1. Hospital length of stay after hip fracture of less than 10 days was associated with a greater risk of death within 30 days of discharge.
2. The increased risk of death per one less day of hospital stay doubled from 2006 to 2012.
Evidence Rating Level: 2 (Good)
Study Rundown: With rising healthcare costs, there has been increased emphasis on the cost-effectiveness of medical interventions and measures that decrease costs without sacrificing quality. For post-operative patients, one such measure includes reducing the length of hospital stay and discharging patients earlier to care in the community setting or at home. However, this carries with it a potential increased risk of complications and death. This study aimed to determine whether changes in length of stay after hip fracture had any effect on the risk of death within 30 days of hospital discharge. Over the 6 years of the study, the average hospital length of stay after hip fracture decreased from 14.2 days in 2006 to 11.2 days in 2012. For every one fewer day that patients stayed in the hospital below 10 days, their risk of death within 30 days of discharge increased by 8% in 2006 and by 16% in 2012. However, for patients that stayed in the hospital for 11 days or more after hip fracture, any one-day reduction in length of stay had no impact on the risk of death within 30 days of discharge.
This study benefited from using a large nationwide registry, the Swedish National Patient Register, which provided data on all Swedish people older than 50 years of age who experienced a hip fracture. No exclusion criteria were applied and so the data are largely generalizable.
However, no data exist on whether patients were discharged to home or to community based living facilities, and so no distinction is made between mortality in one setting versus the other. Additionally, the authors do not demonstrate that the decreased average length of stay over the six-year study period actually resulted in decreased healthcare costs. Overall, this study suggests that decreased hospital length of stay after hip fracture, specifically less than 10 days, may in fact result in increased risk of death within 30 days after discharge and directs further research into this phenomenon.
Relevant Reading: Length of stay: How short should hospital care be?
In-Depth [retrospective cohort]: This study utilized data from the Swedish National Patient Register to identify the 116,111 patients greater than 50 years of age who experienced a hip fracture resulting in an inpatient hospital stay between 2006 and 2012. Age was the single strongest predictor of the risk of death within one year of admission (OR 1.072, CI95% 1.071-1.074). For length of stay, the average in 2006 after hip fracture was 14.2 days (range 0-343) but this decreased to 11.6 days (range 0-137) in 2012 (p<0.001). In fact, even adjusting for covariates, patients with a length of stay of 1-5 days had nearly twice the risk of death within 30 days of discharge compared to those with stays of 15 days or more (OR 1.97, CI95% 1.83-2.13). A threshold was determined at which this increased risk of death occurred. In particular, for patients with stays of 10 days or less, every one day reduction in the length of stay resulted in an 8% (OR 1.076, CI95% 1.033-1.121) increased risk of death within 30 days of discharge in 2006 and a 16% (OR 1.164, CI95% 1.122-1.208) increased risk of death in 2012. However, for patients who stayed in the hospital for 11 days or more, every one-day fewer they were inpatient did not alter risk of death within 30 days of discharge.
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