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Shorter hospital length of stay not associated with worse outcomes for patients without DNR orders

Although the amount of time that patients spent in the hospital declined dramatically between 1991 and 1997, this decline did not seem to result in worse outcomes for patients after discharge, according to research funded by the Agency for Healthcare Research and Quality (AHRQ grant HS09969).

The researchers, led by David Baker, M.D., M.P.H., of Feinberg School of Medicine, Northwestern University, examined trends in the risk of death during the 30 days after discharge for 83,895 Medicare patients hospitalized between 1991 and 1997. They analyzed data for patients at all 30 non-Federal hospitals in greater metropolitan Cleveland discharged alive with a principal diagnosis of acute myocardial infarction, congestive heart failure, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, pneumonia, or stroke.

Overall, the researchers found no evidence that shorter length of stay was associated with higher rates of death or readmission after discharge. However, trends varied depending upon whether a DNR order was written. For patients who did not have a DNR order written, the risk of death during the 30 days after discharge generally remained stable over the study period. However, post-discharge mortality increased between 1991 and 1997 among patients with pneumonia, acute myocardial infarction, or stroke who had a DNR order written on the first or second hospital day.

The researchers believe the findings provide some reassurance that it is possible to reduce length of stay without jeopardizing patients' health. However, the findings for patients with early DNR orders raise concern. The increasing post-discharge mortality rate could reflect positive changes in end-of-life care, such as more widespread use of hospice, or this could indicate a decline in the quality of care for patients who are terminally ill. The researchers caution that additional studies are needed to examine whether in-hospital quality of care for patients with DNR orders has declined.

Details are in "Trends in post-discharge mortality and readmissions: Has length of stay declined too far?" by Dr. Baker, Doug Einstadter, M.D., M.P.H., Scott S. Husak, B.S., and Randall D. Cebul, M.D., in the March 8, 2004, issue of Archives of Internal Medicine 164, pp. 538-544.

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