Predictors of length of hospitalization after cardiac surgery

The cardiac surgical data base at Georgetown University Hospital was reviewed for patients operated on between January 1, 1980, and September 30, 1986, to determine predictors of length of postoperative hospitalization. Mortality among the 1,919 operations was 115 (6%). In the study group of 1,804 operations resulting in survival for at least 30 days, the following factors were analyzed: type of operation, age, sex, New York Heart Association (NYHA) Functional Class, urgency of operation, preoperative myocardial infarction (MI), weight, body surface area, hypertension, diabetes mellitus, previous cardiac operation, smoking history, and family history of cardiac disease. The overall mean length of hospitalization was 10.7 +/- 5.6 days. The analyses indicated that valve operation, age less than 30 and greater than 60 years, female sex, NYHA Class IV, urgent operation, preoperative MI 1 to 4 weeks before operation, and diabetes mellitus requiring medical treatment prolonged hospitalization, but generally by only 2 days. Major prolongation of hospitalization was associated with age in the 20- to 30-year and 80- to 90-year brackets. Unexpectedly, heavy body weight and smoking were not predictive.

Lengths of stay of patients with uncomplicated acute myocardial infarction at three Boston hospitals: impact of pre-discharge tactics

Variability in length of stay (LOS) and its determinants were studied in 60 patients without complications after acute myocardial infarction (AMI) at three teaching hospitals. The patients at the three hospitals had similar clinical presentations and in-hospital courses. However, 81% of patients admitted to the intensive care unit (ICU) at one hospital were transferred to lower levels of care within 48 hours, compared with 40% and 56% at the other two hospitals (p less than 0.05). Patients who underwent pre-discharge exercise tests (ETT) had a longer total LOS than patients who did not (11.9 +/- 4.3 vs 9.2 +/- 2.9 days; p less than 0.01). Similarly, patients who underwent 24-hour ambulatory monitoring (AMB-MON) had a longer total LOS than patients who did not (12.3 +/- 4.3 vs 9.1 +/- 2.8 days; p less than 0.001). No differences in clinical characteristics or in survival at six months were detected between patients who did and did not undergo ETT or AMB-MON. Total LOS correlated with whether patients underwent 0, 1, or both of these tests (p less than 0.0001); each test was associated with a 2.3-day increase in the duration of hospitalization. The authors conclude that such tests may prolong total LOS of patients without complications after AMI.

Financial risk, hospital cost, and complications and comorbidities in medical non-complications and comorbidity-stratified diagnosis-related groups

A number of methods are being studied to modify and improve the accuracy of the Medicare Diagnosis-Related Group (DRG) hospital classification system. This study analyzed resource consumption for 2,431 medical Medicare patients in the 53 non-complicating condition-stratified (i.e., non-complication and comorbidity) medical DRGs. Resource consumption per patient increased as the number of complications and comorbidities per patient per DRG increased, as measured by total hospital cost, hospital length of stay, the number of diagnoses and procedures per patient, the percent outliers, and mortality. Patients with more than four complications and comorbidities generated significant financial risk ($5,667 loss per patient) under DRG reimbursement. This study raises the question of the equity of DRG reimbursement for the medical non-complication and comorbidity-stratified DRGs. A method for DRG adjustment based on complications and comorbidities should be implemented by Congress to assure equitable payment for patients in these medical DRGs.

Distribution of patients between faculty and residents in a teaching hospital clinic

The authors tried to determine whether housestaff are systematically assigned clinic patients who are more "difficult": the elderly, the poor, those with many problems, and those who cannot speak English. This cross-sectional study was carried out in the outpatient department of a university health care insurance. A systematic sample of 1,870 patient visits to the medical clinic from 1980 to 1986 was studied. Housestaff were more likely to see patients who did not speak English, who had four or more medical problems, who had visited the clinic five or more times, who had been admitted to the hospital or emergency ward, or who had a skin problem. Multivariate analysis of these individual factors, allowing for the effect of each upon the others, showed that only previous hospital or emergency ward admission, native language, and skin disease retained a significant association with housestaff physicians. None of these factors was strongly associated with physician status, as shown by poor predictive accuracy when the multivariate models were used to predict accuracy when the multivariate models were used to predict physician status in 105 patient visits in 1987. While some factors were statistically associated with physician status, the magnitude of the effect of each was small. An explantation, other than bias in patient assignment, was usually apparent. It is possible to organize an outpatient clinic where housestaff care for patients who are similar to those seen by faculty.

Financial incentives of subregional RAWP

Accounting for the cross boundary flows of residents from one health authority treated by another has been considered by the review of the Resource Allocation Working Party (RAWP) formula by the National Health Service Management Board. A common concern is that the approximate costs used are unfair to those authorities (typically those with teaching hospitals) that are likely to treat more complex cases. This paper argues that when spending exceeds the target allowance for acute services this is more likely to be due to district residents using services at a high rate than to inadequate compensation for inflows. Districts where residents make a high use of services are often those where there are large flows across district boundaries. Since authorities cannot control outflows there is little they can do to reduce their residents' high use of services. Furthermore, curious financial incentives can be inferred for clinicians in these districts if they were to take effective action to bring their district's spending to target levels. These problems are discussed to illuminate problems of accounting for cross boundary flows that alternatives to current practice must resolve.

Impact of shortened hospitalization on outcome parameters

Due to administratively mandated changes in the reimbursement system for inpatient treatment, average length of hospital stay in a geropsychiatric hospital unit decreased by approximately 20% within 1 year. The impact of this change on selected key parameters of effective therapeutic management are analyzed. Three 90-day periods were compared, one before, two after the reduction in length of stay. It was found that postdischarge referrals to facilities with a higher level of restrictiveness than prior to hospitalization increased significantly from Period 1 to Period 2, but returned to the original level in Period 3. These findings were confirmed when data were corrected for changes in the diagnostic composition of the respective samples. Patients who lacked natural support systems were more likely to be referred to a postdischarge setting of greater restrictiveness than before the admission. This finding remained constant. Readmission figures increased by 5% immediately after introduction of the decreased average length of stay (Period 2). When corrected for diagnostic composition, early recidivism also returned to original level in Period 3. Patients' insurance status appeared unrelated to any of the measured variables. Some observations on the composition of the diagnostic mosaic among admissions over time and the relations between diagnostic categories and average length of stay are included.

The referring physician and the teaching center

An adequate patient base is critical to the survival of tertiary care institutions. Since referring physicians send a significant portion of their patients to the teaching center, effective communication with them is vital. A survey of the physicians who refer patients to The University of Virginia Medical Center revealed certain hospital services that needed improvement. Their responses also led researchers to recognize graduate and continuing medical education programs as valuable marketing vehicles that can support the academic medical center. As a result of the survey project, The University of Virginia Medical Center was able to strengthen the contacts with practicing physicians and increase the visibility of the Center's medical expertise and special technology. Drawing on the marketing concept of the derived demand, the referring physician's connection to the tertiary care hospital becomes clear. As he searches for the best health care for his patient, he also helps to maintain an adequate patient base for the tertiary hospital. Responding to the referring physician's opinions and needs is a viable approach to increasing referrals to the tertiary care center.

Audit of work-load of physicians with a special interest in respiratory medicine

A 6-month prospective survey was undertaken to assess the work-load of two consultant general physicians with special interest in respiratory medicine, one in a teaching hospital (TH) and the other in a district general hospital (DGH). The two firms dealt with similar numbers of inpatients of whom half had non-respiratory disease. Eighty per cent of the outpatient work of both firms was respiratory disease. The TH firm saw more referrals from other consultants and referred more patients, especially to other physicians. Practical procedures performed, the proportion of patients seen by the consultant at first attendance and the range of both respiratory and general medical conditions seen by the two firms was similar.

Prospective study of the pattern of utilization of mental health services of a Nigerian university hospital

A prospective study of the pattern of utilization of the mental services offered by a Nigerian university teaching hospital was carried out in 1981. Demographic and other characteristics of the 151 patients registered over a 3-month period are described along with their mode of entry into the health care delivery system of the hospital. The significance and implication of the findings are discussed.

Assessing the appropriateness of hospital utilization to improve efficiency and competitive position

A hospital, induced by a certificate of need process and a newly competitive health care environment, made the transition from passive response to outside pressures to active utilization control.

[The Phlebologic Center of Sienna. Its experience]

In this work we disclose the diagnostic and therapeutic orientation of the "W. Pabisch" Centre of Phlebology, Sclerotherapy and Compression Therapy of the University of Sienna. Attentive clinical examination, Doppler, and luminous reflex rheography represent essential procedures for the correct diagnosis of venous affections. Compression therapy, pharmacological and surgical therapy. as well sclerosis, are the correct indications to be adapted according to the phase of the illness and the condition of the patient. In the tables we report the essential statistical data received from observations of the 4,668 patients monitored in our centre during a period of 14 months.

Parasuicides in a general hospital psychiatric unit: their demographic and clinical characteristics

This study presents a profile of 89 patients admitted to the psychiatric unit of a general hospital for a deliberate but not fatal self-inflicted injury. The role of selected demographic clinical and psychosocial characteristics in the hospital admission of these parasuicide patients and their use of available services during the acute phase of their period of distress are discussed.

Patients who leave without being seen

We conducted this study because very little is known about patients who leave without being seen. A total of 4,868 patients were registered in an emergency department during a six-week study period. Sixty-eight (1.4%) left before treatment was completed; 97% (66 patients) left before ever being seen by a physician. Thirty of the 68 patients were interviewed later in followup A comparison group of 23 patients who did not leave prematurely was also selected and matched for age, sex, urgency of chief complaint, and time of presentation. Fourteen of these patients were interviewed later. Patients who left without being seen (LWBS) and nonLWBS patients did not differ in waiting time in the ED. The two groups also did not differ in the spectrum of chief complaints. Twenty-two of 30 LWBS patients were suffering from acute psychological distress at the time of their visit, however, compared to only one of the comparison group (P = .0005). The walkouts reported recent deaths of relatives or friends, recent bouts of alcoholism, acute financial problems, suicidal thoughts and behavior, court appearances, pregnancies and miscarriages, new people in the home, acute illnesses in relatives, and other psychological and social crises.

"Risk" factors affecting readmission of the elderly into the health care system

One hundred one patients, 70 years and older, who were discharged to the community from an acute-care hospital were followed for 1 year to isolate risk factors affecting the probability of readmission. A total of five interviews were conducted with each patient. Postdischarge outcome at any point in time was defined as either readmission to a health care institution or continuous survival in the community. At 1 year, 47 individuals had experienced at least one unplanned readmission. Logistic regressions were used to study risk factors influencing the probability of readmission at 6 weeks, 6 months, and 1 year after release from the hospital. In the short run, sex, being widowed, a weighted severity-of-illness factor, and life satisfaction were significant; previous hospitalization and admission and discharge location were additional variables significant in the long run. An explanation is offered for why some risk factors useful in postadmission studies do not function as well as risk factors in post-discharge studies.

[A study of utilization review in hospitals--focusing on medical statistics]

It is a matter of course that health care is an important issue closely related to the daily life of residents. In this situation, university hospitals, although their main aim is research and education, also play a significant role as core hospitals in various regions of the community. By reviewing hospital utilization, extended to facilities in a given area, we first analyzed the medical service area and the length of stay in the hospital affiliated to the University of Occupational and Environmental Health, on the basis of discharge various directions of facility planning based on future bed using control, including addition of beds, and also attempted to evaluate the actual state of annual facility management with the aid of computer.

The influence of rural physicians' perception on referral patterns to a university hospital

The patient referral process is based on a complex set of social rewards and costs for the referring physician. For the physician or institution potentially receiving referrals, a key question is, why is one institution selected over other available choices? Factor analysis of a survey of rural physicians revealed five factors of reward and cost associated with the choice of where to refer patients. Further analysis of these factors suggested that the ability to have patients admitted and treated when necessary is central to the satisfaction of the referring physician and their willingness to continue the consultant relationship. Adequate information about the consultants was also important to satisfaction. Other factors have less influence. Further, "admissions when necessary" was the only reward/cost factor which predicted physicians who referred more to the university hospital than to other hospitals. If a university hospital wants to develop strategies to encourage referrals from rural physicians, it must be cognizant of these social reward-cost factors.

A comparison of Western European and US University hospitals. A case report from Leuven, West Berlin, Leiden, London, and San Francisco

To assess how closely US university hospitals resemble those in other Western countries, I compared four major European university hospitals--Leuven, Belgium; Klinikum Steglitz , West Berlin; Leiden, the Netherlands; and St Thomas', London--with a US institution--University of California, San Francisco ( UCSF ). University of California had 1.6 to 2.4 more total employees, 1.1 to 1.7 more registered nurses, 2.1 to 8.5 more staff physicians, and 1.5 to 3.0 more house officers per adjusted occupied bed. University of California's costs per bed were 2.2 to 3.5 times higher, its inclusive per diem charges at least four times higher, and its malpractice premium at least 50 times greater. Medical patients at UCSF and West Berlin were more severely ill, as judged by organ system failure, need for organ system support, and levels of consciousness. Compared with UCSF , the European hospitals had more explicit rationing of care according to age and illness severity. Overall, European university hospitals are larger, less expensive, less technology intensive, staffed by fewer employees and physicians, occupied by less severely ill patients, and more apt to serve as regional referral centers. As US university hospitals move into a price-competitive era, they may come to resemble their European counterparts.

Patients attending an accident and emergency department for primary medical care

An increasing number of people seek primary care at casualty or accident and emergency departments of hospitals. A questionnaire was completed by patients attending for primary care at an Australian hospital. The study aimed to determine why patients chose the hospital for their medical care, whether patients triaged to the Primary Care Unit differed from patients triaged to the Casualty section of the Accident and Emergency Department, and whether the characteristics of patients attending at daytime differed from those attending out of hours. There were no significant differences between daytime and out-of-hours attenders according to sex or whether born in Australia or not. More children presented at night or at the weekend; more older people presented by day. There were more single, divorced, separated and widowed patients among the daytime attenders. Daytime attenders had significantly lower incomes than out-of-hours attenders, were less likely to have a local general practitioner or full health insurance: most had a health care card and cost may have been a factor in their attendance. Out-of-hours attenders who had a local general practitioner appeared to be unaware of any deputizing services or had rejected them in favour of the hospital service.

Review of patients with multiple injuries treated at University Hospital, Kuala Lumpur

This study has analyzed 260 patients with multiple injuries sustained in road accidents admitted to the University Hospital during the period July 1967 to July 1976, in relation to age, sex, and ethnic distribution. The types of injuries sustained have been discussed to highlight their effects on the community in a developing country. The extremities have been most frequently involved, while head injuries followed closely. The causative factors of multiple injury-producing accidents have been evaluated. The categories of victims most liable to multiple injuries have been discussed. The significance of understanding the mechanism of these accidents and the effect of such knowledge in minimizing diagnostic errors, thus enabling management and the urgent need for regional accident services in developing countries, have been stressed.

The effect of outpatient visit volume on inpatient teaching services

Ambulatory clinics at public teaching institutions often have less potential for generating revenues than the inpatient services. In times of fiscal constraint, they are, therefore, vulnerable targets for cutbacks in services. A financial crisis in the Bexar County Hospital District led to administrative changes which caused a 20 percent decline in outpatient visits for the entire year. This resulted in a 10 percent fall in the inpatient census and adverse effects on teaching programs and on hospital finances. A regression of inpatient activity with outpatient activity showed a highly significant correlation (r = .57, p less than .01). The decline in the inpatient census contributed to a renewed institutional commitment to ambulatory services. In addition to their direct role in patient care and training, the outpatient clinics thus appear to be essential to the success of inpatient teaching programs. These data emphasize the importance of "vertical integration" (that is, ownership of facilities providing several levels of care) of services to the survival of academic health centers.

Does practice make perfect? Part II: The relation between volume and outcomes and other hospital characteristics

The effect of a greater volume of patients with similar conditions being treated at a hospital on the outcomes achieved is investigated for almost 500,000 selected surgical and medical patients treated in over 1,200 nonfederal United States hospitals. In Part I the authors found strong and consistent evidence for surgical patients that high volume is associated with better outcome; evidence for medical patients was mixed. In this paper the authors include other hospital variables related both to volume and outcome--hospital size, teaching status, and expenditures--to determine whether they mask the true relationship; still, strong and consistent evidence that greater volume produces better outcome was found for both surgical and medical patients. This relation was significant for low-, medium-, and high-risk patients. Among the hospital variations added, only size was consistently and strongly related to outcome; greater size was associated with poorer outcome after accounting for volume. The potential importance of the findings for reducing deaths and days in hospital on a national level is discussed. The evidence is strongly supportive of the need for policies that would promote greater regionalization of a given service, and not greater size, to obtain better quality outcome for patients treated.

A stochastic model to measure patient effects stemming from hospital-acquired infections

We introduce a Markov chain model to represent a patient's path in terms of the number and type of infections s/he may have acquired during a hospitalization period. The model allows for categories of patient diagnosis, surgery, the four major types of nosocomial (hospital-acquired) infections, and discharge or death. Data from a national medical records survey including 58,647 patients enable us to estimate transition probabilities and, ultimately, perform statistical tests of fit, including a validation test. Novel parameterizations (functions of the transition matrix) are introduced to answer research questions on time-dependent infection rates, time to discharge or death as a function of patient diagnostic groups and conditional infection rates reflecting intervening variables (e.g., surgery).

An iterative estimation and validation procedure for specification of semi-Markov models with application to hospital patient flow

This article presents a methodology to identify and specify a continuous time semi-Markov model of population flow within a network of service facilities. An iterative procedure of state space definition, population disaggregation, and parameter estimation leads to the specification of a model which satisfies the underlying semi-Markov assumptions. We also present a test of the impact of occupancy upon realizations of population flows. The procedure is applied to data describing the movement of obstetric patients in a large university teaching hospital. We use the model to predict length-of-stay distributions. Finally, we compare these results with those that would have been obtained without the procedure, and show the modified model to be superior.

Medical intensive care in a community teaching hospital

The success of efforts at cost containment in medical intensive care units of community hospitals will ultimately depend on accurate assessments of their use by practitioners. This study analyzes 167 consecutive admissions to such a facility, 81 percent of which were supervised by physicians in practice in the community. The results suggest that a significant number of patients are admitted only for observation or conventional medical care, that a substantial proportion of resources is spent on the care of patients who die immediately and that there are few practitioners with enough experience in the daily operation of this facility to develop broad perspectives of its use. Physicians with specific training or more experience in intensive care medicine, such as full-time directors of medical intensive care units, should participate in the decisions about the allocation of the limited resources available to the critically III.

Anaesthetic emergency service at three hospitals--a decade of change

The results of a 6-week survey of anaesthetic emergency work completed in 1978 are compared with those from an earlier survey in 1967. Three hospitals sampled, an undergraduate teaching hospital, a district general hospital and a specialized paediatric hospital. At all three hospitals emergency workload increased relative to the population served, with intensive therapy accounting for much of the extra demand. The consequences for the provision of an anaesthetic service are discussed.

The use of intensive care: a comparison of a university and community hospital

We compared 223 consecutive intensive care unit (ICU) admissions to a community hospital (CH) with 613 such admissions at a university hospital (UH) using a new clinical scale aimed at quantifying severity of illness. Both ICU's had similar technical resources and treatment capabilities. At the CH, however, patients were more often admitted for monitoring rather than for treatment of UH admissions had a substantially greater acute severity of illness (p less than .001) than CH patients in most diagnostic categories. These findings suggest that use of the ICU was substantially different in the two hospitals, with the CH admitting many more stable patients. This study also suggests that evaluation of ICU use is improved by quantitative measurement of severity of illness.

Mental health work in sichuan

Sichuan is the biggest province of the People's Republic of China, with a broad area of over 560 thousand square km and a population of over 90 million people. The central portion of it is a big basin about 200 thousand square km in area, surrounded by many mountains with average altitude between 1,000 and 3,000 m above sea level. About 90 per cent of the population of the province lives in this area. The west portion of the province, called West Sichuan Plateau with average altitude of over 3,000 m, is relatively unpopulated. According to a census of a district of Zigong in 1973, 39.2 per cent of the population was below age 15 and 4.3 per cent above age 65. [In Britain (1975) the corresponding figures were 25 per cent and 14 per cent—Editor].

The use of radiographic studies in a teaching hospital

A study was conducted on the use of radiographic studies by 138 medical residents. They ordered an initial chest film on 88% of their patients and averaged a 34% yield. Though the range of other radiographic studies ordered per patient varied by a factor of 15, more than half the resident physicians ordered an average of less than one for every two patients. These physicians experienced overall yields between 0 and 100%, with half the residents averaging between 33 and 57%. This data base was then used to derive empirical norms of radiographic study utilization that can be employed to evaluate physicians' utilization in providing care to comparable populations.

Dissecting the hospital stay: a method for studying patient staging in hospitals

A methodology is proposed and tested for the staging of patients thorugh a hospital stay. Measurements in a university-affiliated hospital and a community hospital in the Boston area showed similar staging patterns with about half of the sample having abnormal signs and symptoms while under treatment. The second-largest sample group in both hospitals, consisting of 11% of the sample, occupied beds although ready for discharge. The methodology indicated those patient-time units in the hospital which might be amenable to further reduction and gave upper bounds on that compression. Contrary to prior expectations, 90% of the patients sampled followed a well-defined sequence from admission to discharge with only 10% having complications of the admitting diagnosis, new diagnosis or iatrogenic illness.

A critical look at geriatrics in a teaching hospital: Part I. The situation

A survey of the admission and discharge patterns of geriatric patients admitted to Groote Schuur Hospital, Cape Town, during July and August 1978 was conducted. The findings highlight a lack of methodology in the economic use of beds, a lack of rehabilitation services and of follow-up services on discharge, and poor liaison regarding facilities outside the hospital setting.

Variations in surgery in Ontario

In 1974 there was five-to eight-fold variation in the frequency with which tonsillectomy, colectomy, hysterectomy, cholecystectomy and appendectomy were performed in Ontario's 49 counties. All five procedures were resource sensitive; over 50 per cent of the variation in rates was explained by numbers of acute care treatment beds and physicians. Generally, counties with high or low rates for any one procedure had corresponding rates for the other four. The highest rates were found in less populous rural eastern Ontario counties, while university teaching centers ranked among the lowest for all five operations although they had the highest ratios of beds, general practitioners and surgeons. Linkages between university medical centers and community hospitals, widespread dissemination of surgical rate data, surgical audit and review of surgical indications and practices in university centers and community hospitals are proposed to aid in rationalizing surgical practices in Ontario.

Cost of elective surgery and utilization of ancillary services in teaching hospitals

Measures of surgical utilization studied are the number of elective tests performed preoperatively and the total cost per case. The unit of analysis is a matched pair of patients who underwent the same elective procedure, one a Veterans Administration patient, and the other a municipal or voluntary hospital patient. Federal ownership of the hospital ahd the strongest impact on tests and cost per case. On average, costs for the VA patients were 52 percent more per case. The foreign medical graduate variable had a large positive (inflationary) effect on the number of tests, but a slight downward influence in the cost regressions. The fraction of surgeons with faculty appointments had a strong negative (curtailing) impact on elective testing, but an upward influence on cost per case. Additional variables such as age, average laboratory turnaround time, and fraction of the medical school's students doing their surgical clerkship at the hospital ahd a slight upward influence on utilization. The three policy issues raised in the study involve changing the hospital reimbursement incentives, targeting continuing education programs to categories of staff that need it most, and redistributing faculty and students.