Short Hospital Stay for Pulmonary Embolism Linked to Increased Mortality Rate

A short hospital length of stay (LOS) for pulmonary embolism (PE) is associated with an increased risk for postdischarge mortality, according to the results of a study reported in the April 14 issue of the Archives of Internal Medicine.

"The optimal length of stay (LOS) for patients with pulmonary embolism (PE) is unknown," write Drahomir Aujesky, MD, MSc, from the University of Lausanne in Switzerland, and colleagues. "Although reducing LOS is likely to save costs, the effects on patient safety are unclear. We sought to identify patient and hospital factors associated with LOS and assess whether LOS was associated with postdischarge mortality."

The investigators analyzed data from patients discharged with a primary diagnosis of PE from January 2000 through November 2002 from 186 acute care hospitals in Pennsylvania. The relationships between patient and hospital factors and the time to discharge and between LOS and postdischarge mortality within 30 days of presentation were determined with discrete survival models that adjusted for patient and hospital factors.

Median LOS was 6 days, and postdischarge mortality rate was 3.3%, among 15,531 patients who were discharged with a primary diagnosis of PE. Patients from Philadelphia were less likely to be discharged on a given day (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.73 - 0.93), based on multivariate analysis. Findings were similar for black patients (OR, 0.88; 95% CI, 0.82 - 0.94).

Greater severity of illness and lack of private health insurance were associated with markedly decreased odds of discharge. Compared with patients who had an LOS of 5 to 6 days, those with an LOS of 4 days or less had a significantly higher adjusted postdischarge mortality rate (OR, 1.55; 95% CI, 1.21 - 2.00).

"Several hospital and patient factors were independently associated with LOS," the study authors write. "Patients with a very short LOS had greater postdischarge mortality relative to patients with a typical LOS, suggesting that physicians may inappropriately select patients with PE for early discharge who are at increased risk of complications."

Limitations of this study include identifying the patient sample using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for PE rather than accepted clinical criteria; absence of other prognostic factors for PE in the databases; lack of information on clinical stability at the time of discharge or on processes of care potentially associated with LOS and postdischarge mortality; lack of data on nonfatal complications that occurred in the hospital and on socioeconomic factors associated with reduced adherence; lack of data about specific causes of death; exclusion of deaths that occurred during the hospital stay; short follow-up; and inability to exclude the possibility that changing practice patterns may have affected the results.

"Prognostic models and the development of explicit discharge criteria may be helpful to identify patients with PE who can be safely discharged early," the study authors conclude.

In an accompanying editorial, Daniel J. Brotman, MD, and Peter K. Lindenauer, MD, MSc, from Johns Hopkins Hospital in Baltimore, Maryland, note that this study raises important questions about the safety of early discharge that may also apply to other diseases.

"For any potentially lethal condition, we need evidence-based criteria for discharge similar to those criteria that have been developed for other diseases, such as pneumonia," Drs. Brotman and Lindenauer write. "Such criteria should include not only clinical stability but also the quality and accuracy of the inpatient-to-outpatient care transition. Without such tools and strategies, our rush to discharge patients quickly may jeopardize the trust placed in our hands, especially when patients and their families see real challenges and risks associated with going home too soon."

The National Heart, Lung, and Blood Institute, Bethesda, Maryland, and the National Institute of Allergy and Infectious Diseases, Bethesda, supported this study. One of the study authors has obtained funding. The other study authors have disclosed no relevant financial relationships. Drs. Brotman and Lindenauer have disclosed no financial relationships.

Arch Intern Med. 2008;168:683-684, 706-712.