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Acute Care Hospitalization

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Studies show shorter hospital stays for coronary bypass surgery reduce costs without harm to patients

During the 1990s, postoperative stays after coronary artery bypass graft surgery (CABG) became substantially shorter as hospitals took patients off assisted ventilation earlier and mobilized them earlier. A study of New York hospitals found that postoperative length of stay (LOS) for CABG patients declined by 2 days between 1992 and 1998. A second study of New York hospitals concluded that the trend toward early discharge of CABG patients decreased cumulative 60-day costs without adversely affecting patient outcomes. Both studies were led by Patricia A. Cowper, Ph.D., of the Duke Clinical Research Institute, and were supported by the Agency for Healthcare Research and Quality (HS10279). They are briefly described here.

Cowper, P.A., DeLong, E.R., Hannan, E.L., and others (2006, December). "Trends in postoperative length of stay after bypass surgery." American Heart Journal 152, pp. 1194-1200.

The median postoperative length of stay for CABG patients with similar health risks declined 30 percent (about 2 days) at New York hospitals between 1992 and 1998, according to this study. The downward shift was observed across the entire distribution of postoperative LOS and was achieved in part by an increase in transfer of patients to nonacute care settings following surgery.

For example, the probability of transfer to nonacute settings increased from 4 percent in 1992 to 12 percent in 1998. Older patients were more likely to be transferred to nonacute care facilities. Other factors that increased the likelihood of transfer to nonacute care instead of discharge home were female gender, black race, urgency of procedure, severity of cardiac illness, impaired kidney function, diabetes, and prior stroke.

This shifting of care to the less expensive nonacute setting may well represent more efficient care patterns, assuming clinical outcomes are not compromised, note the researchers. They also found that hospitals accounted for 13 to 20 percent of the variation in postoperative LOS that was unexplained by patient characteristics.

During the period of declining stays, hospital variability in CABG postoperative LOS first increased sharply and then fell to lower levels than initially observed, suggesting a new standard for the hospital care of bypass surgery patients. The findings were based on analysis of data from the New York Cardiac Surgery Reporting System and New York Statewide Planning and Research Cooperative System.

Cowper, P.A., DeLong, E.R., Hannan, E.L., and others (2007, January). "Is early too early? Effect of shorter stays after bypass surgery." Annals of Thoracic Surgery 83, pp. 100-107.

This study of New York hospitals suggests that early discharge (postoperative stay below the 15th percentile for patients with similar risk profiles) did not adversely affect the outcomes of elderly CABG patients, but did lower cumulative 60-day costs. From 1995 to 1998, New York hospitals varied in their tendency to discharge CABG patients early.

Although 17 percent of patients overall were discharged early, early discharge varied from 2 percent of CABG patients at some hospitals to 42 percent at other hospitals. Patients who were discharged home early were no more likely to die or be readmitted to the hospital within 60 days of discharge than those with more typical lengths of stay.

In addition, CABG patients who were discharged early had lower postdischarge costs (mean of $3,491 vs. $5,246). This resulted in average cumulative savings of $6,309. Early discharge patients had lower rates of physician, home health, and skilled nursing use than those with typical postoperative stays. Only outpatient hospital costs were higher among patients discharged early, owing to their greater use of physical therapy services.

These results suggest that physicians are successfully identifying appropriate candidates for early discharge. The study was based on analysis of clinical data from the New York Cardiac Surgery Reporting System and claims and mortality data from Medicare and New York State for 55,889 New York CABG patients discharged home from 1995 to 1998.

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