Longer Hospital Stay Linked with Less Evidence-Based Care in NSTEMI

Patients with non-ST-segment elevation myocardial infarction (NSTEMI) with longer hospital stays have more comorbidities and in-hospital complications yet are less likely to receive evidence-based therapies including percutaneous coronary intervention (PCI), according to a study published in the November 2012 issue of the American Journal of Medicine.

Christopher B. Granger, MD, of the Duke Clinical Research Institute (Durham, NC), and colleagues analyzed 39,107 patients with NSTEMI at 351 institutions participating in the Acute Coronary Treatment Intervention Outcomes Network-Get With The Guidelines (ACTION-GWTG) Registry. The patients underwent cardiac catheterization from January 2007 to March 2009 and were divided into 4 groups based on hospital length of stay:

  • No more than 2 days (n = 13,047)
  • 3 to 4 days (n = 15,870)
  • 5 to 7 days (n = 6,325)
  • At least 8 days (n = 3,865)

Length of Stay Related to Therapeutic Options

The overall median length of stay was 3 days (range, 2-5 days). Patients with a length of stay longer than 2 days were older with more comorbidities. Nonetheless, the longer the stay, the less likely patients were to receive evidence-based therapies including clopidogrel or PCI (table 1).

Table 1. Clopidogrel, PCI Use by Length of Stay


≤ 2 days

3-4 days

5-7 days

≥ 8 days

Clopidogrel in First 24 Hours










P < 0.0001 for all comparisons.

Medications such as beta blockers, ACE inhibitors or angiotensin receptor blockers, and statins showed a similar pattern of diminishing use among patients with longer hospital stays.

In addition, those with the longest stays were least likely to be discharged on aspirin (95.8%), clopidogrel (76.0%), or a statin (83.0%) compared with all the other groups (P < 0.0001 for each comparison). They also had the highest rates of MI (2.5%), shock (7.6%), heart failure (18.3%), stroke (2.1%), or major bleeding (38.8%; P < 0.0001 for each comparison).

If patients with lengths of stay longer than 8 days did receive catheterization or PCI, they had the longest delays from presentation to the procedure (49.3 hours and 55.0 hours, respectively).

Among the factors associated with prolonged length of stay (> 4 days) were delay to cath > 48 hours, heart failure or shock on admission, older age, comorbidities such as prior PAD or stroke, female sex, insurance type, and admission on a Thursday or Friday afternoon or evening (vs. Monday-Wednesday). Hospital characteristics such as academic vs. nonacademic or urban vs. rural setting were not associated with prolonged length of stay.

Opportunities for Better, More Efficient Care

In a telephone interview with TCTMD, Dr. Granger said that length of stay for NSTEMI has to be individualized for each patient, and the decision carries enormous implications for resource use. “It’s important to ensure that we’re keeping patients in the hospital for an appropriate period of time,” he added.

The study provides a “benchmark” for the typical length of stay for NSTEMI patients, Dr. Granger commented, although it also shows considerable heterogeneity. “Whenever we see heterogeneity like this, it makes us believe that there’s an opportunity to provide better, more efficient care,” he remarked.

The fact that patients admitted late on Fridays have longer lengths of stay is “not surprising,” Dr. Granger noted, “because we tend not to do cardiac catheterizations on the weekends. But is that an opportunity [to improve care]? Maybe.”

With regard to the finding that patients with longer stays received less evidence-based therapies, he referenced the “risk-treatment paradox,” in which patients at higher risk tend to receive less treatment. There are 2 major reasons for this, Dr. Granger explained. First, these patients may have legitimate contraindications, and second, practitioners “tend to be too worried about the risk of treatments and then patients who would most benefit are denied those benefits.”

In addition, cost is a large issue, Dr. Granger said. “This is just one small example of where there might be opportunities to understand how we can more appropriately decide on the amount of time that a patient needs to be in the hospital. And if we can identify factors that are associated with shorter length of stay, then we can leverage those, perhaps,” he concluded, adding that the goal is not simply to shorten length of stay but to provide the best and most efficient care.

Reported Variation the ‘Tip of the Iceberg’

According to Edward Hannan, PhD, of the University of Albany (Albany, NY), the variation in NSTEMI care, particularly with regard to length of stay, is especially enlightening because until now most studies have focused on STEMI.

However, he noted, because more patients were excluded from the study due to a transfer or not receiving catheterization than were included, the results leave some unanswered questions. “[The excluded] patients are ones whose care is more questionable and maybe had longer lengths of stay and [thus] contribute even more to the variation in care than is reported here,” Dr. Hannan commented. “So I think [the variation seen in the study] “is only the tip of the iceberg. And length of stay is really a symptom of variation in care.”

He added that the regional and temporal variations are “large enough to be concerning in terms of outcomes. The next step would be to try to educate people about the kinds of patterns that are associated with worse outcomes.”

Study Details

The median age of all patients was 64 years; women made up 37.0% of the population, and 82.1% were white. As length of stay increased, patients were older, more often female, and less frequently white.


Vavalle JP, Lopes RD, Chen AY, et al. Hospital length of stay in patients with non-ST-segment elevation myocardial infarction. Am J Med. 2012;125:1085-1094.



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  • Dr. Granger reports receiving research support from Astellas Pharma US, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Glaxo Smith Kline, Medtronic Vascular, and Merck &amp; Co.; and serving as a consultant to AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Glaxo Smith Kline, Hoffman-LaRoche, and Novartis Pharmaceuticals.
  • Dr. Hannan reports no relevant conflicts of interest.