Geometric Mean Length Of Stay Research Articles

Relative Value Unit (RVU) and Medicare Severity Diagnosis-related Group (MS-DRG) Reimbursement in Cervical Spinal Fusion: A 2011-2023 Trends Report.

Level 3 retrospective database study. This study aims to compare work RVU (wRVU), practice expense RVU (peRVU), malpractice RVU (mpRVU), and inflation-adjusted facility price alongside MS-DRG relative weight length of stay (LOS) for cervical spine fusions between 2011 and 2023. Both RVU and MS-DRG reimbursement have been studied in various surgical subspecialties; however, little investigation has centered on cervical spine fusions. To the best of our knowledge, this is the first study to investigate trends in RVU and MS-DRG reimbursement in cervical spine fusion throughout the COVID-19 pandemic. Center for Medicaid and Medicare Services (CMS) physician fee schedule was queried between 2011 and 2023 for RVU and facility reimbursement using common single and multilevel anterior and posterior cervical fusion codes. RVU facility prices were inflation adjusted to 2023. MS-DRG reimbursement data from 2011 to 2022 were compiled for cervical spinal fusion procedures with major complication or comorbidity (MCC) 471, complication or comorbidity (CC) 472, and without CC/MCC 473. Compound annual growth rates (CAGRs), Mean Annual Change, and yearly percent changes were calculated. No changes in wRVU were seen for all cervical CPT codes; however, the CAGR of peRVU (-0.51%±0.60%) and mpRVU (0.69%±0.41%) demonstrated marginal fluctuations. Every CPT code displayed an inflation-adjusted facility price decrease (-2.18%±0.24%). When assessing MS-DRG, there were marginal changes in geometric mean LOS (0.17%±0.45%), arithmetic mean LOS (-0.15%±0.84%), and relative weight (1.09%±0.68%). Unlike RVU reimbursement, the yearly percent change differs between each MS-DRG code. Inflation-adjusted RVU reimbursement facility prices demonstrated a consistent decrease, while DRG code reimbursement stayed relatively consistent over the study period. This data may help surgeons and hospitals become cognizant of temporal variations in reimbursement patterns as it may affect their personal practice. Level III retrospective study.

Virtual Multidisciplinary Rounds to Reduce Length of Stay, Decrease Variation, and Promote Accountability.

Evidence suggests in-person multidisciplinary rounds can help reduce length of stay (LOS) and improve throughput, but there are limited studies about the effectiveness of virtual multidisciplinary rounds on these measures. The authors hypothesized that virtual multidisciplinary rounds could help reduce LOS, improve throughput, promote accountability, and reduce provider variation. The research team designed and implemented virtual multidisciplinary rounds by a phone conference call with key stakeholders, including hospitalists, case managers, the clinical documentation improvement team, physical and occupational therapy, and nursing leaders. To track progress in real time, dashboards were created using data from electronic medical records. After several months, unit-based discharge huddles were also implemented to supplement the process and sustain the improvement. The interventions led to more than 60% of discharges below geometric mean LOS after starting the initiative, compared to approximately 52% before the initiative. Mean observation hours went from around 44 hours to 31.9 hours, and the change was sustained for more than a year. In fiscal year 2021, 3,813 excess days were reduced in 10 months, resulting in combined savings of $6.7 million. A decrease in hospitalist provider variation is noted with the initiative, which is a crucial contributor to the results. Virtual multidisciplinary rounds combined with other interventions can effectively reduce LOS and observation hours. Decreasing variation among hospitalists and improved key stakeholder engagement can be achieved with virtual multidisciplinary rounds. More studies to test the effectiveness of virtual multidisciplinary rounds in various patient care settings would provide more insights.

Comparing the Kids' Inpatient Database and National Inpatient Sample for Pediatric Research

ObjectivePediatric researchers use Agency for Healthcare Research and Quality (AHRQ) Kids’ Inpatient Database (KID) and National Inpatient Sample (NIS) to analyze the national resource use and outcomes of hospitalized children. Inherent KID-NIS sampling design differences may yield disparate findings. We compared discharge counts and length of stay (LOS) between KID and NIS for common and rare reasons for hospitalization. MethodsRetrospective analysis of differences in discharges counts and geometric mean LOS for children ages 0–20 years from KID and NIS in 2019, measured for normal newborns and 331 additional reasons for admission, distinguished by All-Payer Refined Diagnosis Related Groups (APR-DRG) and categorized in deciles by annual discharge volume. We followed AHRQ instructions for data clustering, stratification, and weighting to accommodate the KID and NIS designs, including random samples of 80% and 20% of pediatric discharges, respectively, per hospital. ResultsKID-NIS differences in national estimates for total annual discharge counts differed by only 0.5% for normal newborns and 3.7% for all other admission reasons in children. KID-NIS differences remained small aside from reasons for admission in the two lowest volume deciles: 9.5% (SD 7.9%) for admission volumes 200–520; 41.1% (SD 64.2%) for volumes <200. KID-NIS LOS differences for these two-lowest volume deciles were 7.9% (SD 7.1%) and 26.0% (SD 29.3%), respectively. ConclusionsAlthough KID-NIS differences in discharge counts and LOS were small for high-volume admissions, the differences increased with reasons for admission that had annual discharge volumes approximately 500 or less. For study populations with discharge counts <500, KID may be preferred, given its higher sampling of discharges per hospital.

Effects of Hospital-Acquired Conditions on Readmission Risk: The Mediating Role of Length of Stay

Problem definition: Hospital-acquired conditions (HACs) represent undesirable complications that occur during a hospital stay. HACs can compromise patient safety and care outcomes and result in unnecessary socio-economic costs. Although hospitals are expected to reduce the incidence of HACs, few studies have examined the implications of HACs on other clinical outcomes and measures of hospital performance. This study contributes to the literature by exploring the relationship between exposure to a set of target HACs, length of stay (LOS) performance, and 30-day readmission risk. Methodology/results: To estimate the effects of HACs, we conduct econometric analyses using patient-visit-level data for heart attack, heart failure, and pneumonia patients hospitalized in the U.S. state of Florida during 2010–2014. We define LOS performance as the deviation of LOS from the Geometric Mean LOS (GMLOS), a standard LOS set by the Centers for Medicare and Medicaid Services. First, we find that exposure to HACs leads to a 37% increase in the odds of readmission and a 79% increase in LOS. Second, an increase in LOS is associated with a decrease in readmission risk, and this decrease is stronger for patients exposed to HACs. Third, LOS performance mediates the HACs-readmission risk relationship, such that the increase in the readmission risk of a HAC patient can be fully suppressed by the patient’s LOS. Fourth, we find that for patients exposed to HACs, the benefits of a longer LOS are almost entirely capitalized when the LOS becomes 65% longer than the GMLOS. Managerial implications: We demonstrate that, when addressing the consequences of HACs, clinicians also face indirectly a trade-off between reducing readmissions and controlling costs. We proffer LOS as a potential mechanism under hospitals’ control for mitigating the adverse effects of HACs on readmission risk. Thus, this study offers guidance to clinicians having to decide when to discharge patients with exposure to HACs. Supplemental Material: The online appendix is available at https://doi.org/10.1287/msom.2022.0088 .

Successful Reduction of Postoperative Chest Tube Duration and Length of Stay After Congenital Heart Surgery: A Multicenter Collaborative Improvement Project.

BackgroundCongenital heart disease practices and outcomes vary significantly across centers, including postoperative chest tube (CT) management, which may impact postoperative length of stay (LOS). We used collaborative learning methods to determine whether centers could adapt and safely implement best practices for CT management, resulting in reduced postoperative CT duration and LOS.Methods and ResultsNine pediatric heart centers partnered together through 2 learning networks. Patients undergoing 1 of 9 benchmark congenital heart operations were included. Baseline data were collected from June 2017 to June 2018, and intervention‐phase data were collected from July 2018 to December 2019. Collaborative learning methods included review of best practices from a model center, regular data feedback, and quality improvement coaching. Center teams adapted CT removal practices (eg, timing, volume criteria) from the model center to their local resources, practices, and setting. Postoperative CT duration in hours and LOS in days were analyzed using statistical process control methodology. Overall, 2309 patients were included. Patient characteristics did not differ between the study and intervention phases. Statistical process control analysis showed an aggregate 15.6% decrease in geometric mean CT duration (72.6 hours at baseline to 61.3 hours during intervention) and a 9.8% reduction in geometric mean LOS (9.2 days at baseline to 8.3 days during intervention). Adverse events did not increase when comparing the baseline and intervention phases: CT replacement (1.8% versus 2.0%, P=0.56) and readmission for pleural effusion (0.4% versus 0.5%, P=0.29).ConclusionsWe successfully lowered postoperative CT duration and observed an associated reduction in LOS across 9 centers using collaborative learning methodology.

A comparative approach to quantifying provision of acute therapy services.

This study aims to compare delivery of acute rehabilitation therapy using metrics reflecting distinct aspects of rehabilitation therapy services. Seven general medical-surgical hospitals in Illinois and Indiana prospectively collected rehabilitation therapy data. De-identified data on all patients who received any type of acute rehabilitation therapy (n = 35,449) were extracted and reported as aggregate of minutes of therapy services per discipline. Metrics included therapy types, total minutes, and minutes per day (intensity), as charted by therapists. Extended hospital stay was defined as a length of stay (LOS) longer than Medicare's geometric mean LOS. Discharge destination was coded as postacute care or home discharge. Substantial variability was observed in types, number of minutes, and intensity of therapy services by condition and hospital. The odds of an extended hospital stay increased with increased number of minutes, increased number of therapy types, and decreased with increased rehabilitation intensity. This comparative approach to assessing provision of acute therapy services reflect differential effects of service provision on LOS and discharge destination. Investigators, policymakers, and hospital administrators should examine multiple metrics of rehabilitation therapy provision when evaluating the impact of health care processes on patient outcomes.

Frailty and hospital outcomes within a low socioeconomic population.

Clinical frailty scales (CFS) predict hospital-related outcomes. Frailty is more common in areas of higher socioeconomic disadvantage, but no studies exclusively report on the impact of CFS on hospital-related outcomes in areas of known socioeconomic disadvantage. To evaluate the association of the CFS with hospital-related outcomes. Retrospective observational study in a community hospital within a disadvantaged area in Australia (Social Economic Index for Areas = 0.1%). The CFS was used in the emergency department (ED) for people aged ≥ 75 years. Frailty was defined as a score of ≥4. Associations between the CFS and mortality, admission rates, ED presentations and length of stay (LOS) were analysed using regression analyses. Between 11 July 2017 and 31 March 2018, there were 5151 ED presentations involving 3258 patients aged ≥ 75 years. Frail persons were significantly more likely to be older, represent to the ED and have delirium compared with non-frail persons. CFS was independently associated with 28-day mortality, with odds of mortality increasing by 1.5 times per unit increase in CFS (95% CI: 1.3-1.7). Frail persons with CFS 4-6 were more likely to be admitted (OR: 1.2; 95% CI: 1.0-1.5), have higher geometric mean LOS (1.43; 95% CI 1.15-1.77 days) and higher rates of ED presentations (IRR: 1.12; 95% CI 1.04-1.21) compared with non-frail persons. The CFS predicts community hospital-related outcomes in frail persons within a socioeconomic disadvantage area. Future intervention and allocation of resources could consider focusing on CFS 4-6 as a priority for frail persons within a community hospital setting.

Impact of a care delivery redesign initiative for vascular surgery

ObjectiveA hospital-wide quality improvement process through a care delivery redesign (CDR) was initiated to improve patient care efficiency, clinical documentation, and length of stay (LOS). The impact of CDR was assessed through LOS, unplanned readmission rates, and hospital financial metrics. MethodsThe CDR team consisted of the Chief of Vascular Surgery, inpatient nurse practitioner, dedicated case manager, clinical documentation improvement specialist, and vascular surgery residents and faculty. The nurse practitioner facilitated patient care coordination, resident system-based education, and multidisciplinary collaboration. Tools created to track performance and to ensure sustainability included daily discussions of patient care barriers and solutions; standardized order sets; a mobile app for residents containing resident service expectations, disease-specific resources, and vascular surgery journal links; and a weekly inpatient tracker showing real-time patient care data. Outcome measures included LOS, case mix index, contribution margin, and unplanned readmissions. Each outcome was determined for all inpatient admissions the year before and the 12 months after CDR was initiated. Outcomes were compared between the two groups. ResultsImplementation of CDR resulted in a 23% decrease in LOS (P = .003), reducing the gap to the Centers for Medicare and Medicaid Services geometric mean LOS from 2.1 days to 0.5 day (P < .001). Clinical documentation resulted in an increase in case mix index of 10% (P = .011). The 30-day unplanned readmission rates did not change in the 12 months after CDR was initiated compared with the year before (P = .92). Financial data demonstrated decreased variable cost and increased revenue resulting in a $1.89 million increase in contribution margin. ConclusionsA CDR predicated on a dedicated service line advanced practitioner, clinical documentation education, weekly service tracker review, and real-time management of system-related barriers to patient care is described. Implementation of the CDR reduced hospital LOS with no change in unplanned readmissions and provided significant financial benefit to the hospital by increasing revenue and decreasing variable cost.

Focused Resident Education and Engagement in Quality Improvement Enhances Documentation, Shortens Hospital Length of Stay, and Creates a Culture of Continuous Improvement

System-based practice with an emphasis on quality improvement (QI) is a recent initiative for the American College of Surgeons and a core-competency for surgical trainees. Few surgical training programs have a curriculum for hospital-based QI. Our vascular surgery service implemented several QI initiatives focused on decreasing length of stay (LOS) by targeting resident education and engagement. Residents were educated on terminology and processes impacting hospital and CMS QI metrics such as Medicare geometric mean LOS (CMS GMLOS) and diagnostic-related groups (DRG) with complication or comorbidity (CC/MCC) coding. LOS initiatives focused on identifying, tracking and removing avoidable perioperative delays, and improving accuracy of clinical documentation. Residents were given specific roles in QI initiatives and the impact on LOS was quantified. Patients' CMS GMLOS were compared to actual LOS during daily rounds, with confirmation that resident progress notes contained thorough and accurate documentation of diagnoses, comorbidities, and complications. Ten minutes during weekly preoperative conferences were dedicated to ongoing QI, with LOS metrics for the inpatient census presented by trainees and reviewed by attendings. Feedback was given addressing barriers to avoidable delays and impact on LOS. Data for July 2016-June 2017 (FY17) was compared to preimplementation baseline data (FY16) for vascular discharges overall. Accurate documentation of acuity was evaluated with in-depth review of notes and overall case mix index. Within the first year of implementation, overall vascular admissions demonstrated a 21% reduction in LOS, closing the gap between observed LOS and expected CMS GMLOS, from 2.1days to 0.5days on average. Documentation improved, with a shift in 24% of DRGs to accurately reflect CC/MCC. Overall case mix index increased by 10%, from 3.07 to 3.37. A culture of continuous quality improvement can be created with the establishment of a QI infrastructure that educates and involves trainees as stakeholders. Assigning discrete roles to increase resident accountability supports both formal and informal resident education that can substantially impact hospital benchmarking metrics.

Sooner or Later? Health Information Technology, Length of Stay, and Readmission Risk

Adequate length of stay (LOS) during hospitalization is not only a critical determinant of quality of care, but can be a useful predictor of the risk of future readmissions. Recent studies have shown alarming evidence that the United States leads developed nations in terms of shorter hospital stays, rendering patients with greater risk of future readmissions. We focus on deviation between hospital LOS and the geometric mean LOS (GMLOS), a guideline for care delivery stipulated by the Centers for Medicare and Medicaid Services (CMS). Our objective is to establish the relationship between LOS and readmission risk, examine the role of health IT in reducing the deviation of LOS, and address cost trade‐offs between early discharges and readmissions. Based on a large panel of congestive heart failure (CHF) patients during a 4‐year period, we find that implementation of health IT applications is associated with a reduction in the deviation between LOS and GMLOS. This deviation is associated with a significant increase in future 30‐day readmission risk. Patients whose inpatient stays are shorter than the GMLOS guideline, by 1 day or more, are likely to exhibit a 1.1% greater risk of readmission, and even shorter stays are likely to further exacerbate their readmission risk. Further, we find that the total readmission costs are much higher than the costs incurred in keeping patients longer during their initial hospital visit. Our results have important policy implications for providers and hospital administrators with respect to their discharge policies of CHF patients.

SS10. Financial Impact of Implementing Care Delivery Redesign Initiatives for Vascular Surgery in a Hospital Setting

A fragmented health care system contributes to suboptimal resource utilization and care coordination. A Care Delivery Redesign (CDR) for the vascular surgery service was developed to improve diagnosis-related group (DRG) assignment, to decrease length of stay (LOS), and to minimize care variation through standardized care pathways. We measured the value of CDR through hospital financial metrics. The CDR consisted of a physician champion, inpatient nurse practitioner, and dedicated case manager. The vascular surgery nurse practitioner played a central role in CDR by facilitating all aspects of patient care coordination, resident education, and communication with hospital coding specialists. A real-time weekly inpatient tracker was created and reviewed weekly during vascular conference. The tracker contains patient identifier, admission and discharge date, attending, admission and discharge unit, current LOS, Centers for Medicare and Medicaid Services geometric mean LOS, and corresponding DRG. Tools created to track performance and to ensure sustainability included daily discussions of barriers and solutions on patient rounds, creation of a vascular surgery mobile app for residents, and a patient avoidable delay tracker. End points included LOS, total variable cost, case mix index, and vascular surgery contribution margin compared with pre-CDR contribution margin. Implementation of CDR resulted in a 23% decrease in LOS, reducing the gap to Centers for Medicare and Medicaid Services geometric mean LOS by 1.6 days, from 2.2 days to 0.5 day. Improvement and changes in documentation captured accurate DRGs, which resulted in an increase in case mix index of 21%. This resulted in contribution margin amounting to $1.88 million. The CDR structure as described reduces hospital LOS and improves financial service metrics. The structure is predicated on a dedicated service line advanced practitioner, weekly service tracker review, and real-time management of barriers and solutions to system-related issues. As designed, CDR provided significant financial benefit to the hospital while facilitating patient care.

Physician in Triage Versus Rotational Patient Assignment

BackgroundPhysician in triage and rotational patient assignment are different front-end processes that are designed to improve patient flow, but there are little or no data comparing them. ObjectiveTo compare physician in triage with rotational patient assignment with respect to multiple emergency department (ED) operational metrics. MethodsDesign—Retrospective cohort review. Patients—Patients seen on 23 days on which we utilized a physician in triage with those patients seen on 23 matched days when we utilized rotational patient assignment. ResultsThere were 1,869 visits during physician in triage and 1,906 visits during rotational patient assignment. In a simple comparison, rotational patient assignment was associated with a lower median length of stay (LOS) than physician in triage (219 min vs. 233 min; difference of 14 min; 95% confidence interval [CI] 5–27 min). In a multivariate linear regression incorporating multiple confounders, there was a nonsignificant reduction in the geometric mean LOS in rotational patient assignment vs. physician in triage (204 min vs. 217 min; reduction of 6.25%; 95% CI −3.6% to 15.2%). There were no significant differences between groups for left before being seen, left subsequent to being seen, early (within 72 h) returns, early returns with admission, or complaint ratio. ConclusionsIn a single-site study, there were no statistically significant differences in important ED operational metrics between a physician in triage model and a rotational patient assignment model after adjusting for confounders.

Does Payer Type Influence Pediatric Burn Outcomes? A National Study Using the Healthcare Cost and Utilization Project Kids' Inpatient Database.

Pediatric burns are a considerable source of injury in the United States. Socioeconomic status has been demonstrated to influence other disease outcomes. The goal of this study was to analyze national pediatric burn outcomes based on payer type. A retrospective study was designed using the Kids' Inpatient Database (KID), years 2000 to 2009. Patients 18 years of age and under with Major Diagnostic code number 22 for burn were included. A total of 22,965 patients were identified, estimating 37,856 discharges. Descriptive and bivariate statistics were performed. Multiple regression analysis was used to assess correlation of payer type with complications and length of stay (LOS). The majority of patients were Medicaid (52.3%). Medicaid patients were younger (4.25, P < .05), had a higher rate of being in the first quartile of their zipcode's income (46.26%, P < .05), and contained a higher proportion of African-Americans (30.01%, P < .05). Overall complication rate was higher among Medicaid patients than private insurance and self-pay patients (6.64 vs 5.51 and 4.35%, respectively, P = .11). Logistic regression analysis of complications showed that Medicaid coverage (P < .001) was associated with complications. The geometric mean LOS among Medicaid patients was 3.7 days compared with private insurance (3.5 days) and self-pay patients (3.1 days). Medicaid patients had longer LOS and more complications. Regression analysis revealed that payer type was a factor in LOS and overall complication rate. Identifying dissimilar outcomes based on patient and injury characteristics is critical in providing information on how to improve those outcomes.

Hospital Length of Stay in Individuals With Schizophrenia With and Without Cocaine-Positive Urine Drug Screens at Hospital Admission

Despite the high prevalence of cocaine use disorder (CUD) in individuals with schizophrenia, current understanding of the effect of cocaine on psychiatric hospital length of stay (LOS) in individuals with schizophrenia is limited. We therefore retrospectively examined the medical records of 5106 hospital admissions due to exacerbation of schizophrenia. Linear regression and t-test were used to compare LOS between individuals with schizophrenia with cocaine-positive urine drug test results and those with negative test results. Individuals with schizophrenia who were also positive for cocaine had shorter LOS from both unadjusted (geometric mean LOS, 8.07 ± 1.92 vs. 11.83 ± 1.83 days; p < 0.001) and adjusted (β = 0.69; confidence interval, 0.63-0.76; p < 0.001) analyses. Our results suggest that individuals with schizophrenia who also have comorbid CUD may require shorter inpatient treatment during periods of exacerbation of symptoms. Replication of this finding has relevance in treatment planning and resource allocation for the subpopulation of individuals with schizophrenia who also have stimulant use disorders.

Abstract 374: Quality Improvement Program to Optimize Pre-Operative Evaluation of Elective Cardiovascular Surgery Patients Reduces Complications and Improves Length of Stay

Background: Pre-operative evaluation of elective cardiovascular (CV) surgery patients is limited by varying electronic health records and primary care physician adherence to guideline recommendations. A standardized pre-operative evaluation protocol may optimize medical management prior to elective surgery and reduce common post-operative complications, such as atrial fibrillation (AF), which is associated with increased adverse events and length of stay (LOS). Methods: In April 2013, a quality improvement program was implemented at a high volume center to standardize pre-operative evaluation of elective CV surgery patients. A comprehensive real-time decision support tool was developed based on consensus recommendations for optimal care. Patients qualifying for prophylactic amiodarone based on the PAPABEAR trial received prescriptions upon pre-operative evaluation. Using a shared electronic medical record we reviewed all elective coronary artery bypass graft and/or valve surgeries from April-December 2013. Any complication, post-operative AF, stroke, observed/expected mortality, LOS and percent geometric mean LOS were compared between patients with 1) pre-operative evaluation + amiodarone; 2) pre-operative evaluation + no amiodarone; 3) no pre-operative evaluation + no amiodarone. Results: Among 190 elective CV surgery cases, 28 (14.7%) patients received standardized pre-operative evaluation and qualified for prophylactic amiodarone, 100 (52.6%) received pre-operative evaluation without amiodarone and 62 (32.6%) received no pre-operative evaluation or amiodarone. Pre-operatively evaluated patients receiving amiodarone had the lowest any complication (p=0.009) and post-operative AF (p=0.047). Mean LOS, percent geometric mean LOS and observed/expected mortality were lower but did not reach statistical significance. There were no differences in post-operative stroke (Figure). Conclusions: A standardized pre-operative evaluation protocol in combination with prophylactic amiodarone in appropriate patients was associated with lower overall complications and a reduction in post-operative AF and LOS. Standardized protocols may enable health care providers to optimize pre-operative management of elective surgery patients and improve care quality and outcomes.

Abstract MP29: Patient Characteristics And Outcomes Associated With In-hospital Onset Of Acute Decompensated Heart Failure

Introduction: There has been little focus on hospitalized acute decompensated heart failure (ADHF) that develops after admission, which may occur because of comorbid conditions, over-administration of fluid or post-surgical complications. Aims: To compare patient characteristics, case fatality, and hospital length of stay (LOS) associated with ADHF that develops after hospital admission as compared to those with ADHF at admission. Methods: Hospitalizations with possible ADHF were sampled, based on HF ICD codes, among those aged &gt; 55 years from the four communities of the Atherosclerosis Risk in Communities Study (2005-2010). Medical records were abstracted with events classified by physician panel or computer classified. Case fatality was obtained through the National Death Index. We identified 4,503 (unweighted) events with definite/probable ADHF, after excluding those with unknown time of decompensation (n=81), hospital transfers (n=102), and race other than black or white (n=118). Demographic and clinical characteristics were compared by ADHF onset (at/after admission). Logistic regression was used to evaluate the association of ADHF onset with in-hospital mortality, and 28-days and one-year mortality, adjusted for demographics and comorbidity. Linear regression was used to evaluate the association of ADHF onset with log-transformed hospital LOS, adjusted for demographics. All analyses were weighted to account for the stratified sampling design. Results: Of 21,052 (weighted) ADHF events, 7.4% (n=1561) developed ADHF after admission. Patients with ADHF occurring after admission were older (mean: 79 vs. 75 years), and more likely white and female. Those with ADHF at admission were more likely to have a positive smoking history, COPD, and to be on dialysis. Presence of diabetes, hypertension and coronary artery disease were not significantly different between groups. In hospital mortality (16.5% vs. 6.3%; OR= 2.7, 95% CI=1.9-3.8) and 28-day mortality (23.9% vs. 10.1%; OR= 2.4, 95% CI=1.7-3.4) was higher among those who developed ADHF after admission. One-year case fatality was similar (39.4% vs. 33.6%; OR= 1.2, 95% CI=0.9-1.6). Unadjusted mean LOS was longer for those with ADHF occurring after admission (12.8 days, 95% CI=11.8-13.8) than those with ADHF at admission (7.2 days, 95% CI=6.8-7.6). The adjusted and geometric mean LOS was 1.3 days (95% CI=1.2-1.4) longer for those who developed ADHF after admission. Conclusion: Although patients with ADHF onset after admission were slightly older, differences in comorbidity do not indicate an easily identifiable subgroup for closer in-hospital monitoring. Development of ADHF after admission was associated with an alarmingly high early case fatality and longer hospital LOS compared to those with ADHF at hospital admission.

Observed and Expected Outcomes in Transfer and Nontransfer Patients With a Hip Fracture

Hospitals and providers that accept transfer patients risk lower ratings on publically reported quality measures that are inadequately adjusted for infirmity and complexity. We compared the outcomes of transferred patients and nontransferred patients after treatment of a hip fracture and sought to determine if expected outcomes based on an expansion of All Patient Refined-Diagnosis Related Groups (APR-DRGs) norms are accurately adjusted for transfer status. Retrospective cohort study. Tertiary care referral center. Four hundred six consecutive patients 65 years and older who received operative treatment of an acute hip fracture. Patients who were transferred from another acute care hospital or a skilled nursing facility before treatment were classified as transfer patients (n = 123), and all other patients were nontransfer patients (n = 283). Groups were compared with respect to in-hospital mortality, length of stay (LOS), excess days over the geometric mean length of stay (GMLOS), and readmission rate as well as expected length of stay (Exp LOS) and expected mortality (Exp Mort) based on APR-DRG norms and additional adjustment for transfer status. Transfer patients had significantly greater LOS (10.2 vs 9.6 days; P < 0.05), Exp LOS (9.7 vs 7.7 days; P < 0.001), Exp Mort (0.07 vs 0.03; P = 0.004), and excess days over the GMLOS (4.1 vs 3.3 days; P = 0.025) than nontransfer patients, near-significant greater in-hospital mortality (9.8 vs 4.9%; P = 0.069), and similar readmission rates. The differences in LOS and Exp LOS were nonsignificant in both transfer (P = 0.49) and nontransfer patients (P = 0.10). Patients 65 years and older transferred to a tertiary care facility for treatment of an acute hip fracture have worse outcome than nontransfer patients. Unadjusted data such as in-hospital mortality may be misleading, but risk adjustment using the APR-DRG methodology and additional correction for transfer status may provide meaningful benchmarks.

Is length of stay in hospital a stable proxy for injury severity?

Research questionIs length of stay (LoS) in hospital a stable proxy for severity of injury when monitoring time trends in serious injury incidence?ObjectiveTo investigate whether LoS metrics (mean, median and...

Rural Implications of Medicare's Post‐Acute‐Care Transfer Payment Policy

Under the Medicare post-acute-care (PAC) transfer policy, acute-care hospitals are reimbursed under a per-diem formula whenever beneficiaries are discharged from selected diagnosis-related groups (DRGs) to a skilled nursing facility, home health care, or a prospective payment system (PPS)-excluded facility. Total per-diem payments are below the full DRG payment only when the patient's length of stay (LOS) is short relative to the geometric mean LOS for the DRG; otherwise, the full DRG payment is received. This policy originally applied to 10 DRGs beginning in fiscal year 1999 and was expanded to additional DRGs in FY2004. The Secretary may include other DRGs and types of PAC settings in future expansions. This article examines how the initial policy change affected rural and urban hospitals and investigates the likely impact of the FY2004 expansion and other possible future expansions. The authors used 1998-2001 Medicare Provider Analysis and Review (MEDPAR) data to investigate changes in hospital discharge patterns after the original policy was implemented, compute the change in Medicare revenue resulting from the payment change, and simulate the expected revenue reductions under expansions to additional DRGs and swing-bed discharges. Neither rural nor urban hospitals appear to have made a sustained change in their discharge behavior so as to limit their exposure to the transfer policy. Financial impacts from the initial policy were similar in relative terms for both types of hospitals and would be expected to be fairly similar for an expansion to additional DRGs. On average, including swing-bed discharges in the transfer policy would have a very small financial impact on small rural hospitals; only hospitals that make extensive use of swing beds after a short inpatient stay might expect large declines in total Medicare revenue. Rural hospitals are not disproportionately harmed by the PAC transfer policy. An expanded policy may even benefit rural hospitals by recognizing their lower use of post-acute-care and readjusting DRG weights so that they are paid more appropriately when providing the full course of inpatient care.

Functional outcomes and disability after nontraumatic spinal cord injury rehabilitation: Results from a retrospective study 1,2

New PW. Functional outcomes and disability after nontraumatic spinal cord injury rehabilitation: results from a retrospective study. Objective To describe, in a group of patients undergoing initial inpatient rehabilitation after nontraumatic spinal cord injury (SCI), the demographic characteristics, clinical features, and outcomes, with a focus on the functional status and disability. Design Retrospective data analysis, 3-year case series. Setting Tertiary medical unit specializing in nontraumatic SCI rehabilitation. Participants Consecutive sample of 70 adult inpatient referrals with nontraumatic SCI undergoing initial inpatient rehabilitation. Intervention Chart review. Main outcome measures Primary outcomes were demographic characteristics, clinical features, mortality, length of stay (LOS), neurologic classification, accommodation setting, support services, mobility, bladder and bowel continence, and FIM instrument scores. Results Forty-one patients (58.6%) were paraplegic incomplete, 23 (32.9%) were tetraplegic incomplete, and 6 (8.6%) were paraplegic complete. Eight patients (11.4%) died before hospital discharge. Of those who survived, 47 (75.8%) were discharged home, 11 (17.7%) were transferred to a nursing home, and 4 (6.4%) went elsewhere in the community. The geometric mean LOS was 55.8 days. Nine patients (14.5%) were discharged walking unaided, 27 (43.5%) were walking at least 10m with a gait aid, and 26 (41.9%) were wheelchair dependent for mobility. Thirty patients (48.4%) were voiding on sensation, 7 (11.1%) used intermittent catheterization, 23 (37.2%) had an indwelling catheter, and 2 (2.8%) used reflex voiding. Eleven patients (17.7%) were fecally continent on sensation and 47 (75.8%) were fecally continent with a bowel program, 1 patient (1.6%) had a colostomy, and 3 patients (4.8%) were discharged fecally incontinent. The mean Rasch FIM motor score was 39.6 on admission and 58.7 at discharge (paired t test, t=−11.2; P<.000). Conclusions Most nontraumatic SCI patients returned home with a good level of functioning regarding mobility, bladder, and bowel status, in comparison to other studies of patients with SCI. Patients’ disability was usually significantly reduced during rehabilitation.