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Has Length of Stay Declined Too Far?

David W. Baker, MD, MPH; Doug Einstadter, MD, MPH; Scott S. Husak, BS; Randall D. Cebul, MD

Arch Intern Med. 2004;164:538-544.

Background  Length of hospital stay continues to decline, but the effect on postdischarge outcomes is unclear.

Methods  We determined trends in risk-adjusted mortality rates and readmission rates for 83 445 Medicare patients discharged alive after hospitalization for myocardial infarction, heart failure, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, pneumonia, or stroke. Patients were stratified into deciles of observed/expected length of stay to determine whether patients whose length of stay was much shorter than expected had higher risk-adjusted mortality and readmission rates. Analyses were stratified by whether a do-not-resuscitate (DNR) order was written within 2 days of admission (early) or later.

Results  From 1991 through 1997, risk-adjusted postdischarge mortality generally remained stable for patients without a DNR order. Postdischarge mortality increased by 21% to 72% for patients with early DNR orders and increased for 2 of 6 diagnoses for patients with late DNR orders. Markedly shorter than expected length of stay was associated with higher than expected risk-adjusted mortality for patients with early DNR orders but not for others (no DNR and late DNR). Risk-adjusted readmission rates remained stable from 1991 through 1997, except for a 15% (95% confidence interval, 3%-30%) increase for patients with congestive heart failure. Short observed/expected length of stay was not associated with higher readmission rates.

Conclusions  The dramatic decline in length of stay from 1991 through 1997 was not associated with worse postdischarge outcomes for patients without DNR orders. However, postdischarge mortality increased among patients with early DNR orders, and some of this trend may be due to patients being discharged more rapidly than previously.

From the Center for Health Care Research and Policy (Drs Baker, Einstadter, and Cebul and Mr Husak) and Department of Medicine (Drs Baker, Einstadter, and Cebul), Case Western Reserve University at MetroHealth Medical Center; and Department of Epidemiology and Biostatistics, Case Western Reserve University (Drs Baker, Einstadter, and Cebul), Cleveland, Ohio. Dr Baker is now with the Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill. The authors have no relevant financial interest in this article.

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