Commentary

The magic of 30 and 35


 

It seems that the 30s have become the focus of just about everyone. Or, to be a bit more precise, 30 and 35. Now, I do not mean the 1930s or that often very productive fourth decade of life. Rather, it’s the two numbers that decide penalties for heart failure readmissions and for ICD implants.

As a consequence, we obsess over 30 days becoming 31 days and 36 days becoming 35 days, often to the detriment of our patients. Implicit in this thought process is the mindless "painting by numbers" game that we play, as if something magical happens when 31 days pass from an admission for heart failure that makes it fine to admit the patient. Or when the ejection fraction falls from 36% to 35%, and then it’s acceptable to implant an ICD, as if the risk of sudden cardiac death has measurably increased.

In the absence of good data, we just make it up. We draw false lines and construct false metrics that provide four walls for decision making but do not have any medical significance or relevance to patients. I suppose that there is nothing new here. If the speed limit was lowered from 60 to 59, would we drive any differently, and would there be any impact on rates of accidents? If a round of golf had 17 holes, would Tiger Woods have won more, or fewer, major tournaments?

Still, it is a remarkable state of affairs. Hospitals will engage in intensive interventions for patients with heart failure, but on day 31, the interest wanes. It is akin to Secret Service protection for the major party presidential candidates. On the morning after the election, the losing candidate loses the large contingent of Secret Service agents.

Personally, based on my very careful review of the world’s literature, I think a 29-day readmission rate and a 29% ejection fraction make the most sense.

After all, the 20s are the new 30s.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

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