-ݏ�Y�ރ � �W�� ��=�%n�~,����5~�i[�b�B~���.~__~8�p���|� �w~�*w��E��c��N�.������n��t�&m�z��W���]��EX��S��r}�o�����APz H~5�5^�g$B����F�ח����:�� Length of stay could become a monitor for how well a community and a trauma system is identifying and managing available LTACF beds in the community. The interaction of race/ethnicity and insurance is significant. Have you looked at interaction variables for those key nonmedical social sorts of issues that relate to LOS? Dr Brasel: We looked at this about 4 years ago and found that about 25% to 30% of our extended LOS on a prospective basis was completely nonmedical. Other reasons for an extended LOS may relate to its surrogate for socioeconomic status, including nutritional status, social support networks, and incidence of posttraumatic stress disorder. u��z����m{]wK����ޓ`_]'��B�QЀ2�F��ѦȮ��j�����F������:���҇����҆�j*���R�Kn��,��� -h� %PDF-1.7 %����  VAnderson However, the large number of hospitals from different regions of the United States that do contribute allow many possible regional influences to be overcome. Overall survival was 97%. Conclusions  0j�M��ٛ�&HcV�wAb'@���?��x��Ab�w�f�j�F��{��M���CG#Z�Υ����[$ԅ ^ u�`���u����:}o�%��ԩ=� �zm� Early results suggest that compliance with the identified process measures improves the targeted outcomes.23,24 Other studies have not confirmed that standardized process implementation will have significant effect on outcomes.25 While process measures may correlate directly with desirable outcomes, it is not clear that all process or outcome measures will monitor or measure what is intended to be measured.24-26. Arch Surg 2007 May;142(5):461-5; discussion 465-6 Date 05/23/2007 Pubmed ID 17515488 DOI 10.1001/archsurg.142.5.461 Abstract. The 2004 National Trauma Data Bank (NTDB) data set was used. Using LOS as a process measure rather than a benchmark outcome measure enables an individual trauma center to investigate and address all of these potential reasons. The organization embraced the … •They represent the properties of an object that we are interested in measuring.  LMYaezel Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). Hospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care. Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days, and preceded within an hour by an emergency department visit at the same physical facility Measure Steward: Centers for Medicare & Medicaid Services (CMS) Measure Scoring  JAChristians The patients were assessed as ready to go and the physicians were ready to write the discharge orders, but the consultant had not put a final opinion on the medical record, there was some nursing issue to be done, the discharge supplies were not ready, or there was no bed available in a rehabilitation facility or a nursing facility. 3g�h��ۖ�5��$eOS_�]C�Ҍ;t}����M�-^7��!������[������di��6ɘZ��y�$|')�[���k�2-�+������� ��� endstream endobj 409 0 obj <>stream For multivariate analysis, LOS was converted from a continuous variable to a dichotomous variable, LOS less than or equal to the mean LOS and LOS greater than the mean LOS. Longer than necessary LOS results in excess costs of $1,393,850 annually. While my teenage children may consider home the equivalent of incarceration, I am not sure this is true of trauma patients.  A Quality assessment and assurance: unity of purpose, diversity of means.Â, Crombie  W The effect of complications on length of stay.Â, Case It can also improve outcomes by minimizing the risk of hospital-acquired conditions. Clinical factors alone may capture only 27% of the variation in extended LOS.1 Most risk-adjustment models do not include adjustment for the important nonclinical factors that affect LOS. For each effect from the models, the odds ratio and 95% confidence interval were calculated. The quality measure short stay and long stay definitions are: The short stay resident quality measures show the average quality of resident care in a nursing home for those who stayed in a nursing home for 100 days or less or are covered under the … While unadjusted LOS may not be a valid outcome measure, it may have value as a process measure for many trauma programs. Length of stay should not be used as a comparison between trauma centers or as a benchmark outcome measure unless it is appropriately adjusted. The current data demonstrate that discharge destination had the strongest association with extended LOS, with odds ratios ranging from 1.15 to 3.83 for discharge destinations other than home.  III The financial impact of delayed discharge at a level I trauma center.Â, Collins In multivariate analysis, factors significantly associated with extended LOS included age, sex, race/ethnicity, insurance status, discharge destination, and Revised Trauma Score. 1: Length of stay data for Massachusetts General Hospital. Author Contributions:Study concept and design: Brasel, Lim, Nirula, and Weigelt. Mean LOS was 9.6 days. Dr Brasel: First, with respect to financial data, we did not use either costs or charges in this analysis, although that would be interesting, and all records that we included did have payer source. Subgroup analysis investigated the effect of missing variables; risk estimates did not change significantly and, therefore, data imputation for missing variables was not performed. Others, including pain, function, and quality of life, are more difficult to measure.  JARadford Placement of patients without adequate and appropriate insurance requires substantial personnel time and effort and may often depend on a very few beds in LTACFs in any given community. ��  LB The value of process measures in evaluating an evidence-based guideline.Â,  A resource from the Institute for Healthcare Improvement.Â, Spertus Mean LOS for patients with Medicaid (11.3 days) was significantly longer than for patients with commercial insurance and uninsured patients (each 9.3 days) and patients with Medicare (8.8 days). Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons. The National Trauma Data Bank was queried for all patients older than 18 years with an LOS longer than 48 hours and complete demographic information including age, sex, and race/ethnicity; nonclinical factors including payment type (commercial, Medicaid, Medicare, uninsured, and other) and discharge destination (home, rehabilitation facility, nursing home, and other); and clinical information (body region injured, Injury Severity Score, and Revised Trauma Score).  et al.  Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short-term mortality.Â, Rocco Dr Brasel: All of the factors that the UHC adjusts for are clinical, unlike the Hospital Efficiency Index, which includes some nonclinical adjustment. The ALOS refers to the average … Based on these data, it is tempting to suggest that LOS should not be used as a quality indicator. What is the UHC using as risk adjustments in a trauma population for LOS? Examples include the use of perioperative β-blockers, the timeliness of perioperative antibiotic administration, and the presence of an attending physician at a trauma resuscitation. It can be tracked by a specific timeframe or d… All other things being equal, a shorter stay will reduce the cost per discharge and shift care from inpatient to less expensive post-acute settings. Compliance with evidence-based guidelines is a process measure.  et al.  Discharge disposition from acute care after traumatic brain injury: the effect of insurance type.Â, Schoetz As a process measure, LOS would be used differently. Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors.  GEJurkovich Length of stay. h��Xko۸�+���"ᛔ.�w�M��Ӧ� ��hkK�-����{����#m�]�9�g�)��x$����(m$b��"� .�dB�I���6���A�XF�F�XE14�XG�(чc��-)R�`��ԕT&��B�s�#�$5�HY.”*F�D?�a�Lt�5)K,H�b#�B�E�K�O���GF)��<2�B=���).#�z�Ud&��7��xt�v������i��n1��v���G?~����6��5;���4��Ay�\����,7ۚǑj[h�Po;�Y�WI3�����\�ʝ�+���t��Y���a:����C6�G��)���?����g�m:�zTN"��'d�;Wˣ~������N5���^:��6�:��*-/�w7���|P�d�;I��(�� ������|�W�M���������[G�zӁ��(V����c��ݗ�3;X}� ��0��b'�p1;,�rw�x��N��p�Wp�S������V�ӥ�w�ȳ�?�]�}u8+g�tk�ް�e:���n�#��������&d�$�ń}���5�ouY��Ykp�`L6��{���t�?�.oӺ��s̑�]�� Study supervision: Brasel and Weigelt. title = "Length of stay: An appropriate quality measure? Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons.  SE Did you assess LOS for the various subcategories of discharge destination? h�22�T0P���w�/�+Q0���L)�621�)�I3�RY�����Zlg` �v endstream endobj 406 0 obj <>stream This confirms associations found by others, primarily in small, single-institution studies.28,29,33 Once this relationship is established, it is difficult to look at unadjusted LOS as an outcome measure evaluating quality of hospital-based medical care. Payer status had the next greatest effect; Medicare patients were significantly associated with an LOS less than the mean compared with patients with commercial insurance (odds ratio, 0.77; 95% confidence interval, 0.73-0.82).  RV Defining excess resource utilization and identifying associated factors for trauma victims.Â,  The best medical evidence for the best care management.Â,  Wisconsin Collaborative for Healthcare Quality Web site.Â, Englert  L Outcomes are, simply put, results. Main Outcome Measures  Reducing length of stay Quality, Service Improvement and Redesign Tools: Reducing length of stay What is it? Clearly, age, physiologic status, and body region injured are also important. Length of Stay This measure allows organizations to systematically assess the impact of implementing health information technology (health IT) with the intent to decrease inpatient length of stay (LOS). Quality medical care has become the primary focus in US health care since the 2000 report from the Institute of Medicine.16 Organizationally, performance improvement is the cornerstone on which advances and increases in quality are based. Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank.  HT Beyond health outcomes: the advantages of measuring process.Â, Brook 405 0 obj <>stream '|ⲻg��o�U��SO�b�ir�����oLK��$U�1�� Results of the analysis of variance are given in Table 1; results of the generalized linear model analysis are given in Table 2. A simple comparison using injury severity will be inadequate. Discharge destination and insurance status are major factors in increased LOS in the injured patient. We have not been very successful.  JTemkin Your categories of discharge destination were somewhat broad.  EACleary Therefore, when a patient is well enough to receive care outside of the hospital, they should be discharged and managed in a less costly way. Length of Stay: An Appropriate Quality Measure? Clinical factors were defined as body region injured, Injury Severity Score, and Revised Trauma Score. Did mechanism of injury, for example, blunt vs penetrating trauma or an assault vs a motor vehicle crash, have a significant effect on LOS? Mean ± SD Injury Severity Score was 12.3 ± 9.3.  RHMcGlynn Length of stay: an appropriate quality measure? Patient days that were spent outside the period under calculation should not be counted. All Rights Reserved. Business and industry have recognized the importance of this topic through the Leapfrog Initiative. That would be interesting to do. To identify potential predictors for the final model, the variables were first examined individually using univariate analysis. −, negative correlation. Administrative, technical, and material support: Brasel and Weigelt. Correspondence: Karen J. Brasel, MD, MPH, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (kbrasel@mcw.edu). Conducted within the OhioHealth system, this relatively minor intervention suggests that oncologists can change their behavior and refer patients earlier to hospice care.  LDoctor Faced with declining revenue related to changes in Medicare and Medicaid reimbursements, Memorial Hospital at Gulfport knew additional methods of providing more efficient and cost-effective quality care were needed to maintain long-term success. Based on this work, the answer appears to be no.  GKim  JCauley A simple quality improvement project to increase duration of hospice care for patients has doubled hospice length of stay, reaching the national median in 1 year. Mean LOS was 9.6 days. The prospective payment system in U.S. Medicare for reimbursing hospital care promotes shorter length of stay by paying the same amount for procedures, regardless of days spent in the hospital. I do not think putting them in a separate group would be particularly helpful because then they would be such a small minority, less than 5% in both groups. We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged … David B. Hoyt, MD, Orange, Calif: Embedded in your data is this problem with access to rehabilitation.  DSMcGory Mean ± SD age of patients was 48.2 ± 21.1 years; 62.3% were men. In addition, a multidisciplinary approach would be essential to improve the entire discharge process. You might suggest that readmission rate, as a clinical or nonclinical factor, is influential, but it goes to the point that you need to know what goes into the data and intelligently use the data when you talk with your administrators, and look at your own practice, your hospital's practice, and your system's practice. These realities of rehabilitation and skilled subacute care needs suggest that using LOS as a process measure may be helpful to a trauma system of care. Fig.  KJRasmussen It would be equally interesting to have the same objective comparisons in patients who have a single pathologic condition. El Camino Hospital leaders knew that in order to be successful, they would need to leverage real-time, targeted analytics to identify obstacles and measure improvements.  SF Risk factors for prolonged length of stay after major elective surgery.Â. Initial descriptive analyses were performed to determine whether to use parametric or nonparametric statistics.  M A high number could indicate a problem with the facility’s prescription ordering system.  WHKhuri Patients with head, face or neck, and thorax injuries had stays shorter then the mean, and those with abdominal and spine injuries had stays longer then the mean, However, the magnitude of these associations, as well as the associations of sex, age, Injury Severity Score, and Revised Trauma Score, was relatively small compared with discharge destination and payer type status. The National Trauma Data Bank was queried for all patients older than 18 years with an LOS longer than 48 hours and complete demographic information including age, sex, and race/ethnicity; nonclinical factors including payment type (commercial, Medicaid, Medicare, uninsured, and other) and discharge destination (home, rehabilitation facility, nursing home, and other); and clinical information (body region injured, Injury Severity Score, and Revised Trauma Score).  AN Attribution of inappropriate hospital days requires either prospective determination of clinical need or comparison of carefully selected similar patients with similar diagnoses, in addition to similar clinical and nonclinical factors that affect LOS.  AAGoldberg Despite certain limitations (lack of clinical detail, coding variations, time lags), quality experts regard administrative data as a reliable and usable source for the purpose of assessing hospital quality. ����a�(�]�b�E�gQh�Xd[��6�j|�x�Z?m��P�ͽ��B+��MNq���Kԑ�ˬ(����!��|�o�Z�8(F���oc�,n�?~R�"����w?�x�l�n�Ϧ�#�����:�!���eU���C�c�l���vȎ�k������3�;�̆�g�%������yh����3�Q�c��M��v��W�Ȟ�?̏n������iE_ky;��:�*َ��lD�ހ�-6�x�tv�Nj����W�#$I�"��:�w�a:Y~�^}�vC��IZq�,��m��l�5�Ǭ�>R���._��湿�����"qv�rH� R�{�a@���P��I(-���A��K'�$��׬������N,L8C �1]jD\�$}��pd$����.  KKSomberg Discharge destination had the greatest effect on LOS. Our data from the NTDB involving hospitalized injured patients suggest that nonclinical factors significantly affect LOS. Critical revision of the manuscript for important intellectual content: Brasel, Lim, Nirula, and Weigelt. Approximately one fourth to one third of the LOS may be associated with nonmedical factors.28 However, many organizations using LOS as a quality benchmark do not adjust for these important nonclinical factors.3,6,34 As an outcome measure, LOS must be adjusted for both clinical and nonclinical factors. Measure Type: Process.  IKDavies Variables were identified as significant using a .05 α level, and only these were included in a stepwise method to determine a final model. Utilization of hospital services or procedures as measured by the hospital discharge rate or average length of stay.  et al.  Disparities in the utilization of high-volume hospitals for complex surgery.Â, Brasel  DJBockler They do not adjust for injury severity or anything specific to trauma populations. Mean ± SD LOS was 9.6 ± 12.8 days. University HealthSystem Consortium (UHC), National Surgical Quality Improvement Program (NSQIP), and the NTDB all provide reports to participating hospitals providing LOS performance data indexed to some benchmark. Many current quality improvement efforts focus on measuring structure and process because these are usually easier to measure than outcomes.20,21 The relationship of structure and process to outcomes can be direct or indirect. Quality | Quality improvement. 1-5 The American College of Surgeons Committee on Trauma uses LOS as an example outcome measure for a performance improvement program.  TCDaley Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank. Forty percent of the patients had commercial insurance, 11% had Medicaid, 25% had Medicare, 16% were uninsured, and 9% had other insurance. We hypothesized that nonclinical factors, specifically payer status, would similarly affect LOS in injured patients. These quality control measures relate to reducing medical errors and protecting patients.  C Outpatient mastectomy: clinical, payer, and geographic influences.Â, Kagan  MSteiner ���rV���٭�3��-�bS*�� } ���"Y�c���z�Y�˧�2b��9��]d#?� The analysis included 313 144 medical records. Accessibility Statement, Mean Length of Stay by Race/Ethnicity and Payer Status*, Factors Associated With Extended Length of Stay, O’Keefe We did not overwhelm the model with interaction terms, but that interaction term was significant.  POdling-Smee Although much of the influence of discharge destination on extended LOS may be because of insurance status, payment type has an independent influence in the multivariate model second only to discharge status. Results  An extended stay was defined as an LOS greater than the mean LOS. hތP]k�@�+�^t�Ns� B�.�֚R���H�Br����-}������2�� �%]׀�R�t�)0{"�����5.�)Z�h!��>�.cz����pE#�x&��kn��{d*����S�`i�ˍ�]L�ÁK�1W[��01�x)�l�,�9�.s!Ƙ`�"��H�"C�C� Nonclinical factors significantly influence LOS. With respect to the uninsured, one of the problems with the NTDB is that it is not population-based, so these results, although I believe they would be relatively similar given the population-based sample, can only be generalized to the NTDB records. Your study demonstrates that LOS is really process-related and not a quality outcome. Analysis and interpretation of data: Brasel, Lim, and Nirula. Different hospitals may have different inclusion criteria for patient inclusion in a trauma registry. The type of payment was categorized into the following 5 groups: commercial, Medicaid, Medicare, uninsured, and other. Seventy-four percent of the patients were white, 17% were black, 6% were Hispanic, 1% were Asian/Pacific Islander, and 0.5% were Native American or Native Alaskan. Adjustment for clinical factors, or risk adjustment, is also inadequate. 6 Although the influence of many clinical factors on LOS is both intuitive and supported by data, studies … . Retrospective database analysis. Dr Brasel: We did not look at level of trauma center. Structure is simply the infrastructure of the health care system, which includes the individuals, the equipment, and the physical plant. HYPOTHESIS: Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. R. Stephen Smith, MD, Wichita, Kan: Since the report “To Err Is Human” was published by the Institute of Medicine in 2000, there has been an appropriate emphasis on quality of care and performance improvement. In the multivariate generalized linear models, 8 factors were associated with discharge destination (Table 2): sex, race/ethnicity, age, payment type, body region injured, discharge destination, Injury Severity Score, emergency department Revised Trauma Score, and the interaction term race/ethnicity × payer status. 2007;142(5):461–466.  KJWeigelt  JHZingmond The ACA has brought to light the importance of collecting data and using quality and outcome measures to determine how well an entity is performing. The influence of race/ethnicity and payment type on other outcome measures of resource use has been noted by others.27-29 Liu et al27 found that Medicaid patients, blacks, Hispanics, and Asians were less likely to receive complex surgical care at high-volume hospitals. Length of stay is a widely accepted marker for health care quality, and possible reduction measures include earlier subspecialist consultation, preoperative counseling regarding the anticipated length of stay, and the wider adoption of a formal multidisciplinary, clinical pathway. ", abstract = "Hypothesis: Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. hެTmo�@�+���"��\� In hospitalized injured patients, LOS in an acute care hospital is clearly affected by the need for rehabilitation or long-term care.  SDMcClellan Model of the correlation between Quality of care, Length of stay and patient satisfaction. If LOS is used as a quality measure for injured patients, adjustment for these factors is necessary.  et al.  “Ideal” length of stay after colectomy: whose ideal?Â, Schwartz Process involves the various steps involved in the delivery of health care. Dr Brasel and her colleagues have brought forward an important issue: How is quality measured? Something that can, and does, vary.  EHHerrin In multivariate analysis, factors significantly associated with extended LOS included age, sex, race/ethnicity, insurance status, discharge destination, and Revised Trauma Score. However, do you believe that any assessment of LOS is relevant if readmission rates are not included?  SL Effect of pre-existing disease on length of hospital stay in trauma patients.Â, McAleese 2011 Oct 1; 58(4):s266-s267. Compared with patients discharged to home, the odds ratio for an extended LOS for patients discharged to another hospital, rehabilitation facility, or nursing home was 2.23, 3.74, and 3.83, respectively.  DLHopson Discharge destination had the greatest association with extended LOS. We have case managers who work on that actively. There is hardly any research on how patients in general appreciate the actual length of a hospital stay. Medicaid patients and those designated as self-payers were associated with an extended LOS (Table 2).  et al.  Health-related quality of life and postoperative length of stay for patients with colorectal cancer.Â, Thomas I do not think we are going to be able to throw out LOS. Source: The user community Arch Surg. �� 5h�A��6C�̐i�sF�i���{��`��1}wۍø(g��G`��Θ0�cS�OX������-���ȥ����.�J�.�:�� ���S��U�m���yQw�m!��"�����0P�`:`‚Q���/%N*�)O�Y�/�:IG�:����|�J����0�6I�p��,]��8�S���9.p�+\c��Xa�/�����fk�W��kb�D�O6C�-�;�ܵ����dQA��A��q\|�t� This comparison between hospitals is used as one measure of the quality of care provided. Length of stay (LOS) has been suggested as a meaningful outcome measure that is a potential target for quality improvement activities.  PD Quality of health care, part 2: measuring quality of care.Â, Brasel Building on the foundations established by Shewhart17 and Deming,18 Donabedian19 enumerated the 3 essential components necessary to measure the quality of health care—structure, process, and outcome.  KMKoch We did look at some interaction terms. The Tukey multiple pairwise comparison test was used to control the type I error rate.13,14 Before developing the regression model, the following variables were recategorized for further analysis. Scott R. Petersen, MD, Phoenix, Ariz: Hospital administrators are constantly looking at LOS and, subsequently, direct variable costs. Intensive care unit LOS and need for admission to the intensive care unit were initially included in the models but were ultimately excluded because intensive care unit LOS is essentially a subset of total hospital LOS. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days).  RS Variations in healthcare measures by insurance status for patients receiving ventilator support.Â, MacKenzie We obtained 313 144 medical records. Length of stay measurement can be used throughout a hospital or for a specific therapy area, such as acute myocardial infarctions (AMIs). We did not assess regional differences. However, an assumption that cuts through most performance improvement or quality programs is that attention to structure and process will result in better outcomes.  MJEvery Length of stay is a commonly used outcome measure. Comorbid conditions, clearly shown to affect LOS in hospitalized injured patients, were not considered in the model because of the large amount of missing data and quality of this field in the version used.  JWedderburn In your database, did you look at high-volume trauma centers, different levels of trauma centers, and how that influenced LOS?  NR What are you tracking now in your own facility insofar as LOS? STS measures have either been endorsed or are being considered for endorsement by the National Quality Forum. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). The average length of stay in hospitals (ALOS) is often used as an indicator of efficiency. Methods  Accepted for Publication: December 31, 2006.  JA  MVFrankenfield Complication Rate:The percentage of patients who develop complications (typically surgical complications) as a result of care. Length of stay could be part of assessing rehabilitation and long-term care similarly to assessing acute care. Dr Brasel: I am not sure I have a short or a simple answer to that question, but I do think it is important. However, the large cross-sectional sample suggests that the results reflect general associations with extended LOS. It did not turn out to be independently significant, although, as you might imagine, patients who are injured through blunt mechanisms are significantly different with respect to some of those nonclinical factors from patients who are injured via penetrating mechanisms. I would like to say we have reduced that. Drafting of the manuscript: Brasel, Lim, and Nirula.  AABroyles As a medical director of a hospital trauma service line, I am informed on a quarterly basis about our direct variable costs and where the service is in relation to our goal. Length of stay is a quantitative indicator that can be used to measure quality of care on older adult inpatient wards and is affected by a number of different factors, such as severity of mental illness, compliance with treatment plan, physical health issues and discharge delays.  WM Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis.Â, Liu Body region injured was categorized into the following 6 groups: head, face and neck, thorax, abdomen, spine, and upper or lower extremity. Terms of Use|  DLMundy 6�nlb�X��4Du$[����9�H�֗\{��)� xX�I endstream endobj 410 0 obj <>stream It is my impression that victims of violent acts are much more difficult to place and, thus, have a prolonged LOS even though their injuries are essentially equivalent to those of others.  WA The application of statistics as an aid in maintaining quality of a manufactured product.Â, Donabedian 2. Length of stay is commonly used as a quality metric.  D Impact of pre-trauma center care on length of stay and hospital charges.Â, Holloway Some of this is moderated by race/ethnicity, inasmuch as interaction terms between groups were significant. Benchmarking & Reducing Length of Stay in Hospitals pMD prides itself on helping providers and practices accomplish their goals and measure their quality improvement initiatives. "#|��Z�0�v)�Ė�?�KV�B�q�q�t������~���&��/�-��]�']�_��/�[�ܜu"�.�/���xs�tAV�ޭ =E/�RRI�n��L�K���Q�@$� ���U�� �j�1.x�Q2D�!G@_�(t��@���G���1����&��@���7K(����>�@�"�I����F%K��r�>dM��������?�������k���E�� O�F�'r����'��]�3=����J�}_"ԗ$������9z�Э And that was not even because of some of these nonclinical factors. Records were excluded from the analysis if they met any of the following criteria: patient younger than 18 years; LOS missing, less than 48 hours, or longer than 365 days; or LOS less than the number of days in the intensive care unit.  B Transfer agreements for rehabilitation and LTACF care could be incorporated into a trauma center's overall care plan. In some communities, none of these beds may be available. However, it becomes overwhelmed by those other nonclinical factors. Customize your JAMA Network experience by selecting one or more topics from the list below.  GJMaier  JA Reasons for delayed discharge of trauma patients.Â, Chan The authors have thoughtfully and convincingly demonstrated that a seemingly simple and straightforward statistic is influenced by myriad complex factors, many of which are nonclinical and beyond the control or influence of surgeons or hospitals.  LW  et al. Canadian CABG Surgery Quality Indicator Consensus Panel, The identification and development of Canadian coronary artery bypass graft surgery quality indicators.Â, American College of Surgeons Committee on Trauma,Â, Khaliq •Conceptualization or conceptual definition. I have 2 questions: Have you looked at the direct variable costs in your facility? Improving and reducing length of stay (LOS) improves financial, operational, and clinical outcomes by decreasing the costs of care for a patient. Length of stay should be used as a process measure rather than an outcome measure to truly improve the quality of care that we give. Patients with Medicaid insurance had the longest stay (mean ± SD), 11.3 ± 15.8 days, while those with Medicare insurance had the shortest stay, 8.8 ± 11.3 days (Table 3). As with other aspects of a well-run trauma system, this approach should be inclusive and enable postacute care for all patients including the uninsured or underinsured. For example, adherence to a guideline for management of patients with splenic injuries improved outcome, measured as splenic salvage rate.22 Process measures are also used in the Institute for Healthcare Improvement 100 000 Lives initiative23 in an effort to reduce catheter-related bloodstream infection, ventilator-associated pneumonia, surgical site infection, in-hospital cardiopulmonary arrest, death after myocardial infarction, and adverse drug events. Continued extended LOS might indicate an unmet LTACF bed need, which would need to be addressed at the system level. © 2020 American Medical Association. Goals/Objective: To achieve the following by 7/31/10 (50% of benchmark): 1. For example, discharge to home included the subcategories of home, home with health care assistance, psychiatric facility, and jail.  G Because the analysis of variance showed differences in LOS by group, generalized linear models were created to examine the association of demographic, clinical, and nonclinical factors, as well as the interaction term of race/ethnicity × payer status, with an LOS greater than the mean. Definitions of excessive, increased, or extended LOS are varied, and there is no acceptable gold standard.1,30 Length of stay greater than the mean or median has been used by others31,32 and is appropriate in this large database containing patients with many different injury diagnoses. By continuing to use our site, or clicking "Continue," you are agreeing to our, 2020 American Medical Association. We have all heard recently, and frequently, the mantra of “pay for performance,” which will greatly affect our practices regardless of our geographic locations and our practice setting. I think it is an important concept. Gregory J. Jurkovich, MD, Seattle, Wash: Two quick questions: First, do you know what the UHC uses as risk adjustment?  MRosenblatt Longer stays result in higher costs and extra burdens on patients and their families. Are you certain that your data are broadly representative of patients with injury? Mean LOS for patients with Medicaid (11.3 days) was significantly longer than for patients with commercial insurance and uninsured patients (each 9.3 days) and patients with Medicare (8.8 days). Discharge destination had the greatest effect on LOS. We obtained 313 144 medical records. Length of stay greater than the mean. The UHC adjusts for age and comorbidity. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force, 2007;142(5):461-466. doi:10.1001/archsurg.142.5.461. Discharge destination was home for 63% of patients, a rehabilitation facility for 16%, a nursing home or other long-term care facility for 13%, another hospital for 4%, and other for 4%. However, there was a significant interaction effect between race/ethnicity × payer status on LOS (Table 2). It comes down to realizing that hospital care usually costs more for patients and the organization than care in outpatient settings. I grouped discharge destination primarily based on my experience in that patients whom I discharge to jail or psychiatric facilities essentially must be able to take care of themselves, somewhat similar to patients whom I discharge to home. Total patient days can be calculated by adding the length of stay of all patients during the period under calculation. Previous Presentation: This study was presented at the 114th Scientific Session of the Western Surgical Association, November 15, 2006; Los Cabos, Mexico; and is published after peer review and revision. Finally, based on your analysis, is LOS a meaningless parameter of quality measurement? The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript. Some of these factors include discharge destination, the presence or absence of family support, payer status, and the availability of rehabilitation or long-term care facilities. Statistical analysis: Lim and Nirula. Commercial entities such as HealthGrades have attempted to assess the quality of care provided by both institutions and physicians and have made their conclusions available to the public. the Average Length Of Stay (ALOS) for patients under Hospitalist care exceed the benchmarks for large community non-teaching hospitals. Your study population was a diverse trauma population. My question is: How can we take these data and turn them around and create a national forum to really increase access to rehabilitation, which is one of the frontiers of trauma systems that is totally undeveloped. It is suggested that if LOS decreases, care has become more efficient and more effective, because patients with extended LOS often consume substantial hospital resources. Rather, we suggest these data bring into question whether LOS should be considered a process measure or an outcome measure. Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. Were there state or regional differences in either LOS or the nonclinical factors that seemed to influence LOS? Privacy Policy| 266 Emergency Department Length of Stay as a Quality Measure: Will There Be Unintended Consequences for Safety-Net Emergency Departments?.  JrEdelstein Can a single statistic serve as a valid indicator of quality and efficiency? h�22�P0P����+�-�6 2��]��b�� U�� endstream endobj 407 0 obj <>stream �)g�rZ�"*g���*4N�")��ɠ���\Td�Ri�F��� �I�  N If you are just discharging people from the hospital after a first admission and they return and are readmitted for another 4, 5, or 6 days, that probably does not influence resource consumption and may be an indicator of poorer quality of care rather than improved quality of care.  JElbel  EJMorris Hospital length of stay (LOS) has long been a crucial barometer of hospital efficiency and quality of care. Overall average length of stay decreased from 19 days to 7.5 days Average acute length of stay decreased from 6 days to 4 days Average ALC length of stay decreased from 25 days to 22 days There was a 48% improvement in assigning the expected date of discharge (from 50% to 98%) There was a 66% improvement for meeting the expected date of Get free access to newly published articles.  MALambert  SSarosi What I would like to see is LOS used intelligently and to work with administrators rather than having them spend inordinate amounts of personnel time and statistical time fudging the statistics to make LOS look good. While acute care is provided without concern for insurance status in most cases, rehabilitation or placement in a long-term acute care facility (LTACF) is done only after an assessment of payment has been made. In the final regression model, we examined not only the significance of the risk coefficients but also the strength of association. Nonclinical factors were defined as demographic and socioeconomic factors, including age, sex, race/ethnicity, payer status, and discharge status. Nonclinical factors significantly influence LOS. All Rights Reserved.  RWRoberton Acquisition of data: Brasel.  CWeigelt Although injury severity was significantly associated with extended LOS, other factors had much stronger associations. doi:10.1001/archsurg.142.5.461.  ML 31 4.  KE Using clinical practice analysis to improve care.Â, Guru 7}���u��N�_��r��[��'������ ���\ endstream endobj 408 0 obj <>stream © 2020 American Medical Association. h��W�n�8�>njkx'Ph�]$[�5��F�j�b�4�gđ-��,Z`_D�<3�9�� �#4Q��_G\N� [9I��!�o�$k��_��I���|։��/�d���|�r�p\��p�H7���2��E�O�"ٞ0���X}�6�deU��II�����W�.�G���xW���s�E�/�Y��&�Iy"��,�0e"߃��L��llaX����>h����5~z0~~�����n�=ʖ�_X�~����*�!V��bUǠjz�4o�ۆQ�k�iX����H|�����~DQG>M9Q$#�����r�J��ò�7�l�g�,M�z��!cOދ~�l��8;9��)�o.��C���j�v�^\�yr����M�ްi��a3��i}��?���� This study has limitations. The expected length of stay is based on a comparison with ... Hospital occupancy can be affected by this measure. Dr Brasel: I would say, probably not. Your multivariate logistic regression shows a number of these variables as being individually important, but I cannot imagine that many of these are not related to each other. There are a lot of nondesignated centers in the NTDB or centers that have chosen not to report a designation. And I think, going back to one of Dr Smith's questions, looking at this on a regional basis may help, or looking at a smaller subset where we might have days in rehabilitation, and use LOS as a system aspect rather than just in acute hospital care. The relationship of LOS, effectiveness, and efficiency may not always be direct.  RJJacobs We included mechanism of injury, blunt vs penetrating trauma, in early analyses. hospitals to improve length of stay efficiency • evaluates the effectiveness of targeted programs and better practice guidance. P<.05 was considered statistically significant.13,15 Analyses were carried out using SAS statistical software (version 9; SAS Institute, Cary, NC).14.  JHenderson Second, have you considered interaction between the variables used in your regression analyses? Mark Talamonti, MD, Chicago, Ill: Length of stay is also used as a measure of quality in surgical oncology, and is very complex in that setting. For example, the percentage of uninsured patients, 16% in your study, seems small for a trauma population. Many facilities that submit data to the NTDB do not include financial information such as payer type. Dr Brasel and her colleagues could have entitled this paper “Lies, Damn Lies, and Statistics.” I have several questions. 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Analysis of variance was use for continuous variable and a χ2 test was used for categorical variables.  GMFremes  M The use of hospital care: do insurance status, prospective payment, and the unit of payments make a difference?Â, Schnitzler 1. Our website uses cookies to enhance your experience. We aimed to disentangle the correlations between these interrelated measures and propose a new way of combining them to evaluate the quality of hospital care.  SHChalian Number Of Medication Errors:The frequency of errors when prescribing medication. •Any characteristic that can take on more than one form or value. to download free article PDFs, =mE�;��]f7���J�  et al. Acute Myocardial Infarction Working Group of the American Heart Association/American College of Cardiology First Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, Challenges and opportunities in quantifying the quality of care for acute myocardial infarction.Â, Bradley STS continues to develop and maintain quality performance measures in the areas of adult cardiac, general thoracic, and congenital heart surgery. Length of stay (LOS) has been suggested as a meaningful outcome measure that is a potential target for quality improvement activities.1-5 The American College of Surgeons Committee on Trauma uses LOS as an example outcome measure for a performance improvement program.6 Although the influence of many clinical factors on LOS is both intuitive and supported by data, studies from medical and elective surgical patients confirm the additional importance of nonclinical factors.7-12 One of these factors is insurance or payer status. Seagrasses Adaptations In Coral Reefs, 1 Samuel 17 Niv, Fuji Gfx 100 Vs Phase One, Kraft Chipotle Aioli Sauce, Transpose Of A Matrix In C, Industrial Heavy Duty Fans, Ryobi One+ Hedge Trimmer Kit, Giraffe Transparent Background, Costa Rica Weather In January 2020, " />

length of stay quality measure

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length of stay quality measure

In your first slide, you showed that the UHC did have risk-adjusted LOS. •What is measurement? If LOS is used as a quality measure for injured patients, adjustment for these factors is necessary. What is a variable?  RW Generalized linear models.Â, Shewhart  et al.  Impact of age on clinical care pathway length of stay after complex head and neck resection.Â, Nelder Measure 2: Patients are excluded from the denominator if the patient did not expire in hospice care or the patient received any continuous home care, respite care, or general inpatient care in the last 7 days of life, or had a length of stay of one day. Should organizations that purport to measure quality of care abandon LOS as an indicator of effective and efficient care?  JrRue Implementation of the weekly long length of stay patient reviews as set out in ‘reducing long length of stays’ 14 May 2019 Shared learning. Measure Category: Clinical Outcomes Quality Domain: Patient Safety; Efficiency Current Findings in the Literature: Patients may Other papers that have examined LOS in surgical oncology have tried to relate it to high-volume centers and to complexity of cases. Efforts to measure ED quality are in their infancy, focusing on a small set of conditions and timeliness measures, such as waiting times and length-of-stay. This relationship is best illustrated with process measures. +, positive correlation. Length of hospital stay (LOS) following surgical cancer care is an important measure of short-term quality of care. The NTDB is a nonsystematic sample of hospitalized injured patients using data submitted voluntarily by participating hospitals, and population-based estimates or conclusions are impossible.  JDavis Donald E. Low, MD, Seattle: Many of the comparisons in which we see LOS used as the most relevant factor have to do with the evolution from open to minimally invasive and even interventional types of procedures. Discharge destination was grouped into the following 5 categories: home (home, home with home health assistance, jail, or psychiatric facility), rehabilitation facility, nursing home (skilled nursing facility or nursing home), another hospital, and other (unknown discharge destination or patient unable to complete treatment). ADDRESSING BARRIERS TO REDUCING LENGTH OF STAY IN HOSPITAL �Bp=�؆ę.BL!o�z��msh7���z�8�fp��X�|֮���㲣���$*0@B=����bn� �{,�O3�q��i߰��K�p�-dп�O�gdHݎ}�rF��`�o��p�9{s��٧%G�"���h�i�9F�`F譽�)�`$^��HD��@ 5a4x!L4�����a�G��5� This project will review measures addressing length of stay, all-cause admissions and hospital readmissions from applicable settings, such as skilled nursing facilities and inpatient rehabilitation facilities, and will include the ad-hoc review of #1789 Hospital-Wide, All-Cause Unplanned Readmissions.Read more Ni���K*$��T,�v� m�*���/i�P���'�c. Because we included all injuries in patients surviving more than 48 hours, this difference in inclusion criteria should have a minimal effect. Hypothesis  •Variables are what are measured. The NHS has, for a long time, focused on attempting to reduce patient length of stay in hospital. There are several ways to meas… Charges. It is so easy to measure and is such a part of the administrative culture. Design  The American College of Surgeons Committee on Trauma suggests the use of LOS as an example outcome measure in a performance improvement program. Brasel KJ, Lim HJ, Nirula R, Weigelt JA. ��Q*�U}��p@4HP�N���ΗP6��}�"�����ϒ)���� Your article has highlighted that LOS and indirectly controllable costs are not necessarily a provider-only outcome but a process of care. While extended LOS certainly demonstrates holes in our health care system, is this an appropriate measure of quality of care in a trauma center? Records were also excluded if any of the primary variables of interest were missing. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). Insights from Definitive Healthcare based on most recent available CMS data, hospital cost report period, 2018 (accessed July 2019). Equity Measures While not associated with any particular IOM domain, descriptive measures can convey the hospital’s capacity for providing quality of care and service. The variable of race/ethnicity was divided into the following 4 groups: white, black, Hispanic, and other (Asian/Pacific Islander, Native American, and Native Alaskan). Descriptive statistics were used to summarize the data.  CJohantgen ʗ�nibl�T�o������p���49�B-\��(�Y49"ڥL�;P�joD�W�kMX���!u��>-ݏ�Y�ރ � �W�� ��=�%n�~,����5~�i[�b�B~���.~__~8�p���|� �w~�*w��E��c��N�.������n��t�&m�z��W���]��EX��S��r}�o�����APz H~5�5^�g$B����F�ח����:�� Length of stay could become a monitor for how well a community and a trauma system is identifying and managing available LTACF beds in the community. The interaction of race/ethnicity and insurance is significant. Have you looked at interaction variables for those key nonmedical social sorts of issues that relate to LOS? Dr Brasel: We looked at this about 4 years ago and found that about 25% to 30% of our extended LOS on a prospective basis was completely nonmedical. Other reasons for an extended LOS may relate to its surrogate for socioeconomic status, including nutritional status, social support networks, and incidence of posttraumatic stress disorder. u��z����m{]wK����ޓ`_]'��B�QЀ2�F��ѦȮ��j�����F������:���҇����҆�j*���R�Kn��,��� -h� %PDF-1.7 %����  VAnderson However, the large number of hospitals from different regions of the United States that do contribute allow many possible regional influences to be overcome. Overall survival was 97%. Conclusions  0j�M��ٛ�&HcV�wAb'@���?��x��Ab�w�f�j�F��{��M���CG#Z�Υ����[$ԅ ^ u�`���u����:}o�%��ԩ=� �zm� Early results suggest that compliance with the identified process measures improves the targeted outcomes.23,24 Other studies have not confirmed that standardized process implementation will have significant effect on outcomes.25 While process measures may correlate directly with desirable outcomes, it is not clear that all process or outcome measures will monitor or measure what is intended to be measured.24-26. Arch Surg 2007 May;142(5):461-5; discussion 465-6 Date 05/23/2007 Pubmed ID 17515488 DOI 10.1001/archsurg.142.5.461 Abstract. The 2004 National Trauma Data Bank (NTDB) data set was used. Using LOS as a process measure rather than a benchmark outcome measure enables an individual trauma center to investigate and address all of these potential reasons. The organization embraced the … •They represent the properties of an object that we are interested in measuring.  LMYaezel Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). Hospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care. Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days, and preceded within an hour by an emergency department visit at the same physical facility Measure Steward: Centers for Medicare & Medicaid Services (CMS) Measure Scoring  JAChristians The patients were assessed as ready to go and the physicians were ready to write the discharge orders, but the consultant had not put a final opinion on the medical record, there was some nursing issue to be done, the discharge supplies were not ready, or there was no bed available in a rehabilitation facility or a nursing facility. 3g�h��ۖ�5��$eOS_�]C�Ҍ;t}����M�-^7��!������[������di��6ɘZ��y�$|')�[���k�2-�+������� ��� endstream endobj 409 0 obj <>stream For multivariate analysis, LOS was converted from a continuous variable to a dichotomous variable, LOS less than or equal to the mean LOS and LOS greater than the mean LOS. Longer than necessary LOS results in excess costs of $1,393,850 annually. While my teenage children may consider home the equivalent of incarceration, I am not sure this is true of trauma patients.  A Quality assessment and assurance: unity of purpose, diversity of means.Â, Crombie  W The effect of complications on length of stay.Â, Case It can also improve outcomes by minimizing the risk of hospital-acquired conditions. Clinical factors alone may capture only 27% of the variation in extended LOS.1 Most risk-adjustment models do not include adjustment for the important nonclinical factors that affect LOS. For each effect from the models, the odds ratio and 95% confidence interval were calculated. The quality measure short stay and long stay definitions are: The short stay resident quality measures show the average quality of resident care in a nursing home for those who stayed in a nursing home for 100 days or less or are covered under the … While unadjusted LOS may not be a valid outcome measure, it may have value as a process measure for many trauma programs. Length of stay should not be used as a comparison between trauma centers or as a benchmark outcome measure unless it is appropriately adjusted. The current data demonstrate that discharge destination had the strongest association with extended LOS, with odds ratios ranging from 1.15 to 3.83 for discharge destinations other than home.  III The financial impact of delayed discharge at a level I trauma center.Â, Collins In multivariate analysis, factors significantly associated with extended LOS included age, sex, race/ethnicity, insurance status, discharge destination, and Revised Trauma Score. 1: Length of stay data for Massachusetts General Hospital. Author Contributions:Study concept and design: Brasel, Lim, Nirula, and Weigelt. Mean LOS was 9.6 days. Dr Brasel: First, with respect to financial data, we did not use either costs or charges in this analysis, although that would be interesting, and all records that we included did have payer source. Subgroup analysis investigated the effect of missing variables; risk estimates did not change significantly and, therefore, data imputation for missing variables was not performed. Others, including pain, function, and quality of life, are more difficult to measure.  JARadford Placement of patients without adequate and appropriate insurance requires substantial personnel time and effort and may often depend on a very few beds in LTACFs in any given community. ��  LB The value of process measures in evaluating an evidence-based guideline.Â,  A resource from the Institute for Healthcare Improvement.Â, Spertus Mean LOS for patients with Medicaid (11.3 days) was significantly longer than for patients with commercial insurance and uninsured patients (each 9.3 days) and patients with Medicare (8.8 days). Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons. The National Trauma Data Bank was queried for all patients older than 18 years with an LOS longer than 48 hours and complete demographic information including age, sex, and race/ethnicity; nonclinical factors including payment type (commercial, Medicaid, Medicare, uninsured, and other) and discharge destination (home, rehabilitation facility, nursing home, and other); and clinical information (body region injured, Injury Severity Score, and Revised Trauma Score).  et al.  Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short-term mortality.Â, Rocco Dr Brasel: All of the factors that the UHC adjusts for are clinical, unlike the Hospital Efficiency Index, which includes some nonclinical adjustment. The ALOS refers to the average … Based on these data, it is tempting to suggest that LOS should not be used as a quality indicator. What is the UHC using as risk adjustments in a trauma population for LOS? Examples include the use of perioperative β-blockers, the timeliness of perioperative antibiotic administration, and the presence of an attending physician at a trauma resuscitation. It can be tracked by a specific timeframe or d… All other things being equal, a shorter stay will reduce the cost per discharge and shift care from inpatient to less expensive post-acute settings. Compliance with evidence-based guidelines is a process measure.  et al.  Discharge disposition from acute care after traumatic brain injury: the effect of insurance type.Â, Schoetz As a process measure, LOS would be used differently. Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors.  GEJurkovich Length of stay. h��Xko۸�+���"ᛔ.�w�M��Ӧ� ��hkK�-����{����#m�]�9�g�)��x$����(m$b��"� .�dB�I���6���A�XF�F�XE14�XG�(чc��-)R�`��ԕT&��B�s�#�$5�HY.”*F�D?�a�Lt�5)K,H�b#�B�E�K�O���GF)��<2�B=���).#�z�Ud&��7��xt�v������i��n1��v���G?~����6��5;���4��Ay�\����,7ۚǑj[h�Po;�Y�WI3�����\�ʝ�+���t��Y���a:����C6�G��)���?����g�m:�zTN"��'d�;Wˣ~������N5���^:��6�:��*-/�w7���|P�d�;I��(�� ������|�W�M���������[G�zӁ��(V����c��ݗ�3;X}� ��0��b'�p1;,�rw�x��N��p�Wp�S������V�ӥ�w�ȳ�?�]�}u8+g�tk�ް�e:���n�#��������&d�$�ń}���5�ouY��Ykp�`L6��{���t�?�.oӺ��s̑�]�� Study supervision: Brasel and Weigelt. title = "Length of stay: An appropriate quality measure? Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons.  SE Did you assess LOS for the various subcategories of discharge destination? h�22�T0P���w�/�+Q0���L)�621�)�I3�RY�����Zlg` �v endstream endobj 406 0 obj <>stream This confirms associations found by others, primarily in small, single-institution studies.28,29,33 Once this relationship is established, it is difficult to look at unadjusted LOS as an outcome measure evaluating quality of hospital-based medical care. Payer status had the next greatest effect; Medicare patients were significantly associated with an LOS less than the mean compared with patients with commercial insurance (odds ratio, 0.77; 95% confidence interval, 0.73-0.82).  RV Defining excess resource utilization and identifying associated factors for trauma victims.Â,  The best medical evidence for the best care management.Â,  Wisconsin Collaborative for Healthcare Quality Web site.Â, Englert  L Outcomes are, simply put, results. Main Outcome Measures  Reducing length of stay Quality, Service Improvement and Redesign Tools: Reducing length of stay What is it? Clearly, age, physiologic status, and body region injured are also important. Length of Stay This measure allows organizations to systematically assess the impact of implementing health information technology (health IT) with the intent to decrease inpatient length of stay (LOS). Quality medical care has become the primary focus in US health care since the 2000 report from the Institute of Medicine.16 Organizationally, performance improvement is the cornerstone on which advances and increases in quality are based. Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank.  HT Beyond health outcomes: the advantages of measuring process.Â, Brook 405 0 obj <>stream '|ⲻg��o�U��SO�b�ir�����oLK��$U�1�� Results of the analysis of variance are given in Table 1; results of the generalized linear model analysis are given in Table 2. A simple comparison using injury severity will be inadequate. Discharge destination and insurance status are major factors in increased LOS in the injured patient. We have not been very successful.  JTemkin Your categories of discharge destination were somewhat broad.  EACleary Therefore, when a patient is well enough to receive care outside of the hospital, they should be discharged and managed in a less costly way. Length of Stay: An Appropriate Quality Measure? Clinical factors were defined as body region injured, Injury Severity Score, and Revised Trauma Score. Did mechanism of injury, for example, blunt vs penetrating trauma or an assault vs a motor vehicle crash, have a significant effect on LOS? Mean ± SD Injury Severity Score was 12.3 ± 9.3.  RHMcGlynn Length of stay: an appropriate quality measure? Patient days that were spent outside the period under calculation should not be counted. All Rights Reserved. Business and industry have recognized the importance of this topic through the Leapfrog Initiative. That would be interesting to do. To identify potential predictors for the final model, the variables were first examined individually using univariate analysis. −, negative correlation. Administrative, technical, and material support: Brasel and Weigelt. Correspondence: Karen J. Brasel, MD, MPH, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (kbrasel@mcw.edu). Conducted within the OhioHealth system, this relatively minor intervention suggests that oncologists can change their behavior and refer patients earlier to hospice care.  LDoctor Faced with declining revenue related to changes in Medicare and Medicaid reimbursements, Memorial Hospital at Gulfport knew additional methods of providing more efficient and cost-effective quality care were needed to maintain long-term success. Based on this work, the answer appears to be no.  GKim  JCauley A simple quality improvement project to increase duration of hospice care for patients has doubled hospice length of stay, reaching the national median in 1 year. Mean LOS was 9.6 days. The prospective payment system in U.S. Medicare for reimbursing hospital care promotes shorter length of stay by paying the same amount for procedures, regardless of days spent in the hospital. I do not think putting them in a separate group would be particularly helpful because then they would be such a small minority, less than 5% in both groups. We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged … David B. Hoyt, MD, Orange, Calif: Embedded in your data is this problem with access to rehabilitation.  DSMcGory Mean ± SD age of patients was 48.2 ± 21.1 years; 62.3% were men. In addition, a multidisciplinary approach would be essential to improve the entire discharge process. You might suggest that readmission rate, as a clinical or nonclinical factor, is influential, but it goes to the point that you need to know what goes into the data and intelligently use the data when you talk with your administrators, and look at your own practice, your hospital's practice, and your system's practice. These realities of rehabilitation and skilled subacute care needs suggest that using LOS as a process measure may be helpful to a trauma system of care. Fig.  KJRasmussen It would be equally interesting to have the same objective comparisons in patients who have a single pathologic condition. El Camino Hospital leaders knew that in order to be successful, they would need to leverage real-time, targeted analytics to identify obstacles and measure improvements.  SF Risk factors for prolonged length of stay after major elective surgery.Â. Initial descriptive analyses were performed to determine whether to use parametric or nonparametric statistics.  M A high number could indicate a problem with the facility’s prescription ordering system.  WHKhuri Patients with head, face or neck, and thorax injuries had stays shorter then the mean, and those with abdominal and spine injuries had stays longer then the mean, However, the magnitude of these associations, as well as the associations of sex, age, Injury Severity Score, and Revised Trauma Score, was relatively small compared with discharge destination and payer type status. The National Trauma Data Bank was queried for all patients older than 18 years with an LOS longer than 48 hours and complete demographic information including age, sex, and race/ethnicity; nonclinical factors including payment type (commercial, Medicaid, Medicare, uninsured, and other) and discharge destination (home, rehabilitation facility, nursing home, and other); and clinical information (body region injured, Injury Severity Score, and Revised Trauma Score).  AN Attribution of inappropriate hospital days requires either prospective determination of clinical need or comparison of carefully selected similar patients with similar diagnoses, in addition to similar clinical and nonclinical factors that affect LOS.  AAGoldberg Despite certain limitations (lack of clinical detail, coding variations, time lags), quality experts regard administrative data as a reliable and usable source for the purpose of assessing hospital quality. ����a�(�]�b�E�gQh�Xd[��6�j|�x�Z?m��P�ͽ��B+��MNq���Kԑ�ˬ(����!��|�o�Z�8(F���oc�,n�?~R�"����w?�x�l�n�Ϧ�#�����:�!���eU���C�c�l���vȎ�k������3�;�̆�g�%������yh����3�Q�c��M��v��W�Ȟ�?̏n������iE_ky;��:�*َ��lD�ހ�-6�x�tv�Nj����W�#$I�"��:�w�a:Y~�^}�vC��IZq�,��m��l�5�Ǭ�>R���._��湿�����"qv�rH� R�{�a@���P��I(-���A��K'�$��׬������N,L8C �1]jD\�$}��pd$����.  KKSomberg Discharge destination had the greatest effect on LOS. Our data from the NTDB involving hospitalized injured patients suggest that nonclinical factors significantly affect LOS. Critical revision of the manuscript for important intellectual content: Brasel, Lim, Nirula, and Weigelt. Approximately one fourth to one third of the LOS may be associated with nonmedical factors.28 However, many organizations using LOS as a quality benchmark do not adjust for these important nonclinical factors.3,6,34 As an outcome measure, LOS must be adjusted for both clinical and nonclinical factors. Measure Type: Process.  IKDavies Variables were identified as significant using a .05 α level, and only these were included in a stepwise method to determine a final model. Utilization of hospital services or procedures as measured by the hospital discharge rate or average length of stay.  et al.  Disparities in the utilization of high-volume hospitals for complex surgery.Â, Brasel  DJBockler They do not adjust for injury severity or anything specific to trauma populations. Mean ± SD LOS was 9.6 ± 12.8 days. University HealthSystem Consortium (UHC), National Surgical Quality Improvement Program (NSQIP), and the NTDB all provide reports to participating hospitals providing LOS performance data indexed to some benchmark. Many current quality improvement efforts focus on measuring structure and process because these are usually easier to measure than outcomes.20,21 The relationship of structure and process to outcomes can be direct or indirect. Quality | Quality improvement. 1-5 The American College of Surgeons Committee on Trauma uses LOS as an example outcome measure for a performance improvement program.  TCDaley Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank. Forty percent of the patients had commercial insurance, 11% had Medicaid, 25% had Medicare, 16% were uninsured, and 9% had other insurance. We hypothesized that nonclinical factors, specifically payer status, would similarly affect LOS in injured patients. These quality control measures relate to reducing medical errors and protecting patients.  C Outpatient mastectomy: clinical, payer, and geographic influences.Â, Kagan  MSteiner ���rV���٭�3��-�bS*�� } ���"Y�c���z�Y�˧�2b��9��]d#?� The analysis included 313 144 medical records. Accessibility Statement, Mean Length of Stay by Race/Ethnicity and Payer Status*, Factors Associated With Extended Length of Stay, O’Keefe We did not overwhelm the model with interaction terms, but that interaction term was significant.  POdling-Smee Although much of the influence of discharge destination on extended LOS may be because of insurance status, payment type has an independent influence in the multivariate model second only to discharge status. Results  An extended stay was defined as an LOS greater than the mean LOS. hތP]k�@�+�^t�Ns� B�.�֚R���H�Br����-}������2�� �%]׀�R�t�)0{"�����5.�)Z�h!��>�.cz����pE#�x&��kn��{d*����S�`i�ˍ�]L�ÁK�1W[��01�x)�l�,�9�.s!Ƙ`�"��H�"C�C� Nonclinical factors significantly influence LOS. With respect to the uninsured, one of the problems with the NTDB is that it is not population-based, so these results, although I believe they would be relatively similar given the population-based sample, can only be generalized to the NTDB records. Your study demonstrates that LOS is really process-related and not a quality outcome. Analysis and interpretation of data: Brasel, Lim, and Nirula. Different hospitals may have different inclusion criteria for patient inclusion in a trauma registry. The type of payment was categorized into the following 5 groups: commercial, Medicaid, Medicare, uninsured, and other. Seventy-four percent of the patients were white, 17% were black, 6% were Hispanic, 1% were Asian/Pacific Islander, and 0.5% were Native American or Native Alaskan. Adjustment for clinical factors, or risk adjustment, is also inadequate. 6 Although the influence of many clinical factors on LOS is both intuitive and supported by data, studies … . Retrospective database analysis. Dr Brasel: We did not look at level of trauma center. Structure is simply the infrastructure of the health care system, which includes the individuals, the equipment, and the physical plant. HYPOTHESIS: Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. R. Stephen Smith, MD, Wichita, Kan: Since the report “To Err Is Human” was published by the Institute of Medicine in 2000, there has been an appropriate emphasis on quality of care and performance improvement. In the multivariate generalized linear models, 8 factors were associated with discharge destination (Table 2): sex, race/ethnicity, age, payment type, body region injured, discharge destination, Injury Severity Score, emergency department Revised Trauma Score, and the interaction term race/ethnicity × payer status. 2007;142(5):461–466.  KJWeigelt  JHZingmond The ACA has brought to light the importance of collecting data and using quality and outcome measures to determine how well an entity is performing. The influence of race/ethnicity and payment type on other outcome measures of resource use has been noted by others.27-29 Liu et al27 found that Medicaid patients, blacks, Hispanics, and Asians were less likely to receive complex surgical care at high-volume hospitals. Length of stay is a widely accepted marker for health care quality, and possible reduction measures include earlier subspecialist consultation, preoperative counseling regarding the anticipated length of stay, and the wider adoption of a formal multidisciplinary, clinical pathway. ", abstract = "Hypothesis: Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. hެTmo�@�+���"��\� In hospitalized injured patients, LOS in an acute care hospital is clearly affected by the need for rehabilitation or long-term care.  SDMcClellan Model of the correlation between Quality of care, Length of stay and patient satisfaction. If LOS is used as a quality measure for injured patients, adjustment for these factors is necessary.  et al.  “Ideal” length of stay after colectomy: whose ideal?Â, Schwartz Process involves the various steps involved in the delivery of health care. Dr Brasel and her colleagues have brought forward an important issue: How is quality measured? Something that can, and does, vary.  EHHerrin In multivariate analysis, factors significantly associated with extended LOS included age, sex, race/ethnicity, insurance status, discharge destination, and Revised Trauma Score. However, do you believe that any assessment of LOS is relevant if readmission rates are not included?  SL Effect of pre-existing disease on length of hospital stay in trauma patients.Â, McAleese 2011 Oct 1; 58(4):s266-s267. Compared with patients discharged to home, the odds ratio for an extended LOS for patients discharged to another hospital, rehabilitation facility, or nursing home was 2.23, 3.74, and 3.83, respectively.  DLHopson Discharge destination had the greatest association with extended LOS. We have case managers who work on that actively. There is hardly any research on how patients in general appreciate the actual length of a hospital stay. Medicaid patients and those designated as self-payers were associated with an extended LOS (Table 2).  et al.  Health-related quality of life and postoperative length of stay for patients with colorectal cancer.Â, Thomas I do not think we are going to be able to throw out LOS. Source: The user community Arch Surg. �� 5h�A��6C�̐i�sF�i���{��`��1}wۍø(g��G`��Θ0�cS�OX������-���ȥ����.�J�.�:�� ���S��U�m���yQw�m!��"�����0P�`:`‚Q���/%N*�)O�Y�/�:IG�:����|�J����0�6I�p��,]��8�S���9.p�+\c��Xa�/�����fk�W��kb�D�O6C�-�;�ܵ����dQA��A��q\|�t� This comparison between hospitals is used as one measure of the quality of care provided. Length of stay (LOS) has been suggested as a meaningful outcome measure that is a potential target for quality improvement activities.  PD Quality of health care, part 2: measuring quality of care.Â, Brasel Building on the foundations established by Shewhart17 and Deming,18 Donabedian19 enumerated the 3 essential components necessary to measure the quality of health care—structure, process, and outcome.  KMKoch We did look at some interaction terms. The Tukey multiple pairwise comparison test was used to control the type I error rate.13,14 Before developing the regression model, the following variables were recategorized for further analysis. Scott R. Petersen, MD, Phoenix, Ariz: Hospital administrators are constantly looking at LOS and, subsequently, direct variable costs. Intensive care unit LOS and need for admission to the intensive care unit were initially included in the models but were ultimately excluded because intensive care unit LOS is essentially a subset of total hospital LOS. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days).  RS Variations in healthcare measures by insurance status for patients receiving ventilator support.Â, MacKenzie We obtained 313 144 medical records. Length of stay measurement can be used throughout a hospital or for a specific therapy area, such as acute myocardial infarctions (AMIs). We did not assess regional differences. However, an assumption that cuts through most performance improvement or quality programs is that attention to structure and process will result in better outcomes.  MJEvery Length of stay is a commonly used outcome measure. Comorbid conditions, clearly shown to affect LOS in hospitalized injured patients, were not considered in the model because of the large amount of missing data and quality of this field in the version used.  JWedderburn In your database, did you look at high-volume trauma centers, different levels of trauma centers, and how that influenced LOS?  NR What are you tracking now in your own facility insofar as LOS? STS measures have either been endorsed or are being considered for endorsement by the National Quality Forum. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). The average length of stay in hospitals (ALOS) is often used as an indicator of efficiency. Methods  Accepted for Publication: December 31, 2006.  JA  MVFrankenfield Complication Rate:The percentage of patients who develop complications (typically surgical complications) as a result of care. Length of stay could be part of assessing rehabilitation and long-term care similarly to assessing acute care. Dr Brasel: I am not sure I have a short or a simple answer to that question, but I do think it is important. However, the large cross-sectional sample suggests that the results reflect general associations with extended LOS. It did not turn out to be independently significant, although, as you might imagine, patients who are injured through blunt mechanisms are significantly different with respect to some of those nonclinical factors from patients who are injured via penetrating mechanisms. I would like to say we have reduced that. Drafting of the manuscript: Brasel, Lim, and Nirula.  AABroyles As a medical director of a hospital trauma service line, I am informed on a quarterly basis about our direct variable costs and where the service is in relation to our goal. Length of stay is a quantitative indicator that can be used to measure quality of care on older adult inpatient wards and is affected by a number of different factors, such as severity of mental illness, compliance with treatment plan, physical health issues and discharge delays.  WM Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis.Â, Liu Body region injured was categorized into the following 6 groups: head, face and neck, thorax, abdomen, spine, and upper or lower extremity. Terms of Use|  DLMundy 6�nlb�X��4Du$[����9�H�֗\{��)� xX�I endstream endobj 410 0 obj <>stream It is my impression that victims of violent acts are much more difficult to place and, thus, have a prolonged LOS even though their injuries are essentially equivalent to those of others.  WA The application of statistics as an aid in maintaining quality of a manufactured product.Â, Donabedian 2. Length of stay is commonly used as a quality metric.  D Impact of pre-trauma center care on length of stay and hospital charges.Â, Holloway Some of this is moderated by race/ethnicity, inasmuch as interaction terms between groups were significant. Benchmarking & Reducing Length of Stay in Hospitals pMD prides itself on helping providers and practices accomplish their goals and measure their quality improvement initiatives. "#|��Z�0�v)�Ė�?�KV�B�q�q�t������~���&��/�-��]�']�_��/�[�ܜu"�.�/���xs�tAV�ޭ =E/�RRI�n��L�K���Q�@$� ���U�� �j�1.x�Q2D�!G@_�(t��@���G���1����&��@���7K(����>�@�"�I����F%K��r�>dM��������?�������k���E�� O�F�'r����'��]�3=����J�}_"ԗ$������9z�Э And that was not even because of some of these nonclinical factors. Records were excluded from the analysis if they met any of the following criteria: patient younger than 18 years; LOS missing, less than 48 hours, or longer than 365 days; or LOS less than the number of days in the intensive care unit.  B Transfer agreements for rehabilitation and LTACF care could be incorporated into a trauma center's overall care plan. In some communities, none of these beds may be available. However, it becomes overwhelmed by those other nonclinical factors. Customize your JAMA Network experience by selecting one or more topics from the list below.  GJMaier  JA Reasons for delayed discharge of trauma patients.Â, Chan The authors have thoughtfully and convincingly demonstrated that a seemingly simple and straightforward statistic is influenced by myriad complex factors, many of which are nonclinical and beyond the control or influence of surgeons or hospitals.  LW  et al. Canadian CABG Surgery Quality Indicator Consensus Panel, The identification and development of Canadian coronary artery bypass graft surgery quality indicators.Â, American College of Surgeons Committee on Trauma,Â, Khaliq •Conceptualization or conceptual definition. I have 2 questions: Have you looked at the direct variable costs in your facility? Improving and reducing length of stay (LOS) improves financial, operational, and clinical outcomes by decreasing the costs of care for a patient. Length of stay should be used as a process measure rather than an outcome measure to truly improve the quality of care that we give. Patients with Medicaid insurance had the longest stay (mean ± SD), 11.3 ± 15.8 days, while those with Medicare insurance had the shortest stay, 8.8 ± 11.3 days (Table 3). As with other aspects of a well-run trauma system, this approach should be inclusive and enable postacute care for all patients including the uninsured or underinsured. For example, adherence to a guideline for management of patients with splenic injuries improved outcome, measured as splenic salvage rate.22 Process measures are also used in the Institute for Healthcare Improvement 100 000 Lives initiative23 in an effort to reduce catheter-related bloodstream infection, ventilator-associated pneumonia, surgical site infection, in-hospital cardiopulmonary arrest, death after myocardial infarction, and adverse drug events. Continued extended LOS might indicate an unmet LTACF bed need, which would need to be addressed at the system level. © 2020 American Medical Association. Goals/Objective: To achieve the following by 7/31/10 (50% of benchmark): 1. For example, discharge to home included the subcategories of home, home with health care assistance, psychiatric facility, and jail.  G Because the analysis of variance showed differences in LOS by group, generalized linear models were created to examine the association of demographic, clinical, and nonclinical factors, as well as the interaction term of race/ethnicity × payer status, with an LOS greater than the mean. Definitions of excessive, increased, or extended LOS are varied, and there is no acceptable gold standard.1,30 Length of stay greater than the mean or median has been used by others31,32 and is appropriate in this large database containing patients with many different injury diagnoses. By continuing to use our site, or clicking "Continue," you are agreeing to our, 2020 American Medical Association. We have all heard recently, and frequently, the mantra of “pay for performance,” which will greatly affect our practices regardless of our geographic locations and our practice setting. I think it is an important concept. Gregory J. Jurkovich, MD, Seattle, Wash: Two quick questions: First, do you know what the UHC uses as risk adjustment?  MRosenblatt Longer stays result in higher costs and extra burdens on patients and their families. Are you certain that your data are broadly representative of patients with injury? Mean LOS for patients with Medicaid (11.3 days) was significantly longer than for patients with commercial insurance and uninsured patients (each 9.3 days) and patients with Medicare (8.8 days). Discharge destination had the greatest effect on LOS. We obtained 313 144 medical records. Length of stay greater than the mean. The UHC adjusts for age and comorbidity. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force, 2007;142(5):461-466. doi:10.1001/archsurg.142.5.461. Discharge destination was home for 63% of patients, a rehabilitation facility for 16%, a nursing home or other long-term care facility for 13%, another hospital for 4%, and other for 4%. However, there was a significant interaction effect between race/ethnicity × payer status on LOS (Table 2). It comes down to realizing that hospital care usually costs more for patients and the organization than care in outpatient settings. I grouped discharge destination primarily based on my experience in that patients whom I discharge to jail or psychiatric facilities essentially must be able to take care of themselves, somewhat similar to patients whom I discharge to home. Total patient days can be calculated by adding the length of stay of all patients during the period under calculation. Previous Presentation: This study was presented at the 114th Scientific Session of the Western Surgical Association, November 15, 2006; Los Cabos, Mexico; and is published after peer review and revision. Finally, based on your analysis, is LOS a meaningless parameter of quality measurement? The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript. Some of these factors include discharge destination, the presence or absence of family support, payer status, and the availability of rehabilitation or long-term care facilities. Statistical analysis: Lim and Nirula. Commercial entities such as HealthGrades have attempted to assess the quality of care provided by both institutions and physicians and have made their conclusions available to the public. the Average Length Of Stay (ALOS) for patients under Hospitalist care exceed the benchmarks for large community non-teaching hospitals. Your study population was a diverse trauma population. My question is: How can we take these data and turn them around and create a national forum to really increase access to rehabilitation, which is one of the frontiers of trauma systems that is totally undeveloped. It is suggested that if LOS decreases, care has become more efficient and more effective, because patients with extended LOS often consume substantial hospital resources. Rather, we suggest these data bring into question whether LOS should be considered a process measure or an outcome measure. Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. Were there state or regional differences in either LOS or the nonclinical factors that seemed to influence LOS? Privacy Policy| 266 Emergency Department Length of Stay as a Quality Measure: Will There Be Unintended Consequences for Safety-Net Emergency Departments?.  JrEdelstein Can a single statistic serve as a valid indicator of quality and efficiency? h�22�P0P����+�-�6 2��]��b�� U�� endstream endobj 407 0 obj <>stream �)g�rZ�"*g���*4N�")��ɠ���\Td�Ri�F��� �I�  N If you are just discharging people from the hospital after a first admission and they return and are readmitted for another 4, 5, or 6 days, that probably does not influence resource consumption and may be an indicator of poorer quality of care rather than improved quality of care.  JElbel  EJMorris Hospital length of stay (LOS) has long been a crucial barometer of hospital efficiency and quality of care. Overall average length of stay decreased from 19 days to 7.5 days Average acute length of stay decreased from 6 days to 4 days Average ALC length of stay decreased from 25 days to 22 days There was a 48% improvement in assigning the expected date of discharge (from 50% to 98%) There was a 66% improvement for meeting the expected date of Get free access to newly published articles.  MALambert  SSarosi What I would like to see is LOS used intelligently and to work with administrators rather than having them spend inordinate amounts of personnel time and statistical time fudging the statistics to make LOS look good. While acute care is provided without concern for insurance status in most cases, rehabilitation or placement in a long-term acute care facility (LTACF) is done only after an assessment of payment has been made. In the final regression model, we examined not only the significance of the risk coefficients but also the strength of association. Nonclinical factors were defined as demographic and socioeconomic factors, including age, sex, race/ethnicity, payer status, and discharge status. Nonclinical factors significantly influence LOS. All Rights Reserved.  RWRoberton Acquisition of data: Brasel.  CWeigelt Although injury severity was significantly associated with extended LOS, other factors had much stronger associations. doi:10.1001/archsurg.142.5.461.  ML 31 4.  KE Using clinical practice analysis to improve care.Â, Guru 7}���u��N�_��r��[��'������ ���\ endstream endobj 408 0 obj <>stream © 2020 American Medical Association. h��W�n�8�>njkx'Ph�]$[�5��F�j�b�4�gđ-��,Z`_D�<3�9�� �#4Q��_G\N� [9I��!�o�$k��_��I���|։��/�d���|�r�p\��p�H7���2��E�O�"ٞ0���X}�6�deU��II�����W�.�G���xW���s�E�/�Y��&�Iy"��,�0e"߃��L��llaX����>h����5~z0~~�����n�=ʖ�_X�~����*�!V��bUǠjz�4o�ۆQ�k�iX����H|�����~DQG>M9Q$#�����r�J��ò�7�l�g�,M�z��!cOދ~�l��8;9��)�o.��C���j�v�^\�yr����M�ްi��a3��i}��?���� This study has limitations. The expected length of stay is based on a comparison with ... Hospital occupancy can be affected by this measure. Dr Brasel: I would say, probably not. Your multivariate logistic regression shows a number of these variables as being individually important, but I cannot imagine that many of these are not related to each other. There are a lot of nondesignated centers in the NTDB or centers that have chosen not to report a designation. And I think, going back to one of Dr Smith's questions, looking at this on a regional basis may help, or looking at a smaller subset where we might have days in rehabilitation, and use LOS as a system aspect rather than just in acute hospital care. The relationship of LOS, effectiveness, and efficiency may not always be direct.  RJJacobs We included mechanism of injury, blunt vs penetrating trauma, in early analyses. hospitals to improve length of stay efficiency • evaluates the effectiveness of targeted programs and better practice guidance. P<.05 was considered statistically significant.13,15 Analyses were carried out using SAS statistical software (version 9; SAS Institute, Cary, NC).14.  JHenderson Second, have you considered interaction between the variables used in your regression analyses? Mark Talamonti, MD, Chicago, Ill: Length of stay is also used as a measure of quality in surgical oncology, and is very complex in that setting. For example, the percentage of uninsured patients, 16% in your study, seems small for a trauma population. Many facilities that submit data to the NTDB do not include financial information such as payer type. Dr Brasel and her colleagues could have entitled this paper “Lies, Damn Lies, and Statistics.” I have several questions. Patients   LMWoodward sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles. Analysis of variance was use for continuous variable and a χ2 test was used for categorical variables.  GMFremes  M The use of hospital care: do insurance status, prospective payment, and the unit of payments make a difference?Â, Schnitzler 1. Our website uses cookies to enhance your experience. We aimed to disentangle the correlations between these interrelated measures and propose a new way of combining them to evaluate the quality of hospital care.  SHChalian Number Of Medication Errors:The frequency of errors when prescribing medication. •Any characteristic that can take on more than one form or value. to download free article PDFs, =mE�;��]f7���J�  et al. Acute Myocardial Infarction Working Group of the American Heart Association/American College of Cardiology First Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, Challenges and opportunities in quantifying the quality of care for acute myocardial infarction.Â, Bradley STS continues to develop and maintain quality performance measures in the areas of adult cardiac, general thoracic, and congenital heart surgery. Length of stay (LOS) has been suggested as a meaningful outcome measure that is a potential target for quality improvement activities.1-5 The American College of Surgeons Committee on Trauma uses LOS as an example outcome measure for a performance improvement program.6 Although the influence of many clinical factors on LOS is both intuitive and supported by data, studies from medical and elective surgical patients confirm the additional importance of nonclinical factors.7-12 One of these factors is insurance or payer status.

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