Worries regarding short length of stay (LOS) adversely impacting quality of care prompted us to assess the relation between hospital LOS and inpatient guideline adherence in patients with acute coronary syndrome. We used the American Heart Association’s Get with The Guidelines (GWTG)—Coronary Artery Disease data set. Data were collected from January 2, 2000, to March 21, 2010, for patients with acute coronary syndrome from 405 different sites. Of the 119,398 patients in the study, the mean LOS was 5.5 days with a median of 4 days. There was no difference in the LOS on the basis of hospital size, hospital type, or cardiac surgery availability. The population with an LOS <4 days were younger (63.8 ± 14.1 vs 70 ± 14.5, p <0.0001), men (63.8% vs 55.3%, p <0.0001) and had fewer clinical co-morbidities. The overall adherence was high in the GWTG participating hospitals. Those with the LOS <4 days were more likely to receive aspirin (adjusted odds ratio [OR] 1.12, 95% CI 1.06 to 1.19; p <0.001), clopidogrel (OR 1.77, 95% CI 1.60 to 1.95; p <0.001), lipid-lowering therapy if indicated (OR 1.13, 95% CI 1.05 to 1.21; p <0.001), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for left ventricular systolic dysfunction (OR 1.10, 95% CI 1.01 to 1.21; p = 0.04) and smoking cessation counseling (OR 1.17, 95% CI 1.1 to 1.24; p <0.001) compared to those with the LOS ≥4 days. In contrast, those with the LOS <4 days were less likely to receive beta blockers (OR 0.88, 95% CI 0.84 to 0.93; p <0.001). The odds of receiving defect-free care were greater for patients with the LOS <4 days (OR 1.15, 95% CI 1.1 to 1.21; p <0.001). In conclusion, in GWTG participating hospitals, a shorter LOS did not appear to adversely affect adherence to discharge quality of care measures.
In the year 2009, 1.19 million inpatients were discharged with a primary or secondary diagnosis of acute coronary syndrome (ACS). The American College of Cardiology and the American Heart Association have published guidelines in regards to quality of care measures for this ACS population. These guidelines include: aspirin, clopidogrel, β blockers, lipid-lowering medications, along with smoking cessation counseling to name a few. These interventions have shown to improve outcomes in the ACS population in various studies. Despite the proved efficacy of these measures and implicit guideline recommendations, there still exists a gap between these recommendations and actual clinical practice. Also, in today’s practice environment, with many cost-saving measures in place, there is a strong push to discharge patients as soon as possible. Recent data have shown a steady decrease in length of stay (LOS) for ACS over the past decade. A worry of clinicians has been that a “push” to quickly discharge patients in an effort to save money, might adversely impact quality of care. Our aim was to assess the relation between hospital LOS and inpatient guideline adherence in patients with ACS.
Methods
We used the American Heart Association’s Get With The Guidelines (GWTG) – Coronary Artery Disease data set. The components of the GWTG program, previously described, include organizational stakeholder and opinion leader meetings, hospital recruitment, collaborative learning sessions, hospital tool kits, local clinical champions, and hospital recognition. The GWTG database measures hospitals’ adherence to secondary prevention guidelines (pharmacologic and lifestyle interventions) for coronary artery disease, heart failure, and stroke. This study included 119,398 patients admitted with ACS at 405 hospitals from January 2, 2000, to March 21, 2010.
Measures assessed in GWTG-Coronary Artery Disease have been previously described. Performance measures were evaluated on the basis of time of discharge. Definitions for aspirin, β blockers, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB) in patients with left ventricular systolic dysfunction (LVSD), and smoking cessation counseling were based on the Joint Commission specifications. An additional performance measure, ACEI/ARB use in all patients with ACS at all levels of left ventricular function, was evaluated using the Joint Commission criteria except for ejection fraction percentage. New lipid-lowering therapy was defined as the percentage of patients who had a low-density lipoprotein (LDL) cholesterol >100 mg/dl without previous treatment, discharged on lipid-lowering therapy. Composite performance measure for 100% compliance was defined as patients discharged on all the following: aspirin, β blockers, ACEI/ARB in patients with LVSD, smoking cessation counseling, and lipid-lowering therapy for LDL cholesterol >100 mg/dl.
Quality of care measures and the characteristics of both the patients and participating hospitals were described by LOS groups. LOS was dichotomized above and below the median; <4 days and ≥4 days. For descriptive analyses, medians (25th and 75th percentiles) were reported for continuous variables and percentages for categorical variables. Comparisons between patients with shorter and longer LOS were made using the Pearson’s chi-square test for categorical variables and Kruskal–Wallis test for continuous variables. The change of LOS over calendar years was tested using Cochran–Mantel–Haenszel nonzero correlation statistic. Multivariate regression analysis was performed to examine the effect of LOS on the use of evidence-based treatments. A secondary analysis was performed after excluding surgically revascularized patients. All statistical analyses were performed using SAS software, version 9.1, (SAS Institute Inc., Cary, North Carolina).
Results
Data were collected from January 2, 2000, to March 21, 2010, for patients with ACS from 405 different sites. Of the 119,398 patients in the study, the mean LOS was 5.5 days with a median (25th and 75th percentiles) of 4 (2 to 7) days and 54% of patients were discharged at ≥4 days. Hospital characteristics are outlined in Table 1 . There was no difference in the LOS on the basis of hospital size, hospital type, or cardiac surgery availability. Hospitals with LOS <4 days were those with residents, sites with primary percutaneous intervention for ST-elevation myocardial infarction and interventional hospitals. Also, those in the Northeast and South were less likely to have an LOS <4 days compared with the other regions in the country. Patient characteristics are listed in Table 2 . Compared with patients treated medically and by percutaneous coronary intervention (PCI), the mean LOS was significantly longer in patients treated with coronary artery bypass grafting (CABG; 11.4 days vs 4.1 and 5.8 days in PCI and medically treated patients). The population with the LOS <4 days were younger (63.8 ± 14.4 vs 70 ± 14.0, p <0.0001), men (63.8% vs 55.3%, p <0.0001) and had fewer clinical co-morbidities.
| Variable | Total (N = 119,398) | Length of Stay (Days) | P-Value | ||
|---|---|---|---|---|---|
| < 4 (N = 55,408) | ≥ 4 (N = 63,990) | ||||
| Bed Size | Median (25%, 75%) | 340(228,505) | 346(228,505) | 338(228,505) | 0.52 |
| STD | 250.32 | 247.31 | 252.88 | ||
| N | 117499 | 54511 | 62988 | ||
| Residents | 44631 (37.4%) | 21016 (37.9%) | 23615 (36.9%) | <0.0001 | |
| Primarily PCI for STEMI | 106869 (89.5%) | 49727(89.8%) | 57142 (89.3%) | 0.0004 | |
| Cardiac Surgery Available | 95783 (80.2%) | 44281 (79.9%) | 51502 (80.5%) | 0.1329 | |
| Heart Transplant Center | 12897 (10.8%) | 5999 (10.8%) | 6898 (10.8%) | 0.6759 | |
| Interventional Hospital | 87823 (73.6%) | 41003 (74.0%) | 46820 (73.2%) | 0.0462 | |
| Hospital Type – Academic | 66781 (55.9%) | 31011 (56.0%) | 35770 (55.9%) | 0.6382 | |
| Region | Northeast | 20562 (17.2%) | 8246(14.9%) | 12316(19.3%) | <0.0001 |
| Midwest | 33013 (27.7%) | 15548(28.1%) | 17465(27.3%) | ||
| South | 37901 (31.7%) | 16729(30.2%) | 21172(33.1%) | ||
| West | 27922 (23.4%) | 14885(26.9%) | 13037(20.4%) | ||
| Length of Stay (Days) | P-Value | ||
|---|---|---|---|
| < 4 | ≥ 4 | ||
| Patients | 55,408 | 63,990 | |
| Age, (yrs) (SD) | 63 (53, 75) | 67 (56, 79) | <0.0001 |
| Male | 63.8% | 55.3% | <0.0001 |
| Race/Ethnicity | |||
| White | 73.4% | 72.4% | <0.0001 |
| Black | 7.7% | 9% | |
| Hispanic | 7.8% | 7.9% | |
| Diabetes, Insulin | 2126 (4.2%) | 3542(5.9%) | <0.0001 |
| Diabetes, Non-Insulin | 4127 (8.1%) | 5399(9.0%) | <0.0001 |
| Atrial Fibrillation | 2765 (5.5%) | 6470 (10.8%) | <0.0001 |
| Hypertension | 33686(66.4%) | 43174 (72.1%) | <0.0001 |
| Hyperlipidemia | 24611(48.5%) | 26338(44.0%) | <0.0001 |
| Smoking | 18440(33.3%) | 15832(24.7%) | <0.0001 |
| Coronary Artery Disease | 8783(17.3%) | 9975(16.7%) | 0.0051 |
| Payment Source | |||
| Medicare | 23.7% | 33.9% | <0.0001 |
| Medicaid | 5.8% | 7.4% | |
| Other | 46.8% | 37.9% | |
| No | 9.2% | 6.9% | |
| Insurance/Missing | |||
| Diagnosis | |||
| Unstable angina | 9148(16.5%) | 3265(5.1%) | <0.0001 |
| NSTEMI | 29050(52.4%) | 43106(67.4%) | <0.0001 |
| STEMI | 16790(30.3%) | 16919(26.4%) | <0.0001 |
The associations of achieving quality of care measures as a function of LOS, after adjustment for patient and hospital characteristics, are presented in Table 3 . Those with the LOS <4 days were more likely to receive aspirin (odds ratio [OR] 1.12, 95% CI 1.06 to 1.19; p <0.001), clopidogrel (OR 1.77, 95% CI 1.60 to 1.95; p <0.001), lipid-lowering therapy if indicated (OR 1.13, 95% CI 1.05 to 1.21; p <0.001), ACEI/ARB for LVSD (OR 1.10, 95% CI 1.01 to 1.21; p = 0.04), and smoking cessation counseling (OR 1.17, 95% CI 1.10 to 1.24; p <0.001) compared to those with the LOS ≥4 days. In contrast, this group (LOS <4 days) was less likely to receive β blockers (OR 0.88, 95% CI 0.84 to 0.93; p <0.001). The odds of receiving defect-free care were greater for patients with the LOS <4 days (OR 1.15, 95% CI 1.10 to 1.21; p <0.001). We also found in our analysis that the LOS for ACS has decreased over time ( Figure 1 ).
| Outcome | Variable | Adjusted ∗ | |
|---|---|---|---|
| OR (95% CI) | P-value | ||
| Defect-free care | LOS: <4 (vs. ≥4 days) | 1.15 (1.10, 1.21) | <0.001 |
| Discharge ACE or ARB for LVSD | LOS: <4 (vs. ≥4 days) | 1.10 (1,01, 1.21) | 0.04 |
| Discharge aspirin | LOS: <4 (vs. ≥4 days) | 1.12 (1.06, 1.19) | <0.001 |
| Discharge beta blockers | LOS: <4 (vs. ≥4 days) | 0.88 (0.84, 0.93) | <0.001 |
| Discharge clopidogrel for AMI and pts with percutaneous intervention | LOS: <4 (vs. ≥4 days) | 1.77 (1.60, 1.95) | <0.001 |
| Discharge smoking cessation/counseling for smokers | LOS: <4 (vs. ≥4 days) | 1.17 (1.10, 1.24) | <0.001 |
| Lipid lowering drugs for LDL>100 mg/dl | LOS: <4 (vs. ≥4 days) | 1.13 (1.05, 1.21) | <0.001 |
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