Variation In Length Of Stay Research Articles

Use of a Publicly Available Database to Determine the Impact of Diabetes on Length of Hospital Stay for Elective Orthopedic Procedures in California.

In California, 1 in 3 hospital beds are occupied by adults with diabetes. The aim of this study was to examine whether diabetes impacts length of stay (LOS) following common elective orthopedic procedures compared to nondiabetic individuals, and also the performance of hospitals across California for these procedures. Using the Public Use California Patient Discharge Data Files for 2010-2012, the authors examined LOS for elective discharges for hip, spine, or knee surgery (n = 318,861) from the total population of all discharges (n = 11,476,073) for 309 hospitals across California. In all, 16% of discharges had a codiagnosis of diabetes. Unadjusted average LOS was 3.11 days without and 3.40 days with diabetes (mean difference 0.29 [95% confidence interval (0.27, 0.31) days, P < 0.01]). After adjusting for covariates, diabetes no longer resulted in a significant difference in LOS. However, the presence of common comorbidities did significantly impact LOS. Average LOS for patients with diabetes also varied widely by hospital, ranging between -50% and +100% of the mean LOS for all hospitals. Diabetes does not prolong LOS after orthopedic procedures unless comorbidities are present. Nevertheless, across California there is significant variation in LOS between individual hospitals, which may inform the decision-making process for prospective patients and payers.

Did the Revision of the Japanese Medical Payment System Work Properly?—An Analysis of Averages and Variances of Length of Hospital Stay for Type 2 Diabetes Patients by Individual Hospital

We evaluated the effects of the 2010 revision of the medical payment system on the length of stay (LOS). In this analysis, we assessed not only the average length of stay (ALOS), but also variance of LOS at individual hospitals. We used a dataset of 18,641 type 2 diabetes patients collected from 51 general hospitals. The variables found to affect LOS were age, comorbidities, complications, acute hospitalization, introduced by other hospitals, winter, one-week hospitalization, specific hospitalization period, and principal diseases coded E11.5, E11.6 and E11.7. Although the effect was marginal, the 2010 revision did reduce ALOS, and the reduction was larger as ALOS became longer. On the other hand, we did not find that the variance of LOS within hospitals became smaller. The results of the study suggest that new incentives and assistance to hospitals to help them make efficient use of medical information are needed.

Length of stay and cost analysis of neonates undergoing surgery at a tertiary neonatal unit in England

Introduction There is a lack of knowledge on the average length of stay (LOS) in neonatal units after surgical repair of common congenital anomalies. There are few if any publications reporting the activity performed by units undertaking neonatal surgery. Such activity is important for contracting arrangements, commissioning specialist services and counselling parents. The aim of this study was to describe postnatal LOS for infants admitted to a single tertiary referral neonatal unit with congenital malformations requiring surgery. Methods Data on nine conditions were collected prospectively for babies on the neonatal unit over a five-year period (2006-2011). For those transferred back to their local unit following surgery, the local unit was contacted to determine the total LOS. Only those babies who had surgery during their first admission to our unit and who survived to discharge were included in the study. Cost estimates were based on the tariffs agreed for neonatal care between our trust and the London specialised commissioning group in 2011-2012. Results The median LOS for the conditions studied was: gastroschisis 35 days (range: 19-154 days), oesophageal atresia 33 days (range: 9-133 days), congenital diaphragmatic hernia 28 days (range: 7-99 days), intestinal atresia 24 days (range: 6-168 days), Hirschsprung's disease 21 days (range: 15-36 days), sacrococcygeal teratoma 17 days (range: 12-55 days), myelomeningocoele 15.5 days (range: 8-24 days), anorectal malformation 15 days (range: 6-90 days) and exomphalos 12 days (range: 3-228 days). The total neonatal bed day costs for the median LOS ranged from £8,701 (myelomeningocoele) to £23,874 (gastroschisis). The cost of surgery was not included. Conclusions There is wide variation in LOS for the same conditions in a single neonatal unit. This can be explained by different types and severity within the same congenital anomalies, different surgeons and other clinical confounders (eg sepsis, surgical complications, associated anomalies). These data will enable us to give more detailed information to families following prenatal or postnatal diagnosis. They also allow more detailed planning of resource allocation for neonatal admissions.

Faith-Based Hospitals and Variation in Psychiatric Inpatient Length of Stay in California, 2002-2011.

We examined current treatment patterns at faith-based hospitals. Psychiatric discharges from all community-based hospitals in California were obtained for 2002-2011 and a Behavioral Model of Health Services Utilization approach used to study hospital religious affiliation and length of stay (LOS). During 10 years there were 1,976,893 psychiatric inpatient discharges, of which 14.3% were from faith-based nonprofit hospitals (eighteen Catholic, seven Seventh-day Adventist, and one Jewish hospital). Modest differences in patient characteristics and shorter LOS (7.5 vs. 8.3 days) were observed between faith-based and other hospitals. Multivariable negative binomial regression found shorter LOS at faith-based nonprofit hospitals (coefficient = -0.1169, p < 0.001, Wald χ (2) = 55) and greater LOS at all nonprofits (coefficient = 1.5909, p < 0.001, Wald χ (2) = 2755) as compared to local government-controlled hospitals. Faith-based hospitals provide a substantial and consistent amount of psychiatric care in California and may have slightly lower LOS after adjusting for patient and other hospital characteristics.

Individual and Regional-level Factors Contributing to Variation in Length of Stay After Cerebral Infarction in Six European Countries.

Using patient-level data for cerebral infarction cases in 2007, gathered from Finland, Hungary, Italy, the Netherlands, Scotland and Sweden, we studied the variation in risk-adjusted length of stay (LoS) of acute hospital care and 1-year mortality, both within and between countries. In addition, we analysed the variance of LoS and associations of selected regional-level factors with LoS and 1-year mortality after cerebral infarction. The data show that LoS distributions are surprisingly different across countries and that there is significant deviation in the risk-adjusted regional-level LoS in all of the countries studied. We used negative binomial regression to model the individual-level LoS, and random intercept models and ordinary least squares regression for the regional-level analysis of risk-adjusted LoS, variance of LoS, 1-year risk-adjusted mortality and crude mortality for a period of 31-365 days. The observed variations between regions and countries in both LoS and mortality were not fully explained by either patient-level or regional-level factors. The results indicate that there may exist potential for efficiency gains in acute hospital care of cerebral infarction and that healthcare managers could learn from best practices.

STANDARDIZED CARE TO REDUCE LENGTH OF STAY AND FACILITATE EARLY DISCHARGE HOME AFTER TRANSCATHETER AORTIC VALVE IMPLANTATION: IMPLEMENTATION OF THE VANCOUVER CLINICAL PATHWAY

Length of stay (LOS) after transfemoral transcatheter aortic valve implantation (TF TAVIaries across programs and regions. Multiple factors are associated with variation in LOS and discharge home in the elderly, including age-related functional decline and deconditioning, exacerbated pre-existing disabilities, hospital-acquired complications, and health services planning. We report retropectively on the implementation and evaluation of risk-stratified peri-procedure practices, a standardized post-procedure clinical pathway, and the development of criteria-based early discharge (EDC) to facilitate safe transition home. A total of 393 consecutive patients were discharged between April 2012 and October 2014; 150 (38.2%) were eligible for EDC and 243 (61.8%) were discharged according to the standard discharge (SDC) protocol. At baseline, SDC patients had more previous balloon aortic valvuloplasty (p=0.002), lower LVEF (p=0.02), worse cognitive function (p=0.04), and were more frail (p<0.001). Peri-procedural practices associated with EDC were local anesthesia (p<0.001), selection of a balloon expandable device (p=0.045), post-procedure removal of the temporary pacemaker (p<0.001), and avoidance of a pre-procedure urinary catheter (p=0.002). Rates of complications were low and similar across both groups. SDC was associated with the need for blood transfusion (p=0.005) and new pacemaker (p=0.01). The median LOS was 3 days (IQR, 3-4) for SDC, and 1 days (IQR, 1-2) for EDC (p <0.001). All EDC patients were discharged home, while 9 (4.7%) SDC patients were transferred to another acute care or rehabilitation facility (p =0.017). There were no differences in rates of 30-day readmission (10.7%) or mortality (1.3%). Early discharge home after TAVI is safe in select patients. Opportunities exist to reduce LOS for all patients. Future research is needed to study the safety and reproducibility of a multimodality, multidisciplinary but minimalist approach to help define optimal LOS after TAVI.

A systematic review of the magnitude and cause of geographic variation in unplanned hospital admission rates and length of stay for ambulatory care sensitive conditions

BackgroundUnplanned hospital admissions place a large and increasing strain on healthcare budgets worldwide. Many admissions for ambulatory care sensitive conditions (ACSCs) are thought to be preventable, a belief supported by significant geographic variations in admission rates. We conducted a systematic review of the evidence on the magnitude and correlates of geographic variation in ACSC admission rates and length of stay (LOS).MethodsWe performed a search of Medline and Embase databases for English language cross-sectional and cohort studies on 28th March 2013 reporting geographic variation in admission rates or LOS for patients receiving unplanned care across at least 10 geographical units for one of 35 previously defined ACSCs. Forward and backward citation searches were undertaken on all included studies. We provide a narrative synthesis of study findings. Study quality was assessed using a modified Newcastle-Ottawa scale.ResultsWe included 39 studies comprising 25 on admission rates and 14 on LOS. Studies generally compared admission rates between regions (e.g. states) and LOS between hospitals. Most of the published research was undertaken in the US, UK or Canada and often focussed on patients with pneumonia, COPD or heart failure. 35 (90 %) studies concluded that geographic variation was present. Primary care quality and secondary care access were frequently suggested as drivers of admission rate variation whilst secondary care quality and adherence to clinical guidelines were often listed as contributors to LOS variation. Several different methods were used to quantify variation, some studies listed raw data, failed to control for confounders and used naive statistical methods which limited their utility.ConclusionsThe substantial geographical variations in the admission rates and LOS of potentially avoidable conditions could be a symptom of variable quality of care and should be a concern for clinicians and policymakers. Policymakers targeting a reduction in unplanned admissions could introduce initiatives to improve primary care access and quality or develop alternatives to admission. Those attempting to curb unnecessarily long LOS could introduce care pathways or guidelines. Methodological work on the quantification and reporting of geographic variation is needed to aid inter-study comparisons.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-0964-3) contains supplementary material, which is available to authorized users.

Determinants of hospital length of stay for people with serious mental illness in England and implications for payment systems: a regression analysis.

BackgroundSerious mental illness (SMI), which encompasses a set of chronic conditions such as schizophrenia, bipolar disorder and other psychoses, accounts for 3.4 m (7 %) total bed days in the English NHS. The introduction of prospective payment to reimburse hospitals makes an understanding of the key drivers of length of stay (LOS) imperative. Existing evidence, based on mainly small scale and cross-sectional studies, is mixed. Our study is the first to use large-scale national routine data to track English hospitals’ LOS for patients with a main diagnosis of SMI over time to examine the patient and local area factors influencing LOS and quantify the provider level effects to draw out the implications for payment systems.MethodsWe analysed variation in LOS for all SMI admissions to English hospitals from 2006 to 2010 using Hospital Episodes Statistics (HES). We considered patients with a LOS of up to 180 days and estimated Poisson regression models with hospital fixed effects, separately for admissions with one of three main diagnoses: schizophrenia; psychotic and schizoaffective disorder; and bipolar affective disorder. We analysed the independent contribution of potential determinants of LOS including clinical and socioeconomic characteristics of the patient, access to and quality of primary care, and local area characteristics. We examined the degree of unexplained variation in provider LOS.ResultsMost risk factors did not have a differential effect on LOS for different diagnostic sub-groups, however we did find some heterogeneity in the effects. Shorter LOS in the pooled model was associated with co-morbid substance or alcohol misuse (4 days), and personality disorder (8 days). Longer LOS was associated with older age (up to 19 days), black ethnicity (4 days), and formal detention (16 days). Gender was not a significant predictor. Patients who self-discharged had shorter LOS (20 days). No association was found between higher primary care quality and LOS. We found large differences between providers in unexplained variation in LOS.ConclusionsBy identifying key determinants of LOS our results contribute to a better understanding of the implications of case-mix to ensure prospective payment systems reflect accurately the resource use within sub-groups of patients with SMI.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1107-6) contains supplementary material, which is available to authorized users.

Has variation in length of stay in acute hospitals decreased? Analysing trends in the variation in LOS between and within Dutch hospitals.

BackgroundWe aimed to get better insight into the development of the variation in length of stay (LOS) between and within hospitals over time, in order to assess the room for efficiency improvement in hospital care.MethodsUsing Dutch national individual patient-level hospital admission data, we studied LOS for patients in nine groups of diagnoses and procedures between 1995 and 2010. We fitted linear mixed effects models to the log-transformed LOS to disentangle within and between hospital variation and to evaluate trends, adjusted for case-mix.ResultsWe found substantial differences between diagnoses and procedures in LOS variation and development over time, supporting our disease-specific approach. For none of the diagnoses, relative variance decreased on the log scale, suggesting room for further LOS reduction. Except for two procedures in the same specialty, LOS of individual hospitals did not correlate between diagnoses/procedures, indicating the absence of a hospital wide policy. We found within-hospital variance to be many times greater than between-hospital variance. This resulted in overlapping confidence intervals across most hospitals for individual hospitals’ performances in terms of LOS.ConclusionsThe results suggest room for efficiency improvement implying lower costs per patient treated. It further implies a possibility to raise the number of patients treated using the same capacity or to downsize the capacity. Furthermore, policymakers and health care purchasers should take into account statistical uncertainty when benchmarking LOS between hospitals and identifying inefficient hospitals.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1087-6) contains supplementary material, which is available to authorized users.

Length of stay of COPD hospital admissions between 2006 and 2010: a retrospective longitudinal study.

BackgroundHospitalizations for COPD are associated with poor patient prognosis. Length of stay (LOS) of COPD admissions in a large urban area and patient and hospital factors associated with it are described.MethodsRetrospective longitudinal study. All COPD patients registered with London general practitioners and admitted as an emergency with COPD (2006–2010), not having been admitted with COPD in the preceding 12 months were included. Association of patient and hospital characteristics with mean LOS of COPD admissions was assessed. Association between hospital and LOS was determined by negative binomial regression.ResultsThe total number of admissions was 38,504, from 22,462 patients. The mean LOS for first admissions fell by 0.8 days (95% confidence interval [CI]: 0.7–1.5) from 8.2 to 7.0 days between 2006 and 2010. Seventy-nine percent of first admissions were ≤10 days, with a mean LOS of 3.7 days (2009–2010). The mean LOS of successive COPD admissions of the same patients was the same or less throughout the study period. The interval between successive admissions fell from a mean of 357 days between the first and second admission to a mean of 19 days after eight admissions. Age accounted for 2.3% of the variance in LOS. Socioeconomic deprivation did not predict LOS. Fewer discharges happened at the weekend (1,893/day) than on weekdays (5,218/day). The mean LOS varied between hospitals, from 4.9 days (95% CI: 3.8–5.9) to 9.5 days (95% CI: 8.6–10.3) when adjusting for clustering, age, sex, and socioeconomic deprivation.ConclusionThe fall in LOS of the first COPD admission between 2006 and 2010 reflects international trends. The stability of LOS in successive admissions suggests that increasing severity of disease does not affect recovery time from an exacerbation. Variations between hospitals of nearly 5 days in LOS for COPD admissions suggests that significant improvements in patient outcomes and in savings in health care utilization could be made in hospitals with longer LOS.

National trends in hospital length of stay for acute myocardial infarction in China.

BackgroundChina is experiencing increasing burden of acute myocardial infarction (AMI) in the face of limited medical resources. Hospital length of stay (LOS) is an important indicator of resource utilization.MethodsWe used data from the Retrospective AMI Study within the China Patient-centered Evaluative Assessment of Cardiac Events, a nationally representative sample of patients hospitalized for AMI during 2001, 2006, and 2011. Hospital-level variation in risk-standardized LOS (RS-LOS) for AMI, accounting for differences in case mix and year, was examined with two-level generalized linear mixed models. A generalized estimating equation model was used to evaluate hospital characteristics associated with LOS. Absolute differences in RS-LOS and 95% confidence intervals were reported.ResultsThe weighted median and mean LOS were 13 and 14.6 days, respectively, in 2001 (n = 1,901), 11 and 12.6 days in 2006 (n = 3,553), and 11 and 11.9 days in 2011 (n = 7,252). There was substantial hospital level variation in RS-LOS across the 160 hospitals, ranging from 9.2 to 18.1 days. Hospitals in the Central regions had on average 1.6 days (p = 0.02) shorter RS-LOS than those in the Eastern regions. All other hospital characteristics relating to capacity for AMI treatment were not associated with LOS.ConclusionsDespite a marked decline over the past decade, the mean LOS for AMI in China in 2011 remained long compared with international standards. Inter-hospital variation is substantial even after adjusting for case mix. Further improvement of AMI care in Chinese hospitals is critical to further shorten LOS and reduce unnecessary hospital variation.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2261-15-9) contains supplementary material, which is available to authorized users.

Psychosocial Determinants of Longer Length of Stay on a Canadian Stroke Inpatient Rehabilitation Unit

Objective: The relationship between availability of psychosocial resources and inpatient stroke rehabilitation length of stay (LOS) has been inadequately studied. The purpose of this prospective observational study was to identify psychosocial determinants that prolong LOS of patients in a stroke rehabilitation program. Methods: Patients admitted to a multidisciplinary inpatient stroke rehabilitation program in southern Ontario, Canada, were consecutively recruited from October 2008 to August 2010. Patients diagnosed as having had a cerebrovascular event resulting in neurological impairments that required intensive rehabilitation were eligible for the study. Independent variables included psychosocial (awaiting long-term care placement, poststroke depression, inadequate family support, limited access to community home care services), medical (comorbidity, medical complications), neurological (type and location of stroke, neurological deficits), and functional (Functional Independence Measure [FIM] score on admission and discharge, Modified Rankin Disability Scale score) factors. The main outcome measure was length of hospital stay (days). Results: A total of 117 patients were recruited. The mean and median LOS were 49.8 and 45 days respectively. Most patients (92.3%) were discharged home. On multivariate linear regression analysis, the significant determinants associated with longer LOS were awaiting long-term care placement (P<0.001), low admission FIM score (P=0.001), post-stroke depression (P=0.007), difficulties arising from inadequate family support (P=0.033), limited access to community home care services (P=0.035), and presence of medical complication(s) (P=0.039). These 6 factors, 4 of which were psychosocial, accounted for 48.8% of the total variance in LOS. Conclusion: Psychosocial factors were key determinants of longer LOS in addition to medical/neurological factors such as severity of stroke and medical complications. Health care systems must incorporate psychosocial information to a greater extent and recognize its fundamental role in rehabilitation outcomes.

A Descriptive Study of Length of Stay at an Intensive Care Unit

ABSTRACT Background and aims As intensive care units (ICUs) are very resource intensive, length of stay (LOS) is of prime importance. This study was done to analyze the LOS in different ICUs and analyze it against a set benchmark. Materials and methods This retrospective study was conducted from April to June 2013 on patients admitted during January to March 2013 in the neurosurgery ICU (NICU), medical ICU (MICU), high dependency unit (HDU) and isolation ICU of a large multispecialty hospital in Pune (India). As per the quality manual of the hospital, benchmark LOS was considered as 3.08 days for ICU. Mean and median LOS was analyzed through Student's t and Chi-square test; proportion of short (&lt;2 days) and long stay (&gt;4 days) patients was also computed. Results Out of 835 patients admitted to the NICU, MICU, HDU and Isolation ICU, the overall mean LOS was 3.37 ± 5.54 days which was statistically significant at a p-value &lt;0.001 (t = 17.58, 95% CI 3-3.75). The overall mean LOS was higher than the benchmarked 3.08 days but still within the optimal range of 2 to 4 days. Mean LOS was statistically significant when tested for department-wise variations with a Chi-value of 173.56 (p-value &lt; 0.001, LR = 113.75). Highest mean LOS was observed for isolation ICU and lowest for MICU. 360 (43.1%) were short stay, 141(16.8%) were long stay and remaining were optimal stay patients. Conclusion The mean LOS for the ICUs varied significantly across the type of ICUs which needs to be continuously monitored. Mean LOS variation across ICU type indicates need for separate benchmarks. How to cite this article Shukla K, Chandrashekhar P, Kumar N, Devade PK. A Descriptive Study of Length of Stay at an Intensive Care Unit. Int J Res Foundation Hosp Healthc Adm 2015;3(1):29-32.

Variation of outcome and charges in operative management for diverticulitis.

Outcomes after surgery for diverticulitis are of continued interest to improve quality of care. The aim of this study was to assess variations in mortality, length of stay, and patient charges between geographic regions of the United States. A retrospective analysis of the Nationwide Inpatient Sample database was performed. Adults with diverticulitis who underwent laparoscopic or open segmental colectomy were identified using ICD-9 codes. Subset analyses were performed by state and then compared. Outcomes included mortality, length of stay (LOS), and total charges. Results were adjusted for age, race, gender, findings of peritonitis, stoma placement, Charlson comorbidity index, and insurance status on multivariate analysis. 148,874 patients underwent segmental colectomy for diverticulitis from 1998 to 2010. Using California as the comparison state and after adjusting for covariates, in-hospital mortality was significantly higher in the State of New York (OR 1.32; 95% CI 1.13-1.55; P<0.05) and Mississippi (OR 2.84; 95% CI 1.24-6.51, P<0.02). Wisconsin had a significant lower mortality rate (OR 0.74; 95% CI 0.59-0.94, P<0.01). LOS was 1.4days longer in New York and 0.54days shorter in Wisconsin than in California (P<0.01). Patients with age >40years, findings of peritonitis, and without private insurance had higher in-hospital mortality and longer length of stay. Average hospital charges differed dramatically between the states in the observation period. The highest hospital charges occurred in California, Nebraska, and Nevada while lowest occurred in Maryland, Wisconsin and Utah. Patients who undergo surgical treatment for diverticulitis in the United States have high geographic variation in mortality, LOS, and hospital charges despite adjusting for demographic and socioeconomic factors. Further analysis should be performed to identify the causes of outlier regions, with the goal of improving and standardizing best practices.

Derivation and validation of a quality indicator of acute care length of stay to evaluate trauma care.

To derive and internally validate a quality indicator (QI) for acute care length of stay (LOS) after admission for injury. Unnecessary hospital days represent an estimated 20% of total LOS implying an important waste of resources as well as increased patient exposure to hospital-acquired infections and functional decline. This study is based on a multicenter, retrospective cohort from a Canadian provincial trauma system (2005-2010; 57 trauma centers; n = 57,524). Data were abstracted from the provincial trauma registry and the hospital discharge database. Candidate risk factors were identified by expert consensus and selected for model derivation using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting. The risk adjustment model explains 37% of the variation in LOS. The QI discriminates well across trauma centers (coefficient of variation = 0.02, 95% confidence interval: 0.011-0.028) and is correlated with the QI on processes of care (r = -0.32), complications (r = 0.66), unplanned readmissions (r = 0.38), and mortality (r = 0.35). Performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.80). We have developed a QI on the basis of risk-adjusted LOS to evaluate trauma care that can be implemented with routinely collected data. The QI is based on a robust risk adjustment model with good internal and temporal validity, and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This QI can be used to target interventions to reduce LOS, which will lead to more efficient resource use and may improve patient outcomes after injury.

S106 Review Of European Copd Audit Data: Factors Affecting Length Of Stay

Introduction and objectives The major cost to health services of COPD care is hospital admission for exacerbation. Reducing length of stay (LOS) will reduce cost, yet there is wide variability across patients and hospitals. We test the hypothesis that these variations may be attributed to either patient characteristics, hospital characteristics and/or the so-called hospital-clustering effect, which indicates that patients with similar characteristics may experience different processes of care and outcomes depending on the hospital to which they are admitted. Methods The European COPD Audit which was carried out in 432 hospitals from 13 countries, included data from 16,018 patients admitted over an 8 week period. The recorded variables included information on the patient and disease characteristics, resources available and clinical practice. Variables in each category associated with LOS were evaluated by a multivariate multilevel analysis and expressed as odds ratios (OR). Results Mean LOS was 8.7 days (median: 7, standard deviation: 8.3, interquartile range: 4–11). Factors associated with an LOS higher than the median (see figure) were clinical with the highest impact in patients with use of mechanical ventilation (OR: 4.74) and higher oxygen flows (OR 2.63). In-hospital treatments, comorbidities and patient-related variables including GOLD class IV (OR 1.77) were also significant. These relationships were maintained with respect to longer LOS (> 21 days). Neither the day of admission, nor any of the resource variables were associated with significant differences in LOS. The crude variability of LOS between the different countries was reduced after accounting for these clinical factors and the clustering effect. Conclusions This study demonstrates a noteworthy reduction in the observed crude inter-hospital variation in LOS after accounting for the hospital-cluster effect and patient related variables. This emphasises the predictor importance of the patients’ clinical conditions and interventions, and understates the impacts of hospital resources and organisational factors. This “real-life” reflection may highlight some valid learning points that may help us to determine which achievable strategies are most relevant to improve outcomes.

Extended length of stay after surgery: complications, inefficient practice, or sick patients?

With the health policy focus on shifting risk to hospitals and physicians, hospital leaders are increasing efforts to reduce excessive resource use, such as patients with extended length of stay (LOS) after surgery. However, the degree to which extended LOS represents complications, patient illness, or inefficient practice style is unclear. To examine the influence of complications on the variance in hospitals' extended LOS rates after colorectal resections. In this retrospective cohort study performed from January 1 through December 31, 2009, we analyzed data from the 2009 American College of Surgeons National Surgical Quality Improvement Program. Study participants were 22 664 adults undergoing colorectal resections in 199 hospitals. Inpatient complications recorded in the American College of Surgeons National Surgical Quality Improvement Program registry. Inpatient complications were identified by the association of the complication's postoperative date with the patient's surgical discharge date. Hospitals' risk-adjusted extended LOS rates, defined as the proportion of patients with a hospital stay greater than the 75th percentile for the entire cohort. A total of 2177 patients (42.8%) with extended LOSs did not have a documented inpatient complication. Although there was wide variation in risk-adjusted extended LOS (14.5%-35.3%) and risk-adjusted inpatient complication (12.1%-28.5%) rates, there was only a weak correlation (Spearman ρ = 0.56, P < .001) between the two. Only 52.0% of the variation in hospitals' extended LOS rates was attributable to hospitals' inpatient complication rates. Much of the variation in hospitals' risk-adjusted extended LOS rates is not attributable to patient illness or complications and therefore most likely represents differences in practice style. Efforts to reduce excess resource use should focus on efficiency of care, such as increased adoption of enhanced recovery pathways.

The Effects of American Society of Anesthesiologists Physical Status on Length of Stay and Inpatient Cost in the Surgical Treatment of Isolated Orthopaedic Fractures

To identify the impact of the American Society of Anesthesiologists (ASA) physical status on postoperative length of stay (LOS) and to document the cost due to LOS after surgical management of the 8 most common lower extremity and 2 most common upper extremity isolated orthopaedic fractures. Retrospective chart review. All patients who presented and underwent one of the 10 selected isolated orthopaedic surgical procedures at a large tertiary care center between January 1, 2000, and December 31, 2010. Charts for patients undergoing the 10 selected isolated orthopaedic surgical fracture procedures more than 10 years were reviewed. Thirteen thousand seven hundred seventy-six distinct operations were identified. One thousand three hundred ninety-eight distinct operations were included in analysis after selection. This was an observational study. Patients who received operative management for isolated orthopaedic fractures were identified utilizing a CPT code search for analysis in a retrospective chart review. LOS and cost secondary to LOS. ASA physical status proved the strongest predictor of postoperative LOS for the 8 most common lower extremity and 2 most common upper extremity isolated orthopaedic procedures. ASA was also a significant predictor of inpatient cost for all isolated orthopaedic procedures included in the study with the exception of CPT code 27536. ASA classification is an indicator for variance in LOS and total inpatient cost for hospitalized patients. Given that ASA classification is a universally collected data point, this method can be used in almost any hospital system and for any operative service. In addition, this study provides a foundation for many other studies to be conducted which will include multiple institutions and fracture types, such that ASA can be used as a more generalizable predictor of LOS and inpatient cost in orthopaedic trauma patients. This model may be used to accurately predict a patient's postoperative course and the expected cost to the health care system of a given procedure. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Influence of hospital volume on outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity in Japan

Little information is available on the relationship between hospital volume and the outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity. This study aimed to investigate the influence of hospital volume on patient outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity using a national administrative database. A total of 5941 comorbid patients treated with laparoscopic gastrectomy for gastric cancer were referred to 741 hospitals in Japan. We collected patients' data from the administrative database to compare laparoscopy-related complications, in-hospital mortality, length of stay (LOS), and medical costs during hospitalization in relation to hospital volume. Hospital volume was categorized into two groups: low (<40 cases in 3 years; n = 4111) and high (≥ 40 cases; n = 1830). There were no significant differences between the groups in laparoscopy-related complications and in-hospital mortality (p = 0.684 and p = 0.200, respectively). However, significant variations in mean LOS and medical costs were observed between hospital volume categories (26.1 days vs. 20.2 days and 16,163.9 US dollars vs. 14,345.9 US dollars, respectively; p < 0.001). Multiple linear regressions revealed that higher hospital volume was significantly associated with shorter LOS and lower medical costs during hospitalization. The unstandardized coefficient for LOS was -4.62 days (95% confidence interval = -5.63--3.60, p < 0.001), whereas that for medical costs was -1424.1 US dollars (95% confidence interval = -1962.5--885.6, p < 0.001). Hospital volume was significantly associated with a decrease of LOS and medical costs of comorbid patients undergoing laparoscopic gastrectomy for gastric cancer.

Total Joint Arthroplasty Surgery: Does Day of Surgery Matter?

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.