length of stay quality measure

Hospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care. In hospitalized injured patients, LOS in an acute care hospital is clearly affected by the need for rehabilitation or long-term care.  WM Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis.Â, Liu 7}���u��N�_��r��[��'������ ���\ endstream endobj 408 0 obj <>stream 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). Were there state or regional differences in either LOS or the nonclinical factors that seemed to influence LOS? In your first slide, you showed that the UHC did have risk-adjusted LOS. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). h�22�T0P���w�/�+Q0���L)�621�)�I3�RY�����Zlg` �v endstream endobj 406 0 obj <>stream We did not assess regional differences. All Rights Reserved. Therefore, when a patient is well enough to receive care outside of the hospital, they should be discharged and managed in a less costly way.  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 Are you certain that your data are broadly representative of patients with injury? The 2004 National Trauma Data Bank (NTDB) data set was used. In your database, did you look at high-volume trauma centers, different levels of trauma centers, and how that influenced LOS? And that was not even because of some of these nonclinical factors. Our website uses cookies to enhance your experience. Patient days that were spent outside the period under calculation should not be counted. title = "Length of stay: An appropriate quality measure? Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank. 266 Emergency Department Length of Stay as a Quality Measure: Will There Be Unintended Consequences for Safety-Net Emergency Departments?. Outcomes are, simply put, results. Source: The user community It can also improve outcomes by minimizing the risk of hospital-acquired conditions.  DJBockler %PDF-1.7 %���� 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. Did you assess LOS for the various subcategories of discharge destination? However, the large cross-sectional sample suggests that the results reflect general associations with extended LOS. In some communities, none of these beds may be available. h��W�n�8�>njkx'Ph�]$[�5��F�j�b�4�gđ-��,Z`_D�<3�9�� We hypothesized that nonclinical factors, specifically payer status, would similarly affect LOS in injured patients. Length of hospital stay (LOS) following surgical cancer care is an important measure of short-term quality of care. +, positive correlation.  KJWeigelt It did not turn out to be independently significant, although, as you might imagine, patients who are injured through blunt mechanisms are significantly different with respect to some of those nonclinical factors from patients who are injured via penetrating mechanisms. University HealthSystem Consortium (UHC), National Surgical Quality Improvement Program (NSQIP), and the NTDB all provide reports to participating hospitals providing LOS performance data indexed to some benchmark. To identify potential predictors for the final model, the variables were first examined individually using univariate analysis. Payer status had the next greatest effect; Medicare patients were significantly associated with an LOS less than the mean compared with patients with commercial insurance (odds ratio, 0.77; 95% confidence interval, 0.73-0.82). You might suggest that readmission rate, as a clinical or nonclinical factor, is influential, but it goes to the point that you need to know what goes into the data and intelligently use the data when you talk with your administrators, and look at your own practice, your hospital's practice, and your system's practice. Reducing length of stay Quality, Service Improvement and Redesign Tools: Reducing length of stay What is it?  JA Reasons for delayed discharge of trauma patients.Â, Chan ����a�(�]�b�E�gQh�Xd[��6�j|�x�Z?m��P�ͽ��B+��MNq���Kԑ�ˬ(����!��|�o�Z�8(F���oc�,n�?~R�"����w?�x�l�n�Ϧ�#�����:�!���eU���C�c�l���vȎ�k������3�;�̆�g�%������yh����3�Q�c��M��v��W�Ȟ�?̏n������iE_ky;��:�*َ��lD�ހ�-6�x�tv�Nj����W�#$I�"��:�w�a:Y~�^}�vC��IZq�,��m��l�5�Ǭ�>R���._��湿�����"qv�rH� R�{�a@���P��I(-���A��K'�$��׬������N,L8C �1]jD\�$}��pd$����. Clinical factors were defined as body region injured, Injury Severity Score, and Revised Trauma Score. Although injury severity was significantly associated with extended LOS, other factors had much stronger associations. Forty percent of the patients had commercial insurance, 11% had Medicaid, 25% had Medicare, 16% were uninsured, and 9% had other insurance. Others, including pain, function, and quality of life, are more difficult to measure. Longer stays result in higher costs and extra burdens on patients and their families. While extended LOS certainly demonstrates holes in our health care system, is this an appropriate measure of quality of care in a trauma center? The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript.  WA The application of statistics as an aid in maintaining quality of a manufactured product.Â, Donabedian 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. Did mechanism of injury, for example, blunt vs penetrating trauma or an assault vs a motor vehicle crash, have a significant effect on LOS? However, the large number of hospitals from different regions of the United States that do contribute allow many possible regional influences to be overcome. 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.  JCauley 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.  JHZingmond  KE Using clinical practice analysis to improve care.Â, Guru �� 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� 1-5 The American College of Surgeons Committee on Trauma uses LOS as an example outcome measure for a performance improvement program. The variable of race/ethnicity was divided into the following 4 groups: white, black, Hispanic, and other (Asian/Pacific Islander, Native American, and Native Alaskan).  EACleary It can be tracked by a specific timeframe or d… 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. Customize your JAMA Network experience by selecting one or more topics from the list below.  VAnderson  D Impact of pre-trauma center care on length of stay and hospital charges.Â, Holloway Previous Presentation: This study was presented at the 114th Scientific Session of the Western Surgical Association, November 15, 2006; Los Cabos, Mexico; and is published after peer review and revision. Second, have you considered interaction between the variables used in your regression analyses? Ninety percent of direct variable cost is directly related to LOS. My question is: How can we take these data and turn them around and create a national forum to really increase access to rehabilitation, which is one of the frontiers of trauma systems that is totally undeveloped. Many current quality improvement efforts focus on measuring structure and process because these are usually easier to measure than outcomes.20,21 The relationship of structure and process to outcomes can be direct or indirect. doi:10.1001/archsurg.142.5.461. It is my impression that victims of violent acts are much more difficult to place and, thus, have a prolonged LOS even though their injuries are essentially equivalent to those of others. In multivariate analysis, factors significantly associated with extended LOS included age, sex, race/ethnicity, insurance status, discharge destination, and Revised Trauma Score.  EJMorris  M The use of hospital care: do insurance status, prospective payment, and the unit of payments make a difference?Â, Schnitzler h�22�P0P����+�-�6 2��]��b�� U�� endstream endobj 407 0 obj <>stream Dr Brasel: We looked at this about 4 years ago and found that about 25% to 30% of our extended LOS on a prospective basis was completely nonmedical. Mean ± SD LOS was 9.6 ± 12.8 days. Hospital length of stay (LOS) has long been a crucial barometer of hospital efficiency and quality of care.  RS Variations in healthcare measures by insurance status for patients receiving ventilator support.Â, MacKenzie Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons.  JA 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.  DLMundy Definitions of excessive, increased, or extended LOS are varied, and there is no acceptable gold standard.1,30 Length of stay greater than the mean or median has been used by others31,32 and is appropriate in this large database containing patients with many different injury diagnoses.  SNMcGwin Discharge destination had the greatest effect on LOS. Retrospective database analysis.  JHenderson Correspondence: Karen J. Brasel, MD, MPH, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (kbrasel@mcw.edu). Structure is simply the infrastructure of the health care system, which includes the individuals, the equipment, and the physical plant. Ni���K*$��T,�v� m�*���/i�P���'�c. © 2020 American Medical Association. A high number could indicate a problem with the facility’s prescription ordering system.  JrRue The average length of stay in hospitals (ALOS) is often used as an indicator of efficiency.  JWedderburn  RW Generalized linear models.Â, Shewhart  JARadford  SSarosi Some of these factors include discharge destination, the presence or absence of family support, payer status, and the availability of rehabilitation or long-term care facilities. If LOS is used as a quality measure for injured patients, adjustment for these factors is necessary. Quality medical care has become the primary focus in US health care since the 2000 report from the Institute of Medicine.16 Organizationally, performance improvement is the cornerstone on which advances and increases in quality are based. Something that can, and does, vary. However, there was a significant interaction effect between race/ethnicity × payer status on LOS (Table 2). ��Q*�U}��p@4HP�N���ΗP6��}�"�����ϒ)����  et al.  “Ideal” length of stay after colectomy: whose ideal?Â, Schwartz 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. Finally, based on your analysis, is LOS a meaningless parameter of quality measurement?  POdling-Smee Implementation of the weekly long length of stay patient reviews as set out in ‘reducing long length of stays’ 14 May 2019 Shared learning. u��z����m{]wK����ޓ`_]'��B�QЀ2�F��ѦȮ��j�����F������:���҇����҆�j*���R�Kn��,��� -h� Dr Brasel: I would say, probably not. Approximately one fourth to one third of the LOS may be associated with nonmedical factors.28 However, many organizations using LOS as a quality benchmark do not adjust for these important nonclinical factors.3,6,34 As an outcome measure, LOS must be adjusted for both clinical and nonclinical factors.  et al.  Discharge disposition from acute care after traumatic brain injury: the effect of insurance type.Â, Schoetz Some of this is moderated by race/ethnicity, inasmuch as interaction terms between groups were significant. Quality | Quality improvement.  SHChalian Records were also excluded if any of the primary variables of interest were missing. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). Nonclinical factors were defined as demographic and socioeconomic factors, including age, sex, race/ethnicity, payer status, and discharge status. Nonclinical factors significantly influence LOS.  KJRasmussen  LB The value of process measures in evaluating an evidence-based guideline.Â,  A resource from the Institute for Healthcare Improvement.Â, Spertus These quality control measures relate to reducing medical errors and protecting patients.  RWRoberton We included mechanism of injury, blunt vs penetrating trauma, in early analyses. If you are just discharging people from the hospital after a first admission and they return and are readmitted for another 4, 5, or 6 days, that probably does not influence resource consumption and may be an indicator of poorer quality of care rather than improved quality of care. Discharge destination was grouped into the following 5 categories: home (home, home with home health assistance, jail, or psychiatric facility), rehabilitation facility, nursing home (skilled nursing facility or nursing home), another hospital, and other (unknown discharge destination or patient unable to complete treatment). •What is measurement? They do not adjust for injury severity or anything specific to trauma populations. Accepted for Publication: December 31, 2006. There are several ways to meas… •Conceptualization or conceptual definition. . Comorbid conditions, clearly shown to affect LOS in hospitalized injured patients, were not considered in the model because of the large amount of missing data and quality of this field in the version used. Length of stay (LOS) has been suggested as a meaningful outcome measure that is a potential target for quality improvement activities.  CJohantgen What is a variable? It is suggested that if LOS decreases, care has become more efficient and more effective, because patients with extended LOS often consume substantial hospital resources.  M Compared with patients discharged to home, the odds ratio for an extended LOS for patients discharged to another hospital, rehabilitation facility, or nursing home was 2.23, 3.74, and 3.83, respectively. It is so easy to measure and is such a part of the administrative culture.  C Outpatient mastectomy: clinical, payer, and geographic influences.Â, Kagan Overall survival was 97%. Conducted within the OhioHealth system, this relatively minor intervention suggests that oncologists can change their behavior and refer patients earlier to hospice care. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force, 2007;142(5):461-466. doi:10.1001/archsurg.142.5.461.  RV Defining excess resource utilization and identifying associated factors for trauma victims.Â,  The best medical evidence for the best care management.Â,  Wisconsin Collaborative for Healthcare Quality Web site.Â, Englert Length of stay is a quantitative indicator that can be used to measure quality of care on older adult inpatient wards and is affected by a number of different factors, such as severity of mental illness, compliance with treatment plan, physical health issues and discharge delays.  KMKoch It would be equally interesting to have the same objective comparisons in patients who have a single pathologic condition. We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged … =mE�;��]f7���J� the Average Length Of Stay (ALOS) for patients under Hospitalist care exceed the benchmarks for large community non-teaching hospitals. Goals/Objective: To achieve the following by 7/31/10 (50% of benchmark): 1. Length of Stay: An Appropriate Quality Measure? �� 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.  SDMcClellan Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank. 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.

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