2000-03-16 -- New England Journal of Medicine Suggests
Early Hospital Discharge for Heart Attack Patients


 Researchers: Release Patients Sooner

By The Associated Press

Researchers suggested today that hospitals could safely move toward
releasing heart attack patients without complications after just three days,
instead of the usual five or six.

The cost-benefit analysis, published today in the New England Journal of
Medicine, sharpens an already touchy medical debate. Shorter stays for heart
attacks could raise a public outcry like the one that led to a 1998 federal
law mandating at least two days of insurance coverage for maternity stays.

Marti Ann Schwartz, who wrote ``Listen to Me, Doctor: Taking Charge of Your
Own Health Care,'' said she fears insurers will seize on such cost-benefit
studies to rush patients out of the hospital.

``They're trying to make up a sheet that the people ... can look at and say,
`It's five days, we cover three days, and it's disallowed,''' Schwartz said.

Hospital stays have become much shorter for heart attacks since the 1950s,
when doctors believed patients needed such care for four to six weeks while
the heart muscle healed.

The latest analysis is apt to push the industry toward even shorter stays,
according to its chief author, Dr. Kristin Newby of Duke Clinical Research
Institute in Durham, N.C. She joined researchers at four other institutions
in carrying out the study, which was funded by pharmaceutical, biotechnology
and medical equipment companies Bayer Corp., Genentech Inc., CIBA-Corning,
ICI and Sanofi.

Reviewing records of 22,361 patients, the researchers calculated that very
few -- perhaps as few as 13 -- benefited from a fourth day in the hospital.
For an average patient, the fourth day yields only another 2.2 days in life
expectancy.

So it would take another 166 days in the hospital for another year of life
expectancy. Thus, at $624 a day in extra hospital and doctor costs, it would
cost more than $100,00 for an additional year of life expectancy -- more
than double the $50,000 figure for kidney dialysis. The kidney procedure is
widely used as a benchmark for deciding if medical care is worth the social
benefit.

Overall savings from shorter heart attack stays could be considerable, since
more than 1 million Americans suffer heart attacks each year. About 60
percent have no complicating conditions, Newby said.

However, she acknowledged that most hospitals aren't yet set up to give
patients all the pre-discharge testing, rehabilitation and advice they may
need within three days.

``This is really outlining a possibility, if we could make our system more
efficient,'' Newby said.

Dr. Donald Young, medical director of the Health Insurance Association of
America, said the study raises points that should be considered. ``Health
care dollars are limited, and we need to know what works and what doesn't
work,'' he said.

While also welcoming the study, some doctors extended cautions. They said it
is very difficult to decide which patients are at highest risk.

Cardiologist Lynn Smaha, president of the American Heart Association, said
he felt ``mixed feelings'' about the analysis.

``We're all trying to do what we can to reduce the cost. At the same time,
we have to keep up the quality of care. Cost should not be the prime
motivator,'' he said.

He said the conclusions of the analysis may be muddied by the fact that the
patients did receive the fourth day of hospital care -- and possibly
benefits that are hard to quantify.

In an editorial in the journal, Boston-based doctors Elliott Antman at
Brigham and Women's Hospital and Karen Kuntz at Harvard School of Public
Health questioned if there is enough evidence for the safety of
pre-discharge stress testing within three days of a heart attack. Such
testing monitors the heart's recovery by putting the patient on a treadmill.