Shorter lengths of stay may mean higher mortality after hip fracture

This study in BMJ just dropped a bomb:

Setting Population greater than or equal to 50 years old living in Sweden as of 31 December 2005 with a first hip fracture the years 2006-12.

Participants 116 111 patients with an incident hip fracture from a closed nationwide cohort.

Main outcome measure Death within 30 days of hospital discharge in relation to hospital length of stay after adjustment for multiple covariates.

Results Mean inpatient length of stay after a hip fracture decreased from 14.2 days in 2006 to 11.6 days in 2012 (P less than 0.001). The association between length of stay and risk of death after discharge was non-linear (P less than 0.001), with a threshold for this non-linear effect of about 10 days. Thus, for patients with length of stay of less than or equal to 10 days (n=59 154), each 1-day reduction in length of stay increased the odds of death within 30 days of discharge by 8% in 2006 (odds ratio 1.08 (95% confidence interval 1.04 to 1.12)), which increased to16% in 2012 (odds ratio 1.16 (1.12 to 1.20)). In contrast, for patients with a length of stay of greater than or equal to 11 days (n=56 957), a 1-day reduction in length of stay was not associated with an increased risk of death after discharge during any of the years of follow up.

Limitations No accurate evaluation of the underlying cause of death could be performed.

Conclusion Shorter length of stay in hospital after hip fracture is associated with increased risk of death after hospital discharge, but only among patients with length of stay of 10 days or less. This association remained robust over consecutive years.

That ought to make administrators and policy makers uneasy.

ACP Hospitalist Weekly quotes this from a related editorial:

The authors of an accompanying editorial discussed the trend in modern health care toward shorter lengths of stay and said that "it is far from clear that reductions in length of stay do not cause harm."

Indeed. That's been a nagging elephant in the room in the United States ever since the Prospective Payment System went into effect in 1984. The concern has not been addressed as it should be although there is a recently emerging literature showing that short lengths of stay in heart failure patients are associated with worse outcomes.