Discharge destination and insurance status are major factors in increased LOS in the injured patient. Length of stay should be used as a process measure rather than an outcome measure to truly improve the quality of care that we give.  CWeigelt By continuing to use our site, or clicking "Continue," you are agreeing to our, 2020 American Medical Association. 31 4. Dr Brasel: I would say, probably not. We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged … Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons.  JA Reasons for delayed discharge of trauma patients.Â, Chan to download free article PDFs, Author Contributions:Study concept and design: Brasel, Lim, Nirula, and Weigelt.  III The financial impact of delayed discharge at a level I trauma center.Â, Collins •What is measurement? Overall survival was 97%. This confirms associations found by others, primarily in small, single-institution studies.28,29,33 Once this relationship is established, it is difficult to look at unadjusted LOS as an outcome measure evaluating quality of hospital-based medical care. '|ⲻg��o�U��SO�b�ir�����oLK��$U�1�� In addition, a multidisciplinary approach would be essential to improve the entire discharge process.  GKim Acquisition of data: Brasel. Gregory J. Jurkovich, MD, Seattle, Wash: Two quick questions: First, do you know what the UHC uses as risk adjustment? That would be interesting to do.  A Quality assessment and assurance: unity of purpose, diversity of means.Â, Crombie © 2020 American Medical Association. h�22�P0P����+�-�6 2��]��b�� U�� endstream endobj 407 0 obj <>stream It can be tracked by a specific timeframe or d…  EACleary For example, discharge to home included the subcategories of home, home with health care assistance, psychiatric facility, and jail. Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank. Measure 2: Patients are excluded from the denominator if the patient did not expire in hospice care or the patient received any continuous home care, respite care, or general inpatient care in the last 7 days of life, or had a length of stay of one day. Overall average length of stay decreased from 19 days to 7.5 days Average acute length of stay decreased from 6 days to 4 days Average ALC length of stay decreased from 25 days to 22 days There was a 48% improvement in assigning the expected date of discharge (from 50% to 98%) There was a 66% improvement for meeting the expected date of However, there was a significant interaction effect between race/ethnicity × payer status on LOS (Table 2). Complication Rate:The percentage of patients who develop complications (typically surgical complications) as a result of care. Retrospective database analysis. All Rights Reserved. Your study population was a diverse trauma population.  JARadford We have not been very successful. Other reasons for an extended LOS may relate to its surrogate for socioeconomic status, including nutritional status, social support networks, and incidence of posttraumatic stress disorder. Length of stay is a commonly used outcome measure. Accessibility Statement, Mean Length of Stay by Race/Ethnicity and Payer Status*, Factors Associated With Extended Length of Stay, O’Keefe Conducted within the OhioHealth system, this relatively minor intervention suggests that oncologists can change their behavior and refer patients earlier to hospice care. Mean LOS was 9.6 days. Donald E. Low, MD, Seattle: Many of the comparisons in which we see LOS used as the most relevant factor have to do with the evolution from open to minimally invasive and even interventional types of procedures.  IKDavies The Tukey multiple pairwise comparison test was used to control the type I error rate.13,14 Before developing the regression model, the following variables were recategorized for further analysis. Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. ʗ�nibl�T�o������p���49�B-\��(�Y49"ڥL�;P�joD�W�kMX���!u��>-ݏ�Y�ރ � �W�� ��=�%n�~,����5~�i[�b�B~���.~__~8�p���|� �w~�*w��E��c��N�.������n��t�&m�z��W���]��EX��S��r}�o�����APz H~5�5^�g$B����F�ח����:�� Discharge destination had the greatest effect on LOS. Length of stay should not be used as a comparison between trauma centers or as a benchmark outcome measure unless it is appropriately adjusted. Brasel KJ, Lim HJ, Nirula R, Weigelt JA. All Rights Reserved. Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days, and preceded within an hour by an emergency department visit at the same physical facility Measure Steward: Centers for Medicare & Medicaid Services (CMS) Measure Scoring Results of the analysis of variance are given in Table 1; results of the generalized linear model analysis are given in Table 2.  RJJacobs Although much of the influence of discharge destination on extended LOS may be because of insurance status, payment type has an independent influence in the multivariate model second only to discharge status.  LW These realities of rehabilitation and skilled subacute care needs suggest that using LOS as a process measure may be helpful to a trauma system of care. However, the large number of hospitals from different regions of the United States that do contribute allow many possible regional influences to be overcome. Ninety percent of direct variable cost is directly related to LOS. 405 0 obj <>stream Length of Stay This measure allows organizations to systematically assess the impact of implementing health information technology (health IT) with the intent to decrease inpatient length of stay (LOS). 0j�M��ٛ�&HcV�wAb'@���?��x��Ab�w�f�j�F��{��M���CG#Z�Υ����[$ԅ ^ u�`���u����:}o�%��ԩ=� �zm� Length of Stay: An Appropriate Quality Measure?  DSMcGory  WM Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis.Â, Liu Scott R. Petersen, MD, Phoenix, Ariz: Hospital administrators are constantly looking at LOS and, subsequently, direct variable costs.  MALambert Nonclinical factors were defined as demographic and socioeconomic factors, including age, sex, race/ethnicity, payer status, and discharge status. Discharge destination was home for 63% of patients, a rehabilitation facility for 16%, a nursing home or other long-term care facility for 13%, another hospital for 4%, and other for 4%. The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript. Mark Talamonti, MD, Chicago, Ill: Length of stay is also used as a measure of quality in surgical oncology, and is very complex in that setting.  SL Effect of pre-existing disease on length of hospital stay in trauma patients.Â, McAleese  et al. Canadian CABG Surgery Quality Indicator Consensus Panel, The identification and development of Canadian coronary artery bypass graft surgery quality indicators.Â, American College of Surgeons Committee on Trauma,Â, Khaliq While my teenage children may consider home the equivalent of incarceration, I am not sure this is true of trauma patients. This study has limitations. sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles. Mean ± SD Injury Severity Score was 12.3 ± 9.3. Faced with declining revenue related to changes in Medicare and Medicaid reimbursements, Memorial Hospital at Gulfport knew additional methods of providing more efficient and cost-effective quality care were needed to maintain long-term success. Clinical factors alone may capture only 27% of the variation in extended LOS.1 Most risk-adjustment models do not include adjustment for the important nonclinical factors that affect LOS.  AABroyles As with other aspects of a well-run trauma system, this approach should be inclusive and enable postacute care for all patients including the uninsured or underinsured.  JrRue Dr Brasel: All of the factors that the UHC adjusts for are clinical, unlike the Hospital Efficiency Index, which includes some nonclinical adjustment. All other things being equal, a shorter stay will reduce the cost per discharge and shift care from inpatient to less expensive post-acute settings. Nonclinical factors significantly influence LOS. I think it is an important concept. +, positive correlation. The average length of stay in hospitals (ALOS) is often used as an indicator of efficiency. Methods   DLHopson  et al.  Disparities in the utilization of high-volume hospitals for complex surgery.Â, Brasel University HealthSystem Consortium (UHC), National Surgical Quality Improvement Program (NSQIP), and the NTDB all provide reports to participating hospitals providing LOS performance data indexed to some benchmark. Utilization of hospital services or procedures as measured by the hospital discharge rate or average length of stay. Ni���K*$��T,�v� m�*���/i�P���'�c. �)g�rZ�"*g���*4N�")��ɠ���\Td�Ri�F��� �I� These quality control measures relate to reducing medical errors and protecting patients.  POdling-Smee Mean LOS for patients with Medicaid (11.3 days) was significantly longer than for patients with commercial insurance and uninsured patients (each 9.3 days) and patients with Medicare (8.8 days). The influence of race/ethnicity and payment type on other outcome measures of resource use has been noted by others.27-29 Liu et al27 found that Medicaid patients, blacks, Hispanics, and Asians were less likely to receive complex surgical care at high-volume hospitals.  et al. Acute Myocardial Infarction Working Group of the American Heart Association/American College of Cardiology First Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, Challenges and opportunities in quantifying the quality of care for acute myocardial infarction.Â, Bradley Placement of patients without adequate and appropriate insurance requires substantial personnel time and effort and may often depend on a very few beds in LTACFs in any given community.  KJRasmussen The National Trauma Data Bank was queried for all patients older than 18 years with an LOS longer than 48 hours and complete demographic information including age, sex, and race/ethnicity; nonclinical factors including payment type (commercial, Medicaid, Medicare, uninsured, and other) and discharge destination (home, rehabilitation facility, nursing home, and other); and clinical information (body region injured, Injury Severity Score, and Revised Trauma Score). The authors have thoughtfully and convincingly demonstrated that a seemingly simple and straightforward statistic is influenced by myriad complex factors, many of which are nonclinical and beyond the control or influence of surgeons or hospitals. I do not think putting them in a separate group would be particularly helpful because then they would be such a small minority, less than 5% in both groups. Medicaid patients and those designated as self-payers were associated with an extended LOS (Table 2). Accepted for Publication: December 31, 2006. the Average Length Of Stay (ALOS) for patients under Hospitalist care exceed the benchmarks for large community non-teaching hospitals. Length of stay greater than the mean. The ACA has brought to light the importance of collecting data and using quality and outcome measures to determine how well an entity is performing. Should organizations that purport to measure quality of care abandon LOS as an indicator of effective and efficient care? h��Xko۸�+���"ᛔ.�w�M��Ӧ� ��hkK�-����{����#m�]�9�g�)��x$����(m$b��"� .�dB�I���6���A�XF�F�XE14�XG�(чc��-)R�`��ԕT&��B�s�#�$5�HY.”*F�D?�a�Lt�5)K,H�b#�B�E�K�O���GF)��<2�B=���).#�z�Ud&��7��xt�v������i��n1��v���G?~����6��5;���4��Ay�\����,7ۚǑj[h�Po;�Y�WI3�����\�ʝ�+���t��Y���a:����C6�G��)���?����g�m:�zTN"��'d�;Wˣ~������N5���^:��6�:��*-/�w7���|P�d�;I��(�� ������|�W�M���������[G�zӁ��(V����c��ݗ�3;X}� ��0��b'�p1;,�rw�x��N��p�Wp�S������V�ӥ�w�ȳ�?�]�}u8+g�tk�ް�e:���n�#��������&d�$�ń}���5�ouY��Ykp�`L6��{���t�?�.oӺ��s̑�]�� We did not overwhelm the model with interaction terms, but that interaction term was significant. Did you assess LOS for the various subcategories of discharge destination?  RHMcGlynn Transfer agreements for rehabilitation and LTACF care could be incorporated into a trauma center's overall care plan. Discharge destination had the greatest effect on LOS. �� 5h�A��6C�̐i�sF�i���{��`��1}wۍø(g��G`��Θ0�cS�OX������-���ȥ����.�J�.�:�� ���S��U�m���yQw�m!��"�����0P�`:`‚Q���/%N*�)O�Y�/�:IG�:����|�J����0�6I�p��,]��8�S���9.p�+\c��Xa�/�����fk�W��kb�D�O6C�-�;�ܵ����dQA��A��q\|�t�  ML Fig. Goals/Objective: To achieve the following by 7/31/10 (50% of benchmark): 1. ", abstract = "Hypothesis: Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. Mean ± SD age of patients was 48.2 ± 21.1 years; 62.3% were men. We obtained 313 144 medical records.  SDMcClellan Measure Category: Clinical Outcomes Quality Domain: Patient Safety; Efficiency Current Findings in the Literature: Patients may Dr Brasel: I am not sure I have a short or a simple answer to that question, but I do think it is important. . We aimed to disentangle the correlations between these interrelated measures and propose a new way of combining them to evaluate the quality of hospital care. Results  Clearly, age, physiologic status, and body region injured are also important. In hospitalized injured patients, LOS in an acute care hospital is clearly affected by the need for rehabilitation or long-term care. hospitals to improve length of stay efficiency • evaluates the effectiveness of targeted programs and better practice guidance. Records were excluded from the analysis if they met any of the following criteria: patient younger than 18 years; LOS missing, less than 48 hours, or longer than 365 days; or LOS less than the number of days in the intensive care unit.
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