AHA Feature: Predicting HF length of stay from the ER is difficult

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The ability to predict how long a heart failure (HF) patient will stay in the hospital upon arrival in the emergency room is very limited, according to a poster presentation at American Heart Association (AHA) Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke held in Washington, D.C., last week.

HF admissions are frequent, resulting in significant expenditures. Identifying predictors of increased length of stay (LOS), particularly above the median LOS, may help providers set expectations for patients and target resources effectively, according to David Whellan, MD, from the Jefferson Heart Institute in Philadelphia, and colleagues.

Thirty-day readmission rates for HF are widely discussed in healthcare. Medicare has mandated the need to reduce 30-day readmission rates. "The Centers for Medicare & Medicaid Services sees readmissions as a failure of the initial admission," Whellan told Cardiovascular Business News.

The impetus for this study, according to Whellan, was the researchers' interest in HF observational units. "Observational units are a way to manage patients when they come back to the emergency room. An observational unit is not considered an admission. It's an outpatient service and is a less expensive and more efficient way to manage these patients," he said.

Whellan and colleagues analyzed approximately 70,000 HF admissions from January 2005 through April 2007 from 246 hospitals in the AHA's Get with the Guidelines-HF program.

Approximately 32,000 patients left the hospital before four days. There was no single baseline characteristic that could reliably define which patients would leave under four days and which patients would stay longer than four days, Whellan said.

"The problem with trying to assess these patients in the ER is you have to make a decision about who is going to be here for a long time versus a short time. This study says we can't do that," he said. "For policymakers and practitioners, they need to recognize that whatever treatment strategy they will implement, they won't know which patients will be there for a long or short time."

However, when lab values were added, the characteristic that seemed to have the most influence for LOS was kidney function. Even without the lab values, the strongest was renal insufficiency, Whellan said.

Characteristics that researchers looked at included admission BUN, systolic blood pressure at admission, heart rate, history of chronic obstructive pulmonary disease, gender, history of renal insufficiency, history of HF and geographic region.

"HF admissions are a great opportunity to educate patients, but we need time to do. This study suggests that we can't determine the length of stay at the beginning of admission to the emergency room. Practitioners should know this so that they allocate their resources wisely," Whellan said.