Getting patients out of the hospital quickly doesn't have to hurt care, a new study suggests. The study looked at 129 Department of Veterans Affairs (VA) hospitals. It covered a 14-year period ending in 2010. In that time, the average length of stay in the hospital dropped 27%. Researchers had thought that the rate of readmission -- returning to the hospital within 30 days -- might increase. But readmissions also dropped. This suggests that most people were not discharged too early. Deaths within 30 and 90 days after leaving the hospital also dropped. Researchers said some aspects of the VA system may help explain the results. Medical care in VA hospitals is provided by hospitalists. These are doctors who care only for people in the hospital. They don't see patients in an office. The use of hospitalists has been linked with higher quality of care. The VA system also has strong links between hospitals and doctor's offices to coordinate care after people go home. The journal Annals of Internal Medicine published the study. HealthDay News wrote about it December 17.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

For most patients admitted to the hospital, two things determine how much insurance companies pay:

• The diagnosis
• Whether the illness is more or less severe

In general, the payment amount does not change based on how long someone is in the hospital.

But the longer a patient stays in the hospital, the more costly it is for the hospital. So it makes sense that hospitals have tried for years to lower the lengths of hospital stays. Many have assumed that this push has led to an increase in hospital readmissions and reduced the quality of care.

The results of this study provide some reassurance that these assumptions are not correct. In fact, the opposite appears to be the case, at least in Veterans Affairs hospitals.

The researchers looked at more than 4 million hospital admissions over a 14-year period. During that time, the average number of days spent in the hospital (length of stay) decreased by about 27%. And instead of going up, hospital readmissions (people returning to the hospital) within 30 days went down by 25%. One statistic reflecting the quality of care also was reassuring. The percentage of deaths within 90 days of discharge from the hospital was actually lower at the end of the study.

Several possible reasons could explain why lengths of stay went down without increasing readmissions:

• Patients may have remained in the hospital longer than was necessary when the study started. Reducing inefficiency could shorten lengths of stay without harm to patients.
• VA hospitals started a new program to help people make sure they take their medicines regularly after discharge. This is called medication reconciliation. Such programs have been shown to decrease readmissions. They are standard in most American hospitals today.
• The VA switched to a hospitalist model. Hospitalists are doctors who only take care of patients in the hospital. They spend all day there instead of running back and forth between their office practice and the hospitals. Hospitals that use hospitalists have shorter lengths of stay. They also have improved measures of quality of care.

What Changes Can I Make Now?

If you need to go into the hospital. there are good reasons that you should want to be discharged as soon as it is safe. A longer hospital stay increases your risk of:

• Developing a hospital-related infection. It can be much more serious than the typical infections you get outside the hospital.
• Forming a blood clot in your leg.
• Losing some of your strength and stamina. After a couple of days of being in bed in a hospital, your muscles start to weaken. You also tend not to breathe as deeply. These factors increase your risk of developing hospital-acquired pneumonia.

You can help make your hospital stay as short as possible and decrease the chance that you will need to come back. Here's what you can do:

• On the day of admission or the following day, ask your nurse and doctor when you will be able to go home. This sounds rushed and they might be vague about a date. But it makes your doctor and nurse aware of your wishes.
• Know the main goal or goals to be achieved while you are in the hospital. This will help you focus on what you can do to speed up your release. You will also understand why your doctor ordered certain tests and therapies.
• Get out of bed as much as the nurse allows. Sit in a chair. Take frequent walks.
• Make sure you have arranged for a ride home. Don't wait until the last minute. If you need help with transportation, let your nurse know right away.
• Before you leave the hospital, review your medicines with a pharmacist, if available. If not, review with your doctor as well as your nurse.
• Request that follow-up appointments be made with your primary care doctor and any specialists before discharge.

What Can I Expect Looking to the Future?

Hospitals will continue to look for ways to improve efficiency of care while maintaining high quality. Reducing hospital readmissions will be the greater challenge in the future.

People with multiple long-lasting conditions are living longer. Despite excellent care, they will have times when they become too sick to treat themselves at home. Often they would rather not go into the hospital. And given the high cost of in-hospital care, we likely will see what was common many years ago -- the doctor coming to the house.