Original article
Temporal trends and prognostic impact of length of hospital stay in uncomplicated ST-segment elevation myocardial infarction in SpainTendencias e impacto pronóstico de la duración de la estancia hospitalaria en el infarto de miocardio con elevación del segmento ST no complicado en España

https://doi.org/10.1016/j.rec.2019.09.016Get rights and content

Abstract

Introduction and objectives

There are few data on the safety of length of stay in uncomplicated ST-segment elevation myocardial infarction. We studied trends in hospital stay and the safety of short (≤ 3 days) vs long hospital stay in Spain.

Methods

Using data from the Minimum Basic Data Set, we identified patients with uncomplicated ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and who were discharged alive between 2003 and 2015. The mean length of stay was adjusted by multilevel Poisson regression with mixed effects. The effect of short length of stay on 30-day readmission for cardiac diseases was evaluated in episodes from 2012 to 2014 by propensity score matching and multilevel logistic regression. We also compared risk-standardized readmissions for cardiac diseases and mortality rates.

Results

The adjusted length of stay decreased significantly (incidence rate ratio < 1; P < .001) for each year after 2003. Short length of stay was not an independent predictor of 30-day readmission (OR, 1.10; 95%CI, 0.92-1.32) or mortality (OR, 1.94; 95%CI, 0.93-14.03). After propensity score matching, no significant differences were observed between short and long hospital stay (OR, 1.26; 95%CI, 0.98-1.62; and OR, 1.50; 95%CI, 0.48-5.13), respectively. These results were confirmed by comparisons between risk-standardized readmissions for cardiac disease and mortality rates, except for the 30-day mortality rate, which was significantly higher, although probably without clinical significance, in short hospital stays (0.103% vs 0.109%; P < .001).

Conclusions

In Spain, hospital stay ≤ 3 days significantly increased from 2003 to 2015 and seems a safe option in patients with uncomplicated ST-segment elevation myocardial infarction.

Resumen

Introducción y objetivos

La información sobre la seguridad de la duración de la estancia es escasa en el infarto de miocardio con elevación del segmento ST no complicado. Se han estudiado las tendencias y la seguridad en España de la estancia corta (≤ 3 días) frente a la prolongada.

Métodos

Se identificaron en el Conjunto Mínimo Básico de Datos los episodios de pacientes con infarto de miocardio con elevación del segmento ST no complicado tratados con intervención coronaria percutánea primaria y dados de alta vivos entre 2003 y 2015. La estancia media se ajustó mediante regresión de Poisson multinivel con efectos mixtos. El efecto de la estancia corta en el reingreso por causa cardiovascular a 30 días se evaluó en episodios de 2012-2014 mediante emparejamiento por puntuaciones de propensión y regresión logística multinivel, comparando las razones estandarizadas de reingreso y mortalidad por riesgo.

Resultados

La estancia ajustada disminuyó significativamente (razón de tasas de incidencia < 1; p < 0,001) cada año desde 2003. La estancia corta no fue un predictor independiente de reingreso (OR = 1,10; IC95%, 0,92-1,32) ni de mortalidad (OR = 1,94; IC95%, 0,93-14,03). Después del emparejamiento, tampoco hubo diferencias significativas en ambos casos (OR = 1,26; IC95%, 0,98-1,62; y OR = 1,50; IC95%, 0,48-5,13). Las comparaciones entre las razones estandarizadas de reingreso y mortalidad por riesgo confirmaron estos resultados, excepto en la de mortalidad a los 30 días, significativamente mayor en la estancia corta, aunque probablemente sin significado clínico (el 0,103 y el 0,109%; p < 0,001).

Conclusiones

La estancia ≤ 3 días aumentó significativamente en España desde 2003 a 2015 y parece una opción segura en el infarto de miocardio con elevación del segmento ST no complicado.

Section snippets

INTRODUCTION

Primary percutaneous coronary intervention (pPCI) is the ideal reperfusion strategy for ST-segment elevation myocardial infarction (STEMI).1 The pPCI rate has been boosted through the implementation of health care networks, reducing complications and shortening hospital stay.1, 2, 3, 4 The current clinical practice guidelines of the European Society of Cardiology consider a short length of hospital stay (48-72 hours) to be a valid option for uncomplicated STEMI.1 However, this recommendation is

Study design, data source, and patient population

This retrospective observational study investigated patients admitted for STEMI to SNS hospitals and treated with PCI. The data source was the Minimum Basic Data Set (MBDS)11 of the Ministry of Health, Consumer Affairs, and Social Welfare. The usefulness of this database for the study of acute coronary syndrome in Spain was recently validated.12 The following events occurring between January 1, 2003, and December 31, 2005, were selected: patients with a principal diagnosis of STEMI who were

Temporal trends in length of hospital stay

In total, 205 016 hospitalization events with STEMI as the principal diagnosis and treatment with PCI were identified; of these, 190 078 patients were discharged alive. Once transfer events were concatenated across hospitals, 188 854 events remained. After exclusions, 134 002 events comprised the study population for the analysis of trends (figure 1).

The crude mean length of hospital stay was 7.2 ± 5.5 days and ranged between an annual maximum of 9.0 ± 7.2 days in 2003 and a minimum of 6.1 ± 4.7 days

DISCUSSION

The main finding of this study is that, with a very large population (that of the Spanish SNS) and an extended period of time (2003-2015), hospitalization of patients with uncomplicated STEMI for ≤ 3 days is practically safe. Our results substantiate the decision of the European clinical practice guidelines to upgrade the level of recommendation for this practice to IIa.1 Another notable finding is the progressive and significant decrease in the mean length of hospital stay in patients admitted

CONCLUSIONS

Hospital stay for uncomplicated STEMI treated with PCI significantly decreased in Spain between 2003 and 2015, although most patients are still hospitalized for 4 or more days. The discharge of these patients in ≤ 3 days can be considered safe in the SNS and its generalization, in line with the recommendations of the European clinical practice guidelines, would improve the efficient use of health care resources.

FUNDING

This study has been funded by an unconditional grant from the Fundación Interhospitalaria de Investigación Cardiovascular, Spain (1-2018).

CONFLICTS OF INTEREST

E. Abu-Assi is an Associate Editor of Revista Española de Cardiología. The other authors do not declare conflicts of interest.

WHAT IS KNOWN ABOUT THE TOPIC?

  • The increased rate of percutaneous coronary intervention in STEMI has helped to reduce complications and shorten length of hospital stay.

  • Although the recommendation has recently been strengthened for discharge in less than 3 days in low-risk patients with STEMI, the scientific evidence is slight overall and entirely lacking in the Spanish SNS.

WHAT DOES THIS STUDY ADD?

  • In Spain, hospital stay in

Acknowledgments

To the Institute for Health Information of the SNS. To the Spanish Ministry of Health, Consumer Affairs, and Social Welfare for partial rights to the MBDS database.

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