 30-day readmission for patients with acute medical illness. Although this may suggest that decreased LOS does not affect quality of care, this finding may also be due to improved efficiencies in a previously inefficient Veteran Affairs (VA) system leading to earlier discharges and increased efforts at bettering transitions of care. LOE = 2b

Reference

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(12):837-845.

Study design

Cohort (retrospective)

Funding source

Government

Allocation

Uncertain

Setting

Inpatient (any location)

Synopsis

To determine whether reductions in LOS adversely affect 30-day readmission rates, these investigators used a national VA administrative database to identify all acute medical admissions to VA hospitals from 1997 to 2010. Patients who died, were transferred to another acute care facility, or whose LOS was longer than 30 days were excluded from consideration. Readmissions were defined as those that were linked to the index admission and occurred within 30 days of discharge. The cohort consisted of more than 4 million admissions and was further subdivided into 5 high-volume diagnoses: heart failure, chronic obstructive pulmonary disease (COPD), heart failure, acute myocardial infarction (AMI), community-acquired pneumonia, and gastrointestinal bleed. After adjusting for hospital and patient characteristics, LOS decreased during the 14-year period from 5.44 days to 3.98 days, and 30-day readmission rates decreased from 16.5% to 13.8%. Among the 5 high-volume conditions, LOS decreased the most for AMI (by almost 3 days) while readmission rates decreased the most for COPD (3.3%). Further analysis of all medical conditions showed that each additional day of stay resulted in a 3% increased rate of readmission. This was likely due to unmeasured severity of illness that affected both LOS and readmission. Of note, however, hospitals that had a mean LOS lower than the average LOS across all hospitals had higher readmissions rates (6% increase for each day lower than the average). Despite this, the overall readmission rate decreased over time as LOS decreased. All-cause mortality at 30 days and 90 days also improved over time.