Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Avoiding hospital admission—are we really falling short?

BMJ 2019; 364 doi: (Published 26 February 2019) Cite this as: BMJ 2019;364:l747

Longer hospital stay - the lesser of 2 evils?

We echo David Oliver’s sensible observation that hospital is often necessary and appropriate, even if patients end up staying too long. [1] A good example is in the management of decompensated heart failure. According to the National Heart Failure (HF) Audit (2016/7), the median length of hospital stay for HF is 9 days if admitted to Cardiology wards, and 6 days if admitted under general medicine. [2] On the other hand, outcomes are better for patients admitted to Cardiology (6.5%) compared to General Medical wards (10.1% inpatient mortality). The longer length of stay for patients receiving specialist care might reflect referral of more severe cases for expert care, and greater care to ensure that the patients are stable before discharge. Importantly, the national audit found patients under Cardiology were more likely to receive disease modifying therapies (e,g, ACE inhibitors, mineralocorticoid receptor antagonists), with proven benefit in prolonging life, reducing further hospitalisation and improving symptoms. So longer hospital stay is sometimes the lesser of two evils.

However, we disagree with the comment that patients ‘often’ freely choose to attend hospital despite awareness of alternatives. For instance, many heart failure patients’ preferred place of care, including end-of-life care, is at home or in the community, but this wish is often thwarted by the need for parenteral diuretics to keep comfortable. [NHS Improvement & National End of Life Strategy]. The British Heart Foundation Observation study demonstrated that outpatient based acute heart failure treatment in the community is safe and effective, although the fact that they claimed 0% mortality would suggest a degree of “cherry-picking”. A randomised controlled trial will hopefully give extra assurance that this strategy is safe, effective and cost-effective. Nevertheless, importantly, 100% of patients were satisfied as were 96% of carers, who would choose out-of-hospital acute heart failure treatment again in the future. [3]

Clearly there are many reasons why patients would favour having shorter length of stay in hospital if their care needs can be met. The King’s Fund publication ‘Continuity of care for older hospital patients – a call for action’ suggests for many older people, a stay in hospital is disempowering: the environment itself, the noise, and the routines on the wards overwhelm and undermine them in ways that affect their ability to recover who they were and how they were living before they were admitted. [4]

Nevertheless, it is wise of Oliver to warn against judgment of every community or integrated care model solely on whether it reduces hospital use or saves money, instead of the range of other benefits it might deliver for patients and families. We all do well to recognise that often the lesser of two evils is to admit to hospital.

1. David Oliver: Avoiding hospital admission—are we really falling short? BMJ 2019;364:l747

2. National Heart Failure Audit 2016/2017
Last accessed 12/03/2019

3. British Heart Foundation. Treating heart failure patients in the community with intravenous diuretics. 2015
Last accessed 12/03/2019

4. Jocelyn Cornwell, Ros Levenson, Lara Sonola, Emmi Poteliakhoff. Continuity of care for older hospital patients- A call for action. The King’s Fund. March 2012.
Last accessed 12/03/2019

Competing interests: No competing interests

12 March 2019
Kenneth Y-K. Wong
Consultant Cardiologist with special interest in Heart Failure; Cardiology Directorate Research Lead
Dr Suzanne YS Wong, Consultant Geriatrician
Lancashire Cardiac Centre
Blackpool Victoria Hospital, Whinney Heys Road, Blackpool FY3 8NR.