HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lawrence H. Muhlbaier Robert H. Jones William L. Holman Eric D. Peterson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cowper, P. A. Articles by Peterson, E. D. Search for Related Content PubMed PubMed Citation Articles by Cowper, P. A. Articles by Peterson, E. D. Related Collections Coronary disease Professional affairs Related Article

Ann Thorac Surg 2007;83:100-107
© 2007 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Is Early Too Early? Effect of Shorter Stays After Bypass Surgery

^a Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
^b Department of Health Policy, Management and Behavior, State University of New York, University at Albany, Rensselaer, New York
^c Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama

Accepted for publication August 1, 2006.

^_* Address correspondence to Dr Cowper, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715. (Email: cowpe001{at}mc.duke.edu).

Adult cardiac surgery: The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.

 

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: Postoperative stays after coronary artery bypass graft surgery (CABG) decreased substantially in the 1990s. Although shorter stays offer clinical benefits, premature discharge could increase adverse events and offset initial savings. This study examined the effect of early discharge after CABG on readmission/death and cost within 60 days of discharge home. Variability in hospitals’ tendencies for early discharge and adverse outcomes was also explored.

METHODS: Analyses were based on clinical and claims data for 55,889 New York CABG patients discharged home 1995 to 1998. Early discharge was defined as a postoperative stay below the 15th percentile for patients with similar risk. The likelihood of early discharge and its effect on readmission/death were examined using hierarchical logistic regression, accounting for patient risk and within-hospital correlation. The correlation between early discharge and adverse outcomes at the hospital level was assessed. The effect of early discharge on subsequent inpatient, outpatient, skilled nursing, and home health costs was examined in the Medicare subset.

RESULTS: Overall, 17% of patients were discharged early, with increasing prevalence over time. The tendency to discharge early varied widely among hospitals (2% to 42% of patients). We found no association between hospitals’ tendencies for early discharge and adverse outcomes. Lower postdischarge costs among patients discharged early (mean = $3,491 versus $5,246 for typical stays) resulted in average cumulative savings of $6,309.

CONCLUSIONS: Patients selected for earlier discharge after CABG did not have increased adverse event rates or higher costs. Variation among hospitals in early discharge suggests that more efficient patient management could be achieved at some hospitals.

Coronary artery bypass surgery (CABG) is an effective treatment for coronary artery disease, offering angina relief and, in some cases, improved survival [1–3]. However, the procedure has been a significant contributor to health care costs and a target of cost-containment efforts. In the 1990s, postoperative stays after CABG decreased substantially with the adoption of aggressive care protocols that facilitated earlier extubation and mobilization of patients [4–8].

Shorter postoperative stays offer advantages, including improved respiratory outcomes, reduced nosocomial infection rates, and the opportunity to recover at home. Premature discharge of inappropriately targeted patients, however, could increase postoperative complications, subsequent readmissions, and mortality. Furthermore, apparent savings associated with shorter stays may be transitory if readmissions increase or care shifts to outpatient or nonacute institutional settings.

Isolating the effects of earlier discharge on outcomes is problematic because the underlying positive relation between patient risk and postoperative length of stay (PLOS) confounds the relation between PLOS and outcomes. Healthier patients are more likely to have both shorter PLOS and fewer complications after discharge. In addition, what constitutes early discharge for a high risk patient may be a typical length of stay for a healthy patient. To adequately evaluate the effects of early discharge, the definition of early discharge must go beyond an arbitrary value for PLOS and vary according to patient risk. To date, no multisite studies examining the effects of PLOS on patient outcomes have addressed this issue.

In this study, we assessed the effect of early discharge after CABG, defined relative to individual patient risk, on rates of readmission and death within 60 days of discharge home. We also assessed variability among hospitals in early discharge and explored the relation between hospitals’ tendencies to discharge early and their likelihood of adverse outcomes. Finally, we examined whether earlier discharge increased subsequent resource use and assessed whether any increases in postdischarge costs offset initial inpatient savings.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Patient Population
The sample was drawn from isolated CABG patients discharged in New York state between January 1, 1995, and October 31, 1998. Patients were excluded if they were not discharged home (in-hospital deaths, transfers), could not be linked to administrative claims data, were out-of-state residents, qualified for federal healthcare coverage other than Medicare, underwent minithoracotomy, or had a PLOS that appeared invalid (2 days with discharge home). The study was approved by the Duke University and State University of New York, Albany, Institutional Review Boards, with waiver of individual patient consent.

The cost analysis was restricted to patients 65 years of age because Medicare claims were the only source for care received outside the inpatient setting. Patients were excluded from the cost analysis if they were likely to have incomplete Medicare charges due to enrollment in health maintenance organizations, discontinuous Medicare enrollment, supplemental insurance coverage, or treatment at all-inclusive rate payer hospitals.

Data Sources
Baseline clinical information was obtained from the Cardiac Surgery Reporting System, which contains patient and hospital identifiers, demographics, risk factors, hospitalization and procedure dates, complications, and discharge status for all CABG cases in New York. Readmissions within 60 days of discharge after CABG were identified using the New York Statewide Planning and Research Cooperative System (SPARCS), which contains claims for all hospitalizations in New York state. Variables extracted included readmission dates, diagnosis and procedure codes, insurance coverage, and diagnosis-related group. Death dates were obtained from the Medicare Enrollment File (patients aged 65 years) and the New York State and New York City Departments of Health. Hospital charges, physician services, hospital-based outpatient care, skilled nursing admissions, and home health care were extracted from Medicare National Claims History files. Hospital-specific, department level cost-to-charge ratios were based on Medicare Cost Reports.

Outcome Variables
Clinical outcomes
The primary clinical outcome was the combined endpoint of all cause death or readmission within 60 days of discharge after CABG. We also examined mortality alone, although death within 60 days of discharge was relatively infrequent. The 60-day follow-up period was designed to capture serious complications (for example, sternal wound infections requiring surgery). However, this period may also include unrelated readmissions. Therefore, secondary analyses restricted to readmissions with a primary diagnosis indicative of a CABG complication were also performed. Included as CABG-related diagnoses were myocardial infarction, angina, infection, heart failure, arrhythmias, pulmonary thromboembolism/deep venous thrombosis, respiratory illness, stroke, gastrointestinal bleeds, and hypertension/hypotension [9].

Resource use and cost outcomes
Resource use outcomes included the proportion of patients requiring inpatient, outpatient, home health, or skilled nursing care during follow-up, as well as rates of resource use. Cost outcomes included the cost of all follow-up care (inpatient, outpatient, skilled nursing, and home health care received within 60 days of discharge), as well as cumulative costs (CABG hospitalization cost plus follow-up costs).

Statistical Analysis
Determination of early discharge
To determine whether a patient was likely to have been discharged early, relative to 1995 practice norms for similar patients, we used a Cox proportional hazards model, with PLOS as the dependent variable and baseline characteristics as independent variables, to estimate a patient-specific distribution of PLOS for 1995. This model was then applied to the data for each patient treated between January 1, 1996, and October 30, 1998, to obtain the distribution of PLOS that would have been expected for that patient if treated in 1995. We defined each patient’s discharge as early (PLOS 15th percentile for 1995), typical (PLOS between 15th and 85th percentiles for 1995), or late (PLOS 85th percentile for 1995), given the patient’s risk profile. The late discharge category was intended to capture patients with complicated courses who would not have been candidates for early discharge. Patient characteristics considered as explanatory variables in the model included demographics, comorbid illnesses, baseline illness severity, insurance coverage, and admission from an institutional setting.

Probability of adverse outcomes after discharge
The association between discharge type (early, late, typical) and adverse clinical outcomes (death/readmission and death), after adjusting for baseline risk, was assessed using hierarchical logistic regression with a random intercept to account for within-hospital correlation in outcomes. Independent variables considered in the model included patient characteristics, discharge type and year of discharge, with hospital as the random intercept.

Because it is difficult to identify complicated stays based on patient risk alone, the typical discharge group may have included patients who would not have been candidates for early discharge. In this instance, the adverse event rate for typical discharges could be overestimated, masking any detrimental effects of early discharge. To assess the sensitivity of results to this possibility, we repeated the analyses of adverse outcomes after excluding patients with postoperative complications or PLOS exceeding 8 days. Within this subset, we also examined outcomes for patients aged 65 years or older, as elderly patients are at higher risk for adverse events. We also assessed the effect on results of excluding off-pump procedures.

Variability in hospitals’ plos and outcomes
To determine whether the tendency to discharge patients early was correlated with an increased likelihood of adverse outcomes at the hospital level, the association between hospitals’ tendencies to discharge early and to have poor outcomes was examined. For this analysis, the tendency for a hospital to discharge early was estimated by incorporating hospital as a random effect along with discharge year in a hierarchical logistic model predicting early discharge (defined by the patient-specific early discharge indicator described above). The tendency for a hospital to have better or worse clinical outcomes relative to the overall norm was estimated by including hospital as a random intercept in a hierarchical logistic regression that predicted readmission/death and adjusted for patient risk and discharge year.

Our analyses excluded patients who died before discharge. It is conceivable that hospitals with relatively high early discharge rates achieved those rates because their severely ill patients did not survive until discharge. We explored this possibility by examining the correlation between hospitals’ tendencies to discharge early and their published risk-adjusted, in-hospital CABG mortality rates [10].

Effect of shorter inpatient stays on subsequent resource use and costs
Services were valued using standardized costs. Standard cost weights for components of hospital care were estimated by regressing hospital costs (calculated from charges using cost-to-charge ratios) against their major determinants (routine days, intensive care days, diagnosis-related group weight, patient risk factors, hospital wage index). Standardized costs for each hospitalization were then calculated using the cost weights from the regression, holding wage index constant. Physician services were valued using Medicare allowable charges, adjusted for locality. Outpatient hospital charges were converted to costs using cost-to-charge ratios and adjusted using the hospital wage index. Home health visits were valued using the Medicare cost limit for each visit type [11]. Skilled nursing admissions were valued using the average daily Medicare payment rate [12]. All costs were expressed in 2003 dollars [13].

Baseline, follow-up, and cumulative costs of patients in the inpatient, outpatient home health, and skilled nursing settings were first compared among discharge types (early, typical, and late) using descriptive statistics. The effect of early discharge on follow-up and cumulative costs was then examined by incorporating discharge type in a linear regression analysis, adjusting costs for baseline patient characteristics. Because of the skewed distribution of cost, the dependent variable was log-transformed in these regressions.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Patient Sample
Of 74,818 isolated CABGs performed in New York state between January 1, 1995, and October 31, 1998, 69,059 (92%) matched with SPARCS data. After removing patients meeting exclusion criteria (in-hospital deaths = 1,348 [2%]; transfers = 6,521 [9%]; out-of-state residents = 2,796 [4%]; federal payer = 371 [<1%]; minithoracotomy = 1,012 [1%]; invalid LOS data = 73 [<1%]; missing bypass claims = 929 [1%]) and selecting each patient’s first CABG, 55,889 remained in the primary sample (1995 reference sample = 14,239; 1996 to 1998 sample = 41,650). The cost sample was drawn from the 22,539 elderly patients in the 1996 to 1998 sample. After excluding patients with incomplete Medicare data, 12,446 patients (55%) remained in the cost sample.

Patients were primarily white (91%) and male (74%), with an average age of 65 years. Approximately 4% of patients had off-pump surgery. The most common comorbid illnesses were diabetes mellitus, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (Table 1). Characteristics of the elderly cost sample were similar to those of the overall sample, with the exception of a slightly higher proportion of females and whites. A comparison of the risk profile of the elderly cost sample with that of the elderly subset from which it was drawn found no differences (Table 1).

Overall, 17% of patients were designated as early discharges. Patient factors that significantly decreased the likelihood of early discharge included older age, female sex, hemodynamic instability, preoperative intra-aortic balloon pump, congestive heart failure, renal insufficiency, and COPD. The likelihood of early discharge increased over time, with adjusted odds ratios of 1.4 for 1997 and 1.7 for 1998 (relative to 1996, p < 0.001).

Clinical Outcomes
Within 60 days of discharge home after CABG, 1% of patients treated in New York died and 19% were readmitted, with a combined endpoint of 20%. About four fifths of readmissions were potentially related to the CABG admission, including infection (20%), heart failure (14%) ischemic heart disease (9%), respiratory illness (7%), arrhythmia (7%), pulmonary embolism/deep venous thrombosis (6%), stroke (4%), and gastrointestinal disorders (2%).

Patients discharged early were less likely to die or be readmitted within 60 days of discharge (15%) than patients with typical (20%) or late discharges (26%). A similar pattern was observed for death alone, with death rates of 0.44 (early discharge), 0.69 (typical discharge), and 1.71 (late discharge). These results persisted after adjusting for baseline risk and within-hospital correlation. The odds ratio was 0.77 for early discharge and 1.62 for late discharge, both relative to typical discharge (p < 0.001). For death alone, the odds ratios were 0.76 and 3.1, respectively (p < 0.001).

Patient characteristics associated with a higher likelihood of readmission or death after discharge included older age, female sex, shock, minority race, limited insurance coverage, nonelective admission, lower ejection fraction, preoperative intravenous nitroglycerin, prior revascularization, congestive heart failure, prior stroke, peripheral vascular disease, hypertension, renal insufficiency, diabetes, COPD, and immune deficiency. A subset of these factors increased the likelihood of death alone, including older age, lower ejection fraction, prior CABG, prior stroke, peripheral vascular disease, renal insufficiency, diabetes, COPD and immune deficiency.

Recognizing that some patients with complicated courses may have been classified as typical cases, we repeated the analysis of adverse outcomes after excluding patients with postoperative complications or PLOS exceeding 8 days. The odds for death or readmission remained the same for patients discharged early (0.78). As expected, the likelihood of adverse events for late discharges fell (1.37). Restricting this subset to elderly patients (65 years) yielded similar results, with an odds ratio for readmission or death after early discharge of 0.71. Results were also similar for the endpoint of death or cardiovascular readmission within 60 days of discharge, and when off-pump procedures were excluded.

Variability Among Hospitals in Clinical Outcomes and Early Discharge
The proportion of patients discharged early relative to risk-based 1995 norms varied substantially across hospitals, ranging from 2% to 42% in 1996 to 1998 (Fig 1). After adjusting for discharge year, the individual hospital odds for early discharge relative to the average ranged from 0.2 to 5.7 (p < 0.001). The likelihood of death or readmission within 60 days of discharge also varied significantly among hospitals, after adjusting for patient risk (individual hospital odds ratios range, 0.7 to 1.4; p < 0.001). However, there was no association at the hospital level between the tendency to discharge early and the likelihood of death or readmission (Kendall’s Tau correlation coefficient = –0.02, p = 0.87; Fig 2). There was also no association between a hospital’s tendency to discharge early and its risk-adjusted in-hospital mortality rate (Kendall’s Tau correlation coefficient = –0.15; p = 0.23).

View larger version (9K): [in this window] [in a new window]   Fig 1. Each bar indicates the percent of patients discharged early in 1996 to 1998 (relative to 1995) in a hospital. Hospitals are ordered by the percent discharged early.

View larger version (7K): [in this window] [in a new window]   Fig 2. The likelihood of death/readmission (vertical axis) is plotted against the likelihood of early discharge (horizontal axis) for each hospital (relative to the overall norms, represented by dashed lines). Each circle represents a hospital, with circle size indicating the hospital’s relative case load. Hospitals falling to the right of the vertical dashed line have relatively high likelihoods of early discharge, while those falling to the left have relatively low likelihoods. Hospitals falling above the horizontal dashed line have relatively high likelihoods of adverse events after discharge, and those below have relatively low likelihoods.

View larger version (17K): [in this window] [in a new window]   Fig 3. Mean costs within 60 days of discharge for elderly cost sample (n = 12,446), by discharge type. Black bars indicate early discharge; white bars indicate typical discharge; gray bars indicate late discharge. (MD = physician.)

View larger version (18K): [in this window] [in a new window]   Fig 4. Mean baseline, 60-day follow-up, and cumulative costs for elderly cost sample (n = 12,446), by discharge type. Black bars indicate early discharge; white bars indicate typical discharge; gray bars indicate late discharge.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

Hospital Variability
The considerable variation among hospitals in the prevalence of early discharge, together with the lack of association between early discharge and clinical outcomes at the hospital level, raises the question of whether shorter stays could be achieved at some hospitals without compromising the quality of care. In depth analyses of care at hospitals with longer stays would be required to determine whether practice patterns could be modified to achieve higher rates of early discharge while maintaining clinical outcomes.

Comparison With Previous Research
Our primary finding that earlier discharge did not increase the risk of readmission or death supports results of previous studies. Single site, observational, pre/post, and randomized studies have failed to detect any adverse outcomes attributable to earlier discharge after bypass surgery [4–7, 14–17]. Similarly, larger studies have found that readmission rates increased with longer postoperative stays [9, 18]. Our study differed from previous large analyses by defining early discharge in terms of both PLOS and patient risk. This approach reduces the chance that low-risk patients with short stays will be falsely identified as early discharges, an error that would dilute the early discharge pool and decrease the likelihood of detecting any adverse effects of shorter stays. In spite of this methodologic refinement, we were unable to detect an increase in adverse outcomes with early discharge. Furthermore, we found no increase in costs within 60 days of discharge associated with early discharge, which is also consistent with previous work [7].

Strengths and Limitations
Strengths of this study include the large sample, comprehensive ascertainment of postdischarge adverse events, and the use of clinical baseline data. However, there are also several limitations. First, the study was observational and relied on statistical adjustment for patient risk. While risk adjustment is imperfect, results were robust to secondary analyses restricted to (1) an uncomplicated subset (PLOS 8 days without in-hospital complications), in which there should be less opportunity for patient risk and postoperative complications to confound the relation between early discharge and outcomes, and (2) a high risk subset (65 years), in which adverse events should be more easily detected. Second, we were able to examine costs only in elderly patients with reliable cost data. Limiting the cost analysis to elderly patients should have improved our ability to identify increases in postdischarge costs because elderly patients are generally at higher risk for adverse outcomes. While the sample was further restricted to patients with cost data, we could find no differences in baseline risk between elderly patients with and without cost data. Third, although we captured the effects of early discharge on the use of outpatient services, we did not account for any increases in physician practice costs that were not reimbursed. Fourth, the effect of early discharge on caregiver burden, informal care costs, and patients’ functional status and satisfaction were not examined. Although earlier discharge did not appear to increase cost within the health care sector, it may increase the financial and emotional burden on patients and their families. Finally, the study period is somewhat dated, ending in 1998. However, the pronounced, widespread reductions in PLOS during this period created a unique setting in which to assess the effect of shorter stays on outcomes. Given that adverse events did not increase with shorter stays in this time of dynamic change, our conclusions are likely robust to the gradual reductions in PLOS since then. Further, although practice has continued to evolve since 1998, with more widespread use of off-pump techniques and the approval of drug-eluting stents, our results remain relevant to the many patients with multivessel disease for whom coronary bypass confers a survival advantage and remains the preferred method of revascularization [3].

In conclusion, patients selected for earlier discharge after CABG did not have increased rates of adverse clinical events or higher health care costs in the subsequent 60 days. However, the wide range among hospitals in the tendency to discharge patients early suggests that postoperative management of CABG patients varies substantially, and more efficient patient management could be achieved at some hospitals without compromising quality of care. Further investigation at the hospital level is needed to determine whether observed variability reflects modifiable differences in inpatient care or more difficult issues such as patients’ lack of social support or inadequate access to postdischarge care.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
This research was funded by the Agency for Healthcare Research and Quality (Grant R01 HS10279). No conflict of interest exists for any authors. We thank ResDAC for assisting with acquisition of Medicare claims, the New York State Department of Health for providing clinical and administrative data, and the New York City Department of Health for providing vital statistics.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

1. Hoffman SN, TenBrook JA, Wolf MP, Pauker SG, Salem DN, Wong JB. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one to eight-year outcomes J Am Coll Cardiol 2003;41:1293-1304.[Abstract/Free Full Text]
2. Pocock SJ, Henderson RA, Seed P, Treasure T, Hampton JR. Quality of life, employment status, and anginal symptoms after coronary angioplasty or bypass surgery3-year follow-up in the Randomized Intervention Treatment of Angina (RITA) trial. Circulation 1996;94:135-142.[Abstract/Free Full Text]
3. Hannan EL, Racz M, Walford G, et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation N Engl J Med 2005;352:2174-2183.[Abstract/Free Full Text]
4. Engelman RM. Mechanisms to reduce hospital stays Ann Thorac Surg 1996;61(Suppl):26-29.
5. George EL, Large AA. Reducing length of stay in patients undergoing open heart surgery: the University of Pittsburgh experience AACN Clin Issues 1995;6:482-488.[Medline]
6. Lee JH, Swain B, Andrey J, Murrell HK, Geha AS. Fast track recovery of elderly coronary bypass surgery patients Ann Thorac Surg 1999;68:437-441.[Abstract/Free Full Text]
7. Cheng DC, Wall C, Djaiani G, et al. Randomized assessment of resource use in fast-track cardiac surgery 1 year after hospital discharge Anesthesiology 2003;98:651-657.[Medline]
8. Lazar HL, Fitzgerald C, Ahmad T, et al. Early discharge after coronary artery bypass graft surgery: are patients really going home earlier? J Thorac Cardiovasc Surg 2001;121:943-950.[Abstract/Free Full Text]
9. Hannan EL, Racz M, Walford G, et al. Predictors of readmission for complications of coronary artery bypass graft surgery JAMA 2003;290:773-780.[Abstract/Free Full Text]
10. New York State Department of Health Coronary artery bypass surgery in New York State 1996-98. 2001January. Available at: www.health.state.ny.us/nydoh/consumer/heart/1996-98cabg. Accessed on June 26, 2006.
11. US Centers for Medicare and Medicaid ServicesDepartment of Health and Human Services Medicare program; home health prospective payment system update for FY 2004; notice Fed Register 2003;68:39768.
12. ABT Associates IncUS Centers for Medicare and Medicaid Services Appropriateness of minimum nurse staffing ratios in nursing homes Report to Congress: phase II final 2001:10-13.
13. US Department of Labor and Bureau of Labor Statistics. Producer price index. Available at: http://www.bls.gov/ppi/home.htm (accessed June 26, 2006).
14. Loubani M, Mediratta N, Hickey MS, Galinanes M. Early discharge following coronary bypass surgery: is it safe? Eur J Cardiothorac Surg 2000;18:22-26.[Abstract/Free Full Text]
15. D’Agostino RB, Jacobson J, Clarkson M, Svensson LG, Williamson C, Shahian DM. Readmission after cardiac operations: prevalence, patterns, and predisposing factors J Thorac Cardiovasc Surg 1999;118:823-832.[Abstract/Free Full Text]
16. Rumble SJ, Jernigan MH, Rudisill PT. Determining the effectiveness of critical pathways for coronary artery bypass graft patients: retrospective comparison of readmission rates J Nurs Care Qual 1996;11:34-40.[Medline]
17. Lahey SJ, Campos CT, Jennings B, Pawlow P, Stokes T, Levitsky S. Hospital readmission after cardiac surgeryDoes "fast track" cardiac surgery result in cost saving or cost shifting?. Circulation 1998;98(19 Suppl):II35-II40.[Medline]
18. Cowper PA, Peterson ED, DeLong ER, Jollis JG, Muhlbaier LH, Mark DB. Impact of early discharge after coronary artery bypass graft surgery on rates of hospital readmission and death J Am Coll Cardiol 1997:908-913.

This article has been cited by other articles:

				R. H. Jones The Year in Cardiovascular Surgery J. Am. Coll. Cardiol., April 29, 2008; 51(17): 1707 - 1718. [Full Text] [PDF]

				K. Accola Invited commentary Ann. Thorac. Surg., January 1, 2007; 83(1): 107 - 107. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lawrence H. Muhlbaier Robert H. Jones William L. Holman Eric D. Peterson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cowper, P. A. Articles by Peterson, E. D. Search for Related Content PubMed PubMed Citation Articles by Cowper, P. A. Articles by Peterson, E. D. Related Collections Coronary disease Professional affairs Related Article