DURHAM, N.C. -- Hospitals could safely discharge patients with low-risk heart attacks within three days, but most keep them five days or more, Duke University researchers report in the March 16 issue of The New England Journal of Medicine.
That inefficient use of resources costs hundreds of millions of dollars each year, the Duke study says.
Cardiologist Kristin Newby and her colleagues studied the records of more than 40,000 patients who had participated in the GUSTO I trial (1990-1993) and found that almost 60 percent had "uncomplicated" or low-risk heart attacks. That meant they did not suffer a second heart attack, have recurrent angina, need emergency bypass or balloon angioplasty, experience heart failure, stroke, shock or die within the first three days following their heart attack.
Because economic pressures, such as managed care, are pushing hospitals to discharge patients sooner than ever before, the Duke researchers were curious about whether shorter stays would affect patient outcomes.
"There is no data now on how long these uncomplicated patients should stay in the hospital, either in terms of best practices or cost," Newby said. "We know that complications after three days in the hospital are rare for low-risk heart attacks, so we wanted to find out what it meant, in terms of both costs and outcomes, to keep the patients hospitalized for a longer period." Newby and colleagues looked at complications that occurred on the fourth hospital day in the more than 22,000 patients who fit the low-risk criteria. They found 16 patients suffered from a severe heart abnormality called ventricular fibrillation and three died, but the other 13 survived because they received emergency treatment in the hospital. Had they been at home, the researchers projected that all 16 would have died.
Since these 16 patients could not be identified before their life-threatening complication, saving them by keeping them hospitalized would require keeping all 22,000 low-risk patients in the hospital for an extra day. The cost of the fourth hospital day was close to $12 million. The standard measure for evaluating the value, or cost effectiveness, of medical therapies is the cost to society to add a year of life with the treatment in question. In the case of low-risk heart attack patients, saving 16 patients by keeping more than 22,000 hospitalized for one extra day translates into a cost of more than $105,000 to society to save one extra year of life for this group of heart attack patients.
"In general, society has accepted the cost of $50,000 per year of life saved, the cost of dialysis treatment for kidney failure, as an amount it is willing to pay for health care," said Dr. Daniel B. Mark, M.D., M.P.H., professor of medicine and the study's senior investigator. "Treatments that cost over $100,000 per year of life saved, like this one, are generally considered inadequate value for the money."
So why don't hospitals discharge these patients after 72 hours? The Duke investigators think inefficiency is one key reason. "Most hospitals aren't currently able to compress the care they give into fewer, highly productive days," Newby said. "That would require a major reorientation, such as having key diagnostic tests performed on weekends."
So despite its tremendous societal costs and relatively small clinical benefit, for now the fourth hospital day may remain standard for uncomplicated heart attack patients.
"It looks like that extra day doesn't buy us a whole lot, but if all of the care a patient needs, such as tests, procedures and education, can't be delivered in a three-day period, we may need to continue the practice," Newby concluded. "It is critical to make sure that the quality of these patients' care is not shortchanged in the name of efficiency. At present, the medical system is not prepared to handle the critical initial testing and education of these patients in an outpatient setting."
Journal
New England Journal of Medicine