Quality of care, length of stay, and readmissions need to be considered

EDITOR—Ham et al report that bed days used for a range of common diagnoses among people aged 65 and over are substantially higher in the NHS than in US managed care programmes.1

Stroke admissions contribute most to the extra bed days in the NHS and also show the largest relative differences from the US comparators. Comparable incidences are not available, but mortality, a reasonable proxy, shows that the United States has much lower rates of stroke than the United Kingdom: age adjusted stroke mortality in the United States is about 35% lower at age 35-74 and 49% at age 75-84.2

However, admission rates for Medicare in California and the United States are about 45% higher than in the NHS, Kaiser's rates being broadly similar. The higher Medicare stroke admission rates in the face of lower incidence seem likely to be due to a higher proportion of readmissions among US patients. A considerable proportion of the longer average stay for NHS patients must simply show that more British patients are admitted only once, rather than repeatedly. Furthermore, the NHS bed days include days spent in intermediate care beds, but these post-acute bed days are not included for the US data.

Randomised controlled trials of stroke units show clear benefits for long term disability and mortality, with none of the trials in a Cochrane systematic review reporting median lengths of stay of less than 13 days.3 That high quality stroke care is consistent with US managed care stays of only four to six days seems implausible. Elderly people with strokes (and other conditions) can be discharged rapidly, but if the consequences are readmission from a failure to apply effective clinical interventions this hardly constitutes successful management.

Ham et al suggest that patients should be “co-providers” of their care. The vision of stroke patients admitted, then readmitted would be a perfect satire on the “cost is all” view of “saving” the NHS, if it were not clear that this message would be greeted enthusiastically by government.