Risk-adjusted Length Of Stay Research Articles

Association between postoperative complications and hospital length of stay: a large-scale observational study of 4,495,582 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry

BackgroundPrecise estimates of risk-adjusted increases in postoperative length of stay (LOS) associated with postoperative complications across a range of complications and operations are not available in the existing literature.MethodsAssociations between preoperative characteristics, postoperative complications and postoperative LOS were tested using medians, interquartile ranges, and nonparametric rank sum tests in a retrospective cohort study using the 2005–2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset. A negative binomial model was used with postoperative LOS as the dependent variable and preoperative characteristics and postoperative complications as independent variables. The model was applied to estimate each patient’s postoperative LOS with and without each postoperative complication to measure the association between each complication and risk-adjusted change in postoperative LOS.ResultsA total of 4,495,582 patients were included. After risk-adjustment, occurrence of each postoperative complication was associated with significantly increased postoperative LOS (between + 3.9 and + 20.1 days, p < 0.0001). The longest risk-adjusted postoperative LOS increases were associated with prolonged ventilator use (+ 20.1 days), wound disruption (+ 19.4 days), and acute renal failure (+ 17.1 days).ConclusionOccurrence of any postoperative complication was associated with increased risk-adjusted postoperative LOS. Degree of increase varied by complication. These data could be useful for patient counseling, allocation of resources, discharge planning, and quality improvement efforts.

Increasing and sustaining discharges by noon – a multi-year process improvement project

High hospital occupancy degrades emergency department performance by increasing wait times, decreasing patient satisfaction, and increasing patient morbidity and mortality. Late discharges contribute to high hospital occupancy by increasing emergency department (ED) patient length of stay (LOS). We share our experience with increasing and sustaining early discharges at a 650-bed academic medical center in the United States. Our process improvement project followed the Institute of Medicine Model for Improvement of successive Plan‒Do‒Study‒Act cycles. We implemented multiple iterative interventions over 41 months. As a result, the proportion of discharge orders before 10 am increased from 8.7% at baseline to 22.2% (p < 0.001), and the proportion of discharges by noon (DBN) increased from 9.5% to 26.8% (p < 0.001). There was no increase in balancing metrics because of our interventions. RA-LOS (Risk Adjusted Length Of Stay) decreased from 1.16 to 1.09 (p = 0.01), RA-Mortality decreased from 0.65 to 0.61 (p = 0.62) and RA-Readmissions decreased from 0.92 to 0.74 (p < 0.001). Our study provides a roadmap to large academic facilities to increase and sustain the proportion of patients discharged by noon without negatively impacting LOS, 30-day readmissions, and mortality. Continuous performance evaluation, adaptability to changing resources, multidisciplinary engagement, and institutional buy-in were crucial drivers of our success.

Abstract 12155: Trends in the Clinical Outcomes and Resource Utilization of Catheter-Based Thrombolytic Therapy vs. Systemic Thrombolytic Therapy in Patients With Acute Pulmonary Embolism

Introduction: Contemporary trends in clinical outcomes and resource utilization in patients with acute pulmonary embolism (PE) undergoing thrombolytic therapy are not well-known. Research Question: We wanted to analyze the trends in outcomes of catheter-based thrombolytic therapy (CDT) vs. systemic thrombolytic therapy (ST) in patients with PE. Aim: We aimed to compare the trends in in-hospital mortality, length of stay (LOS), and hospital costs in patients with PE who underwent CDT vs. ST. Methods: Using the National Inpatient Sample, all adult patients hospitalized with PE from 2012 to 2018 were identified using the International Classification of Disease diagnostic codes. Multivariate linear and logistic regression were used to obtain trends and effect sizes. Results: We identified 1.27 million patients with PE, of which 45,950 underwent thrombolytic therapy (CDT=30.1% and ST=69.9%). The mean age of patients receiving CDT vs. ST wasn't different (59.7 vs. 59.3, P=0.14). The proportion of CDT among all patients with PE increased from 0.4% in 2012 to 1.9% in 2018. Baseline characteristics of patients who underwent CDT vs. ST are shown in panel A. Risk-adjusted mortality was significantly lower in patients receiving CDT vs. ST (AOR=0.38, P=&lt;.01). Risk-adjusted LOS was 0.19 days non-significantly higher in patients with CDT vs. ST (P-value=0.12). The hospital cost was significantly higher in patients who underwent CDT vs. ST (β=2917 USD, P&lt;.01). Temporal trends of these outcomes are shown in panels B-D. Conclusions: It is encouraging to see an increasing trend in the utilization of CDT. In-hospital mortality decreased in patients with CDT and ST, but CDT continues to be superior. The LOS was not significantly different among these groups but significantly decreased in both groups over time. Finally, hospital cost was higher in patients with CDT vs ST, but these cost differences between CDT and ST narrowed due to decreasing cost of CDT and increasing cost of ST over time.

Injury outcomes across Canadian trauma systems: a historical cohort study.

Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems. In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province. The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high. Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.

Association Between Intravenous to Oral Opioid Transition Time and Length of Hospital Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

Transitioning from intravenous (IV) to oral opioids after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is necessary during the postoperative course. However, few studies have assessed the effects of longer transition times on hospital length of stay (LOS). This study investigated the impact of longer IV to oral opioid transition times on LOS after PSF for AIS. The medical records of 129 adolescents (10-18 years old) with AIS undergoing multilevel PSF at a major academic institution from 2013 to 2020 were reviewed. Patients were categorized by IV to oral opioid transition time: normal (≤2 days) vs prolonged (≥3 days). Patient demographics, comorbidities, deformity characteristics, intraoperative variables, postoperative complications, and LOS were assessed. Multivariate analyses were used to determine odds ratios for risk-adjusted extended LOS. Of the 129 study patients, 29.5% (n = 38) had prolonged IV to oral transitions. Demographics and comorbidities were similar between the cohorts. The major curve degree (P = 0.762) and median (interquartile range) levels fused (P = 0.447) were similar between cohorts, but procedure time was significantly longer in the prolonged cohort (normal: 6.6 ± 1.2 hours vs prolonged: 7.2 ± 1.3 hours, P = 0.009). Postoperative complication rates were similar between the cohorts. Patients with prolonged transitions had significantly longer LOS (normal: 4.6 ± 1.3 days vs prolonged: 5.1 ± 0.8 days, P < 0.001) but similar discharge disposition (P = 0.722) and 30-day readmission rates (P > 0.99). On univariate analysis, transition time was significantly associated with extended LOS (OR: 2.0, 95% CI [0.9, 4.6], P = 0.014), but this assocation was not significant on multivariate analysis (adjusted OR: 2.1, 95% CI [1.3, 4.8], P = 0.062). Longer postoperative IV to oral opioid transitions after PSF for AIS may have implications for hospital LOS.

Evaluation of an Expedited Trauma Transfer Protocol: Right Place, Right Time

Trauma patients may initially be evaluated at non-trauma centers. This may cause a delay in treatment, which could affect their outcome. Additionally, advanced imaging may be performed which may be suboptimal or unnecessary, increase time to transfer, or unable to be viewed when the patient reaches a trauma center increasing the delays to treatment or need for repeat imaging. Rapid identification and transfer to definitive trauma care, minimizing unnecessary delays should be the priority. The trauma registry at a regional Level 1 Adult/Pediatric Trauma center was queried for transferred trauma patients over a 3-y period. A retrospective review was performed. Transferred trauma patients were compared prior to an expedited transfer protocol to after implementation. Demographics, mechanism of injury, injury severity score, computerized tomography scans performed prior to transfer, mortality, hospital and intensive care unit length of stay were compared using bivariate and multivariable regression statistics where appropriate. Transferred trauma patients were identified, 683 in the pre-protocol group and 821 in the post-protocol group, an increase of 16.8%. There were no differences in age, sex, injury severity score, mechanism of injury, mortality, hospital, or intensive care unit length of stay (LOS) throughout the study period. There was a significant decrease in time to transfer (263 min ± 222 versus 227 ± 189, P < 0.001) and computerized tomography scans performed prior to transfer (Head 47% versus 32%, C-spine 36% versus 23%, Thorax 22% versus 16%, Abdomen/Pelvis 24% versus 14%, all P values <0.001 except CT Thorax). Interestingly, the rate of underinsured patients did not increase (21% versus 25%, P=0.05). Risk-adjusted mortality and hospital LOS also did not change during the study period. After implementation of an expedited trauma transfer protocol to a regional Level 1 trauma center there was an associated reduced time of arrival to definitive care and decreased advanced imaging done prior to transfer. However, there was noassociated decrease inmortality or LOS among transferred patients. Further studies examining prehospital transport or hospital choice decisions and subsequent care provided at non-trauma facilities regarding imaging obtained, care rendered, and transfer decisions can be explored.

Variation in Diagnostic Testing and Empiric Acyclovir Use for HSV Infection in Febrile Infants.

Clinicians evaluating for herpes simplex virus (HSV) in febrile infants must balance detection with overtesting, and there is no universally accepted approach to risk stratification. We aimed to describe variation in diagnostic evaluation and empirical acyclovir treatment of infants aged 0 to 60 days presenting with fever and determine the association between testing and length of stay (LOS). In this retrospective 44-hospital observational study, we used the Pediatric Health Information System database to identify infants aged ≤60 days evaluated for fever in emergency departments from January 2016 through December 2017. We described hospital-level variation in laboratory testing, including HSV, imaging and other diagnostic evaluations, acyclovir use, and LOS. We assessed the relationship between HSV testing and LOS using generalized linear mixed effects models adjusted for age and illness severity. In 24 535 encounters for fever, the median HSV testing frequency across hospitals was 35.6% (interquartile range [IQR]: 28.5%-53.5%) for infants aged 0 to 21 days and 12% (IQR: 8.6%-15.7%) for infants aged 22 to 60 days. Among HSV-tested patients, median acyclovir use across hospitals was 79.2% (IQR: 68.1%-89.7%) for those aged 0 to 21 days and 63.6% (IQR: 44.1%-73%) for those aged 22 to 60 days. The prevalence of additional testing varied substantially by hospital and age group. Risk-adjusted LOS for HSV-tested infants was significantly longer than risk-adjusted LOS for those not tested (2.6 vs 1.9 days, P < .001). Substantial variation exists in diagnostic evaluation and acyclovir use, and infants who received HSV testing had a longer LOS than infants who did not. This variability supports the need for further studies to help clinicians better risk-stratify febrile infants and to guide HSV testing and treatment decisions.

Recent Trends in Admission Diagnosis and Related Mortality in the Medically Critically Ill.

With decades of declining ICU mortality, we hypothesized that the outcomes and distribution of diseases cared for in the ICU have changed and we aimed to further characterize them. A retrospective cohort analysis of 287,154 nonsurgical-critically ill adults, from 237 U.S. ICUs, using the manually abstracted Cerner APACHE Outcomes database from 2008 to 2016 was performed. Surgical patients, rare admission diagnoses (<100 occurrences), and low volume hospitals (<100 total admissions) were excluded. Diagnoses were distributed into mutually exclusive organ system/disease-based categories based on admission diagnosis. Multi-level mixed-effects negative binomial regression was used to assess temporal trends in admission, in-hospital mortality, and length of stay (LOS). The number of ICU admissions remained unchanged (IRR 0.99, 0.98-1.003) while certain organ system/disease groups increased (toxicology [25%], hematologic/oncologic [55%] while others decreased (gastrointestinal [31%], pulmonary [24%]). Overall risk-adjusted in-hospital mortality was unchanged (IRR 0.98, 0.96-1.0004). Risk-adjusted ICU LOS (Estimate -0.06 days/year, -0.07 to -0.04) decreased. Risk-adjusted mortality varied significantly by disease. Risk-adjusted ICU mortality rate did not change over the study period, but there was evidence of shifting disease burden across the critical care population. Our data provides useful information regarding future ICU personnel and resource needs.

How What You Measure Matters: Risk-Adjusted Length of Stay and Observation Status.

* Abbreviations: OBS — : observation status RA-LOS — : risk-adjusted geometric mean length of stay The underlying vision for pediatric quality measurement is improved care and health outcomes for children. Quality measures help realize this vision, through capturing system successes and failures in supporting child health. There are a large number of quality measures, some of which are focused on processes, some on outcomes, and some on use.1 To accurately assess successes and failures in care delivery, measure design matters. This is because measures can deeply incentivize behavior because of their use in reputational (eg, public reporting) and financial incentive (value-based purchasing) programs. In this issue of Pediatrics , Gay et al2 focus on risk-adjusted geometric mean length of stay (RA-LOS), a commonly used metric for understanding hospital use. Hospitals and payers often use this to assess efficiency and throughput, with the most familiar manifestation being the focus on “discharge before noon.” But increased RA-LOS can also signal issues with patient safety and increased hospital-acquired conditions.3,4 Hence, getting this measure design right is important because the measure informs hospitals not only about their relative efficiency and throughput compared with other hospitals nationally but also about potentially important failures in patient safety. Ga2y et al2 focus on a specific … Address correspondence to Naomi S. Bardach, MD, MAS, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St, Suite 265, San Francisco, CA 94118. E-mail: naomi.bardach{at}ucsf.edu

A Multimodal Interdisciplinary QI Intervention Is Associated with Reduced Variability in Finishing Inpatient Endoscopic Cases and Reduction in Cases after Hours

Performing non-emergent inpatient endoscopic cases after hours poses risks to patient safety, negatively impacts patient and provider satisfaction, and potentially prolongs length of stay (LOS), due to decreased staffing and transitions in care. At our institution, weekday inpatient procedures are performed in dedicated operating rooms with anesthesia support; resource changes at 5PM and 7PM lengthen flow time. At baseline, the mean daily end of workday (EOW), defined by endoscopy-out of the day’s last non-emergent case, was 17:46, but with a wide standard deviation (SD) of 2:20 hours, with only 57.6% days with EOW < 7PM. Using EOW as a proxy for patient/provider dissatisfaction, risk for patient safety events, and prolonged LOS, we performed a prospective evaluation of a staged interdisciplinary multimodal intervention aimed to decrease the EOW variability and increase the proportion of days with EOW < 7PM. We also evaluated the proportion of cases begun > 5PM. We conducted an IRB-approved QI (quality improvement) prospective evaluation of a staged multimodal intervention from 12/2018 to 9/2019. A robust evaluation of current care processes care and root causes for EOW variability was conducted, utilizing a time series study, swimlane map, stakeholder interviews, and third party workflow assessment. We implemented a series of targeted interventions to address the identified delays from 12/2018-5/2019 (Figure 1), including: (1) provider education with workflow tips, (2) expedited transport for select patients, (3) offloading appropriate cases to outpatient endoscopy, and (4) increased resources for high caseload days through resource pooling. We used a statistical process control chart to assess the impact of post-intervention outcomes, including daily EOW, the number of cases performed after hours, and risk-adjusted LOS. The pre-period (S0) was retrospective baseline data from 7/2017-12/2018 and post (S4) was from 5/2019-9/2019. Risk adjusted LOS was calculated using an observed to expected ratio. EOW SD decreased from 2:20 hours in S0 to 1:36 hours in S4 (Figure 2), with an increase in the proportion of EOW < 7pm from 57.6% to 70.7% (OR 0.63, p = 0.045). The odds ratio was 0.39 when adjusted for the day’s caseload (p< 0.001). Despite an increasing caseload (monthly mean number of cases from 140 in S0 to 168 in S4), the percentage of cases begun > 5PM decreased from 17.5% to 14.2% (OR 0.75, p = 0.009). Risk-adjusted LOS decreased slightly (1.5 to 1.1) from S0 to S4 but was not statistically significant (p=0.12). A multimodal intervention successfully reduced EOW variability and the proportion of cases begun > 5PM despite an increased caseload. This study shows how QI tools and methods may be used to design and implement interventions that successfully decrease late inpatient endoscopic procedures.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

4301 Racial/Ethnic variations in discharge destination after inpatient care: A risk-adjusted analysis of a large regional dataset

OBJECTIVES/GOALS: While there are many well-documented factors for racial/ethnic variation in discharge destination, less is known about the role hospital processes play. We hypothesize that variation in hospital processes -defined as the patient length of stay (LOS) adjusted for known confounders - explains racial/ethnic variation in discharge destination. METHODS/STUDY POPULATION: Our sample was 176,686 discharges from 165 hospitals in 2014 using the New York State Inpatient Dataset from the Healthcare Cost and Utilization Project, merged with the 2014 American Hospital Association Annual Survey to build a file of inpatient discharges with patient, disease and socio-economic characteristics. We excluded patients under 18 years, those with LOS of zero, those who died, those admitted to critical access hospitals, and patients from hospitals that lacked sufficient number of minority patients. We used a generalized linear mixed effects model to create an in-hospital risk-adjusted LOS by modelling the relationship between the interaction of race and discharge destination and LOS, controlling for known confounders such as patient, disease and between-hospital characteristics. RESULTS/ANTICIPATED RESULTS: Mean age of sample was 56.5 years, 57.3 % female, 54.9% white, 18.9% black and 13.1% Hispanic; 64.3% were discharged home, 15.8% to a skilled nursing or other intermediate care facility, 15.5% to home with home care and 2.4% left against medical advice. The top 3 discharge diagnoses were vaginal delivery (6.3% of discharges), psychosis (4.7%), and major joint replacement (2.9%). In adjusted analysis compared to white patients, black and Hispanic patients did not have an risk of increased LOS after being discharged to non-home destinations vs. discharged home, (black patients, adjusted OR [AOR], 0.97; 95% CI: 0.94-1.00, p = 0.08; Hispanic patients, AOR, 1.01; 95% CI: 0.98 – 1.05, p = 0.5). However, being black compared to white and discharge to non-home destinations significantly increased LOS. DISCUSSION/SIGNIFICANCE OF IMPACT: In this large sample of patients admitted for inpatient care in 2014 in New York, we found no independent effect between race and discharge destination on a patient’s LOS after controlling for patient, disease and between-hospital characteristics. However race/ethnicity increased LOS, suggesting its effect may play a role on in-hospital processes CONFLICT OF INTEREST DESCRIPTION: Dr. Ghosh has no relevant relationships with commercial interests to disclose Dr. Ibrahim has no relevant relationships with commercial interests to disclose

Risk Factors Portending Extended Length of Stay After Suboccipital Decompression for Adult Chiari I Malformation

For adult patients undergoing surgical decompression for Chiari malformation type I (CM-I), the patient-level factors that influence extended length of stay (LOS) are relatively unknown. The aim of this study was to investigate the impact of patient-baseline comorbidities, demographics, and postoperative complications on extended LOS after intervention after adult CM-I decompression surgery. A retrospective cohort study using the National Inpatient Sample years 2010-2014 was performed. Adults (≥18 years) with a primary diagnosis of CM-I undergoing surgical decompression were identified. Weighted patient demographics, comorbidities, complications, LOS, disposition, and total cost were recorded. A multivariate logistic regression was used to determine the odds ratio for risk-adjusted LOS. A total of 29,961 patients were identified, 6802 of whom (22.7%) had extended LOS. The extended LOS cohort had a significantly greater overall complication rate (normal LOS, 10.6% vs. extended LOS, 29.1%; P < 0.001) and total cost (normal LOS, $14,959 ± $6037 vs. extended LOS, $25,324 ± $21,629; P < 0.001) compared with the normal LOS cohort. On multivariate logistic regression, black race, income quartiles, private insurance, obstructive hydrocephalus, lack of coordination, fluid and electrolyte disorders, and paralysis were all independently associated with extended LOS. Additional duraplasty (P= 0.132) was not significantly associated with extended LOS after adjusting for other variables. The odds ratio for extended LOS was 2.07 (95% confidence interval, 1.59-2.71) for patients with 1 complication and 9.47 (95% confidence interval, 5.86-15.30) for patients with >1 complication. Our study shows that extended LOS after adult CM-I decompression surgery may be influenced by multiple patient-level factors.

Impact of patient and hospital-level risk factors on extended length of stay following spinal fusion for adolescent idiopathic scoliosis.

Health policy changes have led to increased emphasis on value-based care to improve resource utilization and reduce inpatient hospital length of stay (LOS). Recently, LOS has become a major determinant of quality of care and resource utilization. For adolescent idiopathic scoliosis (AIS), the determinants of extended LOS after elective posterior spinal fusion (PSF) remain relatively unknown. In the present study, the authors investigated the impact of patient and hospital-level risk factors on extended LOS following elective PSF surgery (≥ 4 levels) for AIS. The Kids' Inpatient Database (KID) was queried for the year 2012. Adolescent patients (age range 10-17 years) with AIS undergoing elective PSF (≥ 4 levels) were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended hospital LOS was defined as greater than the 75th percentile for the entire cohort (> 6 days), and patients were dichotomized as having normal LOS or extended LOS. Patient demographics, comorbidities, complications, LOS, discharge disposition, and total cost were recorded. A multivariate logistic regression model was used to determine the odds ratio for risk-adjusted LOS. The primary outcome was the degree to which patient comorbidities or postoperative complications correlated with extended LOS. Comorbidities were overall significantly higher in the extended-LOS cohort than the normal-LOS cohort. Patients with extended LOS had a significantly greater proportion of blood transfusion (p < 0.001) and ≥ 9 vertebral levels fused (p < 0.001). The overall complication rates were greater in the extended-LOS cohort (20.3% [normal-LOS group] vs 43.5% [extended-LOS group]; p < 0.001). On average, the extended-LOS cohort incurred $18,916 more in total cost than the normal-LOS group ($54,697 ± $24,217 vs $73,613 ± $38,689, respectively; p < 0.001) and had more patients discharged to locations other than home (p < 0.001) than did patients in the normal-LOS cohort. On multivariate logistic regression, several risk factors were associated with extended LOS, including female sex, obesity, hypertension, fluid electrolyte disorder, paralysis, blood transfusion, ≥ 9 vertebrae fused, dural injury, and nerve cord injury. The odds ratio for extended LOS was 1.95 (95% CI 1.50-2.52) for patients with 1 complication and 5.43 (95% CI 3.35-8.71) for patients with > 1 complication. The authors' study using the KID demonstrates that patient comorbidities and intra- and postoperative complications all contribute to extended LOS after spinal fusion for AIS. Identifying multimodality interventions focused on reducing LOS, bettering patient outcomes, and lowering healthcare costs are necessary to improve the overall value of care for patients undergoing spinal fusion for AIS.

Extended Length of Stay in Elderly Patients After Lumbar Decompression and Fusion Surgery May Not Be Attributable to Baseline Illness Severity or Postoperative Complications

Hospital leaders are seeking ways to improve resource utilization and minimize long postoperative hospital stays. Common explanations for extended length of stay (LOS) are baseline patient illness, postoperative complications, and physician practice differences. The degree to which extended LOS represents illness severity or postoperative complications is unknown. We investigated influence of postoperative complications and patient comorbidities on extended LOS after lumbar spine surgery in elderly patients. This retrospective cohort study from 2008 to 2014 analyzed data from the American College of Surgeons National Surgical Quality Improvement Program for elderly patients undergoing lumbar spine surgery. Patient demographics, comorbidities, LOS, and complications were recorded. Multivariable logistic regression analysis was used to determine odds ratio for risk-adjusted LOS. Primary outcome was the degree extended LOS represented patient illness or postoperative complications. Of 9482 patients, 1909 (20.13%) had extended LOS. A few patients with extended LOS had a history of relevant comorbidities, including diabetes (21.76%), chronic obstructive pulmonary disease (8.17%), congestive heart failure (0.94%), myocardial infarction (0%), acute renal failure (0.47%), and stroke (2.23%). Of patients with normal LOS, 93% had no complications, 5.19% had 1complication, and 1.69% had >1 complication. Among patients with extended LOS, 73.65% had no complications, 18.96% had 1 complication, and 7.39% had >1 complication (P < 0.000). Our study suggests that much of the variation in LOS for elderly patients undergoing lumbar spine surgery is not attributable to baseline patient illness or postoperative complications and most likely represents differences in practice style or surgeon preference.

Extended Length of Stay in Elderly Patients after Anterior Cervical Discectomy and Fusion Is Not Attributable to Baseline Illness Severity or Postoperative Complications

Health care systems are increasing efforts to minimize postoperative hospital stays to improve resource use. Common explanations for extended postoperative stay are baseline patient sickness, postoperative complications, or physician practice differences. However, the degree to which extended length of stay (LOS) represents patient illness or postoperative complications remains unknown. The aim is to investigate the influence of postoperative complications and elderly patient comorbidities on extended LOS after anterior cervical discectomy and fusion. This retrospective study was performed from January 1, 2008, to December 31, 2014, on data from the American College of Surgeons National Surgical Quality Improvement Program. Patient demographics, comorbidities, LOS, and inpatient complications were recorded. Multivariable logistic regression analysis was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree extended LOS represented patient illness or postoperative complications. Of 4730 participants, 1351 (28.56%) had extended LOS. A minority of patients with extended LOS had a history of relevant comorbidities-diabetes (29.53%), chronic obstructive pulmonary disease (9.4%), congestive heart failure (1.04%), myocardial infarction (0.33%), acute renal failure (0.3%), and stroke (5.92%). Among patients with normal LOS, 96.8% had no complications, 2.7% had 1 complication, and 0.5% had greater than 1 complication. In patients with extended LOS, 79.4% had no complications, 14.5% had 1 complication, and 6.1% had greater than 1 complication (P < 0.0001). Our study suggests much of LOS variation after an anterior cervical discectomy and fusion is not attributable to baseline patient illness or complications and most likely represents differences in practice style or surgeon preference.

Hospital and Intensive Care Unit Length of Stay for Injury Admissions: A Pan-Canadian Cohort Study.

To assess the variation in hospital and intensive care unit (ICU) length of stay (LOS) for injury admissions across Canadian provinces and to evaluate the relative contribution of patient case mix and treatment-related factors (intensity of care, complications, and discharge delays) to explaining observed variations. Identifying unjustified interprovider variations in resource use and the determinants of such variations is an important step towards optimizing health care. We conducted a multicenter, retrospective cohort study on admissions for major trauma (injury severity score >12) to level I and II trauma centers across Canada (2006-2012). We used data from the Canadian National Trauma Registry linked to hospital discharge data to compare risk-adjusted hospital and ICU LOS across provinces. Risk-adjusted hospital LOS was shortest in Ontario (10.0 days) and longest in Newfoundland and Labrador (16.1 days; P < 0.001). Risk-adjusted ICU LOS was shortest in Québec (4.4 days) and longest in Alberta (6.1 days; P < 0.001). Patient case-mix explained 32% and 8% of interhospital variations in hospital and ICU LOS, respectively, whereas treatment-related factors explained 63% and 22%. We observed significant variation in risk-adjusted hospital and ICU LOS across trauma systems in Canada. Provider ranks on hospital LOS were not related to those observed for ICU LOS. Treatment-related factors explained more interhospital variation in LOS than patient case-mix. Results suggest that interventions targeting reductions in low-value procedures, prevention of adverse events, and better discharge planning may be most effective for optimizing LOS for injury admissions.

Modelling risk-adjusted variation in length of stay among Australian and New Zealand ICUs.

PurposeComparisons between institutions of intensive care unit (ICU) length of stay (LOS) are significantly confounded by individual patient characteristics, and currently there is a paucity of methods available to calculate risk-adjusted metrics.MethodsWe extracted de-identified data from the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database for admissions between January 1 2011 and December 31 2015. We used a mixed-effects log-normal regression model to predict LOS using patient and admission characteristics. We calculated a risk-adjusted LOS ratio (RALOSR) by dividing the geometric mean observed LOS by the exponent of the expected Ln-LOS for each site and year. The RALOSR is scaled such that values <1 indicate a LOS shorter than expected, while values >1 indicate a LOS longer than expected. Secondary mixed effects regression modelling was used to assess the stability of the estimate in units over time.ResultsDuring the study there were a total of 662,525 admissions to 168 units (median annual admissions = 767, IQR:426–1121). The mean observed LOS was 3.21 days (median = 1.79 IQR = 0.92–3.52) over the entire period, and declined on average 1.97 hours per year (95%CI:1.76–2.18) from 2011 to 2015. The RALOSR varied considerably between units, ranging from 0.35 to 2.34 indicating large differences after accounting for case-mix.ConclusionsThere are large disparities in risk-adjusted LOS among Australian and New Zealand ICUs which may reflect differences in resource utilization.

Association Between Insurance Status and Hospital Length of Stay Following Trauma.

Previous research has demonstrated that nonclinical factors are associated with differences in clinical care, with uninsured patients receiving decreased resource use. Studies on trauma populations have also shown unclear relationships between insurance status and hospital length of stay (LOS), a commonly used metric for evaluating quality of care. The objective of this study is to define the relationship between insurance status and LOS after trauma using the largest available national trauma dataset and controlling for significant confounders. Data from 2007 to 2010 National Trauma Data Bank were used to compare differences in LOS among three insurance groups: privately insured, publically insured, and uninsured trauma patients. Multivariable regression models adjusted for potential confounding due to baseline differences in injury severity and demographic and clinical factors. A total of 884,493 patients met the inclusion criteria. After adjusting for the influence of covariates, uninsured patients had significantly shorter hospital stays (0.3 days) relative to privately insured patients. Publicly insured patients had longer risk-adjusted LOS (0.9 days). Stratified differences in discharge disposition and injury severity significantly altered the relationship between insurance status and LOS. In conclusion, this study elucidates the association between insurance status and hospital LOS, demonstrating that a patient's ability to pay could alter LOS in acute trauma patients. Additional research is needed to examine causes and outcomes from these differences to increase efficiency in the health care system, decrease costs, and shrink disparities in health outcomes.

Inpatient Pediatric Tonsillectomy: Does Hospital Type Affect Cost and Outcomes of Care?

To ascertain whether hospital type is associated with differences in total cost and outcomes for inpatient tonsillectomy. Cross-sectional analysis of the 2006, 2009, and 2012 Kids' Inpatient Database (KID). Children ≤18 years of age undergoing tonsillectomy with/without adenoidectomy were included. Risk-adjusted generalized linear models assessed for differences in hospital cost and length of stay (LOS) among children managed by (1) non-children's teaching hospitals (NCTHs), (2) children's teaching hospitals (CTHs), and (3) nonteaching hospitals (NTHs). Risk-adjusted logistic regression compared the odds of major perioperative complications (hemorrhage, respiratory failure, death). Models accounted for clustering of patients within hospitals, were weighted to provide national estimates, and controlled for comorbidities. The 25,685 tonsillectomies recorded in the KID yielded a national estimate of 40,591 inpatient tonsillectomies performed in 2006, 2009, and 2012. The CTHs had significantly higher risk-adjusted total cost and LOS per tonsillectomy compared with NCTHs and NTHs ($9423.34/2.8 days, $6250.78/2.11 days, and $5905.10/2.08 days, respectively; P < .001). The CTHs had higher odds of complications compared with NCTHs (odds ratio [OR], 1.48; 95% CI, 1.15-1.91; P = .002) but not when compared with NTHs (OR, 1.19; 95% CI, 0.89-1.59; P = .23). The CTHs were significantly more likely to care for patients with comorbidities (P < .001). Significant differences in costs, outcomes, and patient factors exist for inpatient tonsillectomy based on hospital type. Although reasons for these differences are not discernable using isolated claims data, findings provide a foundation to further evaluate patient, institutional, and system-level factors that may reduce cost of care and improve value for inpatient tonsillectomy.

The effect of a hospitalist comanagement service on vascular surgery inpatients

Vascular surgery patients have increased medical comorbidities that amplify the complexity of their care. We assessed the effect of a hospitalist comanagement service on inpatient vascular surgery outcomes. We divided 1059 patients into two cohorts for comparison: 515 between January 2012 and December 2012, before the implementation of a hospitalist comanagement service, and 544 between January 2013 and October 2013, after the initiation of a hospitalist comanagement service. Nine vascular surgeons and 10 hospitalists participated in the hospitalist comanagement service. End points measured were in-hospital mortality, length of stay (LOS), 30-day readmission rates, visual analog scale pain scores (0-10), inpatient adult safety assessments using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, and resident perceptions assessed by survey. The in-hospital mortality rate decreased from 1.75% to 0.37% after the implementation of the hospitalist comanagement service (P = .016), with a decrease in the observed-to-expected ratio from 0.89 to 0.22. The risk-adjusted in-hospital mortality decreased from 1.56% to 0.0008% (P = .003). Mean LOS was lower in the base period, at 5.1 days vs 5.5 days (P < .001), with an observed-to-expected ratio of 0.83 and 0.78, respectively. The risk-adjusted LOS increased from 4.2 days to 4.3 days (P < .001). The overall 30-day readmission rate was unchanged, at 23.1% compared with 22.8% (P = .6). The related 30-day readmission rate was also similar, at 11.5% compared with 11.4% (P = .5). Patients reporting no pain during hospitalization increased from 72.8% before the hospitalist comanagement service to 77.8% after (P = .04). Reports of moderate pain decreased from 14% to 9.6% (P = .016). Mild and severe pain scores were similar between the two groups. Adult safety measured by AHRQ demonstrated a decrease from three to zero patients in the number of deaths among surgical patients with treatable complications (P = .04). Most house staff reported that the comanagement program had a positive effect on patient care and education. The hospitalist comanagement service has resulted in a significant decrease in in-hospital mortality rates, patient safety, as measured by AHRQ, and improved pain scores. Resident surveys demonstrated perceived improvement in patient care and education. Continued observation will be necessary to assess the long-term effect of the hospitalist comanagement service on quality metrics.