Length of stay, conditional length of stay, and prolonged stay in pediatric asthma

Racial differences in length of stay and readmission for asthma in the all of us research program

BACKGROUND

This study addresses the limited research on racial disparities in asthma hospitalization outcomes, specifically length of stay (LOS) and readmission, across the U.S.

METHODS

We analyzed in-patient and emergency department visits from the All of Us Research Program, identifying various risk factors (demographic, comorbid, temporal, and place-based) associated with asthma LOS and 30-day readmission using Bayesian mixed-effects models.

RESULTS

Of 17,233 patients (48.0% White, 30.7% Black, 19.7% Hispanic/Latino, 1.3% Asian, and 0.3% Middle Eastern and North African) with 82,188 asthma visits, Black participants had 20% shorter LOS and 12% higher odds of readmission, compared to White participants in multivariate analyses. Public-insured patients had 14% longer LOS and 39% higher readmission odds than commercially insured patients. Weekend admissions resulted in a 12% shorter LOS but 10% higher readmission odds. Asthmatics with chronic diseases had a longer LOS (range: 6-39%) and higher readmission odds (range: 9-32%) except for those with allergic rhinitis, who had a 23% shorter LOS.

CONCLUSIONS

A comprehensive understanding of the factors influencing asthma hospitalization, in conjunction with diverse datasets and clinical-community partnerships, can help physicians and policymakers to systematically address racial disparities, healthcare utilization and equitable outcomes in asthma care.

Comparing Artificial Intelligence and Traditional Methods to Identify Factors Associated With Pediatric Asthma Readmission

OBJECTIVE

To identify and contrast risk factors for six-month pediatric asthma readmissions using traditional models (Cox proportional-hazards and logistic regression) and artificial neural-network modeling.

METHODS

This retrospective cohort study of the 2013 Nationwide Readmissions Database included children 5 to 18 years old with a primary diagnosis of asthma. The primary outcome was time to asthma readmission in the Cox model, and readmission within 180 days in logistic regression. A basic neural network construction with 2 hidden layers and multiple replications considered all dataset variables and potential variable interactions to predict 180-day readmissions. Logistic regression and neural-network models were compared on area-under-the receiver-operating curve.

RESULTS

Of 18,489 pediatric asthma hospitalizations, 1858 were readmitted within 180 days. In Cox and logistic models, longer index length of stay, public insurance, and nonwinter index admission seasons were associated with readmission risk, whereas micropolitan county was protective. In neural-network modeling, 9 factors were significantly associated with readmissions. Four overlapped with the Cox model (nonwinter-month admission, long length of stay, public insurance, and micropolitan hospitals), whereas 5 were unique (age, hospital bed number, teaching-hospital status, weekend index admission, and complex chronic conditions). The area under the curve was 0.592 for logistic regression and 0.637 for the neural network.

CONCLUSIONS

Different methods can produce different readmission models. Relying on traditional modeling alone overlooks key readmission risk factors and complex factor interactions identified by neural networks.

Risk Factors for Pediatric Asthma Readmissions: A Systematic Review

OBJECTIVE

To systematically review the literature on pediatric asthma readmission risk factors.

STUDY DESIGN

We searched PubMed/MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials for published articles (through November 2019) on pediatric asthma readmission risk factors. Two authors independently screened titles and abstracts and consensus was reached on disagreements. Full-text articles were reviewed and inclusion criteria applied. For articles meeting inclusion criteria, authors abstracted data on study design, patient characteristics, and outcomes, and 4 authors assessed bias risk.

RESULTS

Of 5749 abstracts, 74 met inclusion criteria. Study designs, patient populations, and outcome measures were highly heterogeneous. Risk factors consistently associated with early readmissions (≤30 days) included prolonged length of stay (OR range, 1.1-1.6) and chronic comorbidities (1.7-3.2). Risk factors associated with late readmissions (>30 days) included female sex (1.1-1.6), chronic comorbidities (1.5-2), summer discharge (1.5-1.8), and prolonged length of stay (1.04-1.7). Across both readmission intervals, prior asthma admission was the most consistent readmission predictor (1.3-5.4).

CONCLUSIONS

Pediatric asthma readmission risk factors depend on the readmission interval chosen. Prior hospitalization, length of stay, sex, and chronic comorbidities were consistently associated with both early and late readmissions.

TRIAL REGISTRATION

CRD42018107601.

Pediatric asthma hospitalization: individual and environmental characteristics of high utilizers in South Texas

OBJECTIVE

Few studies have examined factors affecting the high frequency of hospitalization for pediatric asthma. This study identifies individual and environmental characteristics of children with asthma from a low-income community with a high number of hospitalizations.

METHODS

The study population included 902 children admitted at least once to a children's hospital in South Texas because of asthma from 2010 to 2016. The population was divided into three groups by utilization frequency (high: ≥4 times, medium: 2-3 times, or low: 1 time). Individual-level factors at index admission and environmental factors were included for the analysis. Unadjusted and adjusted multivariate ordered logistic regression models were applied to identify significant characteristics of high hospital utilizers.

RESULTS

The high utilization group comprised 2.4% of total patients and accounted for substantial hospital resource utilization: 10.8% of all admissions and 13.5% of days stayed in the hospital. Patients in the high utilization group showed longer length of stay (LOS) and shorter time between admissions on average than the other two groups. The multivariate ordered logistic regression models revealed that age of 5-11 years (OR = 0.57, 95%CI = 0.35-0.93), longer LOS (2 days: OR = 1.80, 95%CI = 1.15-2.84; ≥3 days: OR = 3.38, 95%CI = 2.10-5.46), warm season at index admission (OR = 1.49, 95%CI = 1.01-2.20), and higher average ozone level in children's residential neighborhoods (OR = 1.78, 95%CI = 1.01-3.14) were significantly associated with a higher number of asthma hospitalizations.

CONCLUSIONS

The findings suggest the importance of monitoring high hospital utilizers and establishing strategies for such patients based on their characteristics to reduce repeated hospitalizations and to increase optimal use of hospital resources.

Association of Surgical Practice Patterns and Clinical Outcomes With Surgeon Training in University- or Nonuniversity-Based Residency Program

Importance

Important metrics of residency program success include the clinical outcomes achieved by trainees after transitioning to practice. Previous studies have shown significant differences in reported training experiences of general surgery residents at nonuniversity-based residency (NUBR) and university-based residency (UBR) programs.

Objective

To examine the differences in practice patterns and clinical outcomes between surgeons trained in NUBR and those trained in UBR programs.

Design, Setting, and Participants

This observational cohort study linked the claims data of patients who underwent general surgery procedures in New York, Florida, and Pennsylvania between January 1, 2012, and December 31, 2013, to demographic and training information of surgeons in the American Medical Association Physician Masterfile. Patients who underwent a qualifying procedure were grouped by surgeon. Practice pattern analysis was performed on 3638 surgeons and 1 237 621 patients, representing 214 residency programs. Clinical outcomes analysis was performed on 2301 surgeons and 312 584 patients. Data analysis was conducted from February 1, 2017, to July 31, 2017.

Exposures

NUBR or UBR training status.

Main Outcomes and Measures

Inpatient mortality, complications, and prolonged length of stay.

Results

No significant differences were observed between the NUBR-trained surgeons and UBR-trained surgeons in age (mean, 53.3 years vs 53.7 years), sex (female, 18.2% vs 16.9%), or years of clinical experience (mean, 16.5 years vs 16.5 years). Overall, NUBR-trained surgeons compared with UBR-trained surgeons performed more procedures (median interquartile range [IQR], 328 [93-661] vs 164 [49-444]; P < .001) and performed a greater proportion of procedures in the outpatient setting (risk difference, 6.5; 95% CI, 6.4 to 6.7; P < .001). Before matching, the mean proportion of patients with documented inpatient mortality was lower for NUBR-trained surgeons than for UBR-trained surgeons (risk difference, -1.01; 95% CI, -1.41 to -0.61; P < .001). The mean proportion of patients with complications (risk difference, -3.17%; 95% CI, -4.21 to -2.13; P < .001) and prolonged length of stay (risk difference, -1.89%; 95% CI, -2.79 to -0.98; P < .001) was also lower for NUBR-trained surgeons. After matching, no significant differences in patient mortality, complications, and prolonged length of stay were found between NUBR- and UBR-trained surgeons.

Conclusions and Relevance

Surgeons trained in NUBR and UBR programs have distinct practice patterns. After controlling for patient, procedure, and hospital factors, no differences were observed in the inpatient outcomes between the 2 groups.

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules

BACKGROUND

Concern persists that extended shifts in medical residency programs may adversely affect patient safety.

METHODS

We conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015-2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts. The primary outcome for each program was the change in unadjusted 30-day mortality from the pretrial year to the trial year, as ascertained from Medicare claims. We hypothesized that the change in 30-day mortality in the flexible programs would not be worse than the change in the standard programs (difference-in-difference analysis) by more than 1 percentage point (noninferiority margin). Secondary outcomes were changes in five other patient safety measures and risk-adjusted outcomes for all measures.

RESULTS

The change in 30-day mortality (primary outcome) among the patients in the flexible programs (12.5% in the trial year vs. 12.6% in the pretrial year) was noninferior to that in the standard programs (12.2% in the trial year vs. 12.7% in the pretrial year). The test for noninferiority was significant (P = 0.03), with an estimate of the upper limit of the one-sided 95% confidence interval (0.93%) for a between-group difference in the change in mortality that was less than the prespecified noninferiority margin of 1 percentage point. Differences in changes between the flexible programs and the standard programs in the unadjusted rate of readmission at 7 days, patient safety indicators, and Medicare payments were also below 1 percentage point; the noninferiority criterion was not met for 30-day readmissions or prolonged length of hospital stay. Risk-adjusted measures generally showed similar findings.

CONCLUSIONS

Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety. (Funded by the National Heart, Lung, and Blood Institute and Accreditation Council for Graduate Medical Education; iCOMPARE ClinicalTrials.gov number, NCT02274818.).

Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: a protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine

INTRODUCTION

Medical trainees' duty hours have received attention globally; restrictions in Europe, New Zealand and some Canadian provinces are much lower than the 80 hours per week enforced in USA. In USA, resident duty hours have been implemented without evidence simultaneously reflecting competing concerns about patient safety and physician education. The objective is to prospectively evaluate the implications of alternative resident duty hour rules for patient safety, trainee education and intern sleep and alertness.

METHODS AND ANALYSIS

63 US internal medicine training programmes were randomly assigned 1:1 to the 2011 Accreditation Council for Graduate Medical Education resident duty hour rules or to rules more flexible in intern shift length and number of hours off between shifts for academic year 2015-2016. The primary outcome is calculated for each programme as the difference in 30-day mortality rate among Medicare beneficiaries with any of several prespecified principal diagnoses in the intervention year minus 30-day mortality in the preintervention year among Medicare beneficiaries with any of several prespecified principal diagnoses. Additional safety outcomes include readmission rates, prolonged length of stay and costs. Measures derived from trainees' and faculty responses to surveys and from time-motion studies of interns compare the educational experiences of residents. Measures derived from wrist actigraphy, subjective ratings and psychomotor vigilance testing compare the sleep and alertness of interns. Differences between duty hour groups in outcomes will be assessed by intention-to-treat analyses.

ETHICS AND DISSEMINATION

The University of Pennsylvania Institutional Review Board (IRB) approved the protocol and served as the IRB of record for 40 programmes that agreed to sign an Institutional Affiliation Agreement. Twenty-three programmes opted for a local review process.

TRIAL REGISTRATION NUMBER

NCT02274818; Pre-results.

Effectiveness of Pediatric Asthma Pathways for Hospitalized Children: A Multicenter, National Analysis

OBJECTIVE

To determine if clinical pathways affect care and outcomes for children hospitalized with asthma using a multicenter study.

STUDY DESIGN

This was a retrospective, multicenter cohort study using an administrative database, the Pediatric Health Information System. We evaluated the impact of inpatient pediatric asthma pathways on children age 2-17 years admitted for asthma from 2006 to 2015 in 42 children's hospitals. Date of pathway implementation for each hospital was collected via survey. Using generalized estimating equations with an interrupted time series approach (to account for secular trends), we determined the association of pathway implementation with length of stay (LOS), 30-day readmission, chest radiograph utilization, ipratropium administration >24 hours, and administration of bronchodilators, systemic steroids, and antibiotics. All analyses were risk-adjusted for patient and hospital characteristics.

RESULTS

Clinical pathway implementation was associated with an 8.8% decrease in LOS (95% CI 6.7%-10.9%), 3.1% decrease in hospital costs (95% CI 1.9%-4.3%), increased odds of bronchodilator administration (OR 1.53[1.21-1.95]) and decreased odds of antibiotic administration (OR 0.93[0.87-0.99]) (n = 189 331). We found no associations between pathway implementation and systemic steroid administration, ipratropium administration for >24 hours, chest radiograph utilization, or 30-day readmission.

CONCLUSIONS

Clinical pathways can decrease LOS, costs, and unnecessary antibiotic use without increasing rates of readmissions, leading to higher value care.

Rising utilization of inpatient pediatric asthma pathways

INTRODUCTION

Clinical pathways are detailed care plans that operationalize evidence-based guidelines into an accessible format for health providers. Their goal is to link evidence to practice to optimize patient outcomes and delivery efficiency. It is unknown to what extent inpatient pediatric asthma pathways are being utilized nationally.

OBJECTIVES

(1) Describe inpatient pediatric asthma pathway design and implementation across a large hospital network. (2) Compare characteristics of hospitals with and without pathways.

METHODS

We conducted a descriptive, cross-sectional, survey study of hospitals in the Pediatric Research in Inpatient Settings Network (75% children's hospitals, 25% community hospitals). Our survey determined if each hospital used a pathway and pathway characteristics (e.g. pathway elements, implementation methods). Hospitals with and without pathways were compared using Chi-square tests (categorical variables) and Student's t-tests (continuous variables).

RESULTS

Surveys were distributed to 3-5 potential participants from each hospital and 302 (74%) participants responded, representing 86% (106/123) of surveyed hospitals. From 2005-2015, the proportion of hospitals utilizing inpatient asthma pathways increased from 27% to 86%. We found variation in pathway elements, implementation strategies, electronic medical record integration, and compliance monitoring across hospitals. Hospitals with pathways had larger inpatient pediatric programs [mean 12.1 versus 6.1 full-time equivalents, p = 0.04] and were more commonly free-standing children's hospitals (52% versus 23%, p = 0.05).

CONCLUSIONS

From 2005-2015, there was a dramatic rise in implementation of inpatient pediatric asthma pathways. We found variation in many aspects of pathway design and implementation. Future studies should determine optimal implementation strategies to better support hospital-level efforts in improving pediatric asthma care and outcomes.

National standards for asthma self-management education

BACKGROUND

Asthma education reimbursement continues to be an issue in the United States. Among the greatest barriers is the lack of a standardized curriculum for asthma self-management education recognized by a physician society, non-physician health care professional society or association, or other appropriate source. The applicable Current Procedural Terminology codes for self-management education and training are 98960 through 98962, stating that "if a practitioner has created a training curriculum for educating patients on management of their medical condition, he or she may employ a non-physician health care professional to provide education using a standardized curriculum for patients with that disease." Without a standardized curriculum, reimbursement from payers is beyond reach.

OBJECTIVE

Representatives from the Joint Council of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; American Academy of Allergy, Asthma, and Immunology; American Lung Association; American Thoracic Society; National Asthma Educator Certification Board; American College of Chest Physicians; and Association of Asthma Educators gathered to write a standardized curriculum as a guideline for payer reimbursement.

METHODS

The Task Force began with a review of the American Lung Association and American Thoracic Society's Operational Standards for Asthma Education. Board members of the National Asthma Educator Certification Board incorporated comments, rationale, and references into the document.

RESULTS

This document is the result of final reviews of the standards completed by the Task Force and national health care professional organizations in September 2014.

CONCLUSION

This document meets the requirements of Current Procedural Terminology codes 98960 through 98962 and establishes the minimum standard for asthma self-management education when teaching patients or caregivers how to effectively manage asthma in conjunction with the professional health care team.

Nutritional status and nosocomial infections among adult elective surgery patients in a Mexican tertiary care hospital

Background

Controversy exists as to whether obesity constitutes a risk-factor or a protective-factor for the development of nosocomial Infection (NI). According to the obesity-paradox, there is evidence that moderate obesity is a protective-factor. In Mexico few studies have focused on the nutritional status (NS) distribution in the hospital setting.

Objectives

The aim of this study was to estimate the distribution of NS and the prevalence of nosocomial infection NI among adult elective surgery (ES) patients and to compare the clinical and anthropometric characteristics and length of stays (LOS) between obese and non-obese patients and between patients with and without NI.

Methods

We conducted a cross-sectional study with a sample (n = 82) adult ES patients (21–59 years old) who were recruited from a tertiary-care hospital. The prevalences of each NS category and NI were estimated, the assessments were compared between groups (Mann-Whitney, Chi-squared or the Fisher's-exact-test), and the association between preoperative risk-factors and NI was evaluated using odds ratios.

Results

The distribution of subjects by NS category was: underweight (3.66%), normal-weight (28.05%), overweight (35.36%), and obese (32.93%). The prevalence of NI was 14.63%. The LOS was longer (p<0.001) for the patients who developed NI. The percentages of NI were: 33.3% in underweight, 18.52% in obese, 17.39% in normal-weight, and 6.90% in overweight patients.

Conclusion

The prevalence of overweight and obesity in adult ES patients is high. The highest prevalence of NI occurred in the underweight and obese patients. The presence of NI considerably increased the LOS, resulting in higher medical care costs.

An empirical comparison of key statistical attributes among potential ICU quality indicators

OBJECTIVE

Good quality indicators should have face validity, relevance to patients, and be able to be measured reliably. Beyond these general requirements, good quality indicators should also have certain statistical properties, including sufficient variability to identify poor performers, relative insensitivity to severity adjustment, and the ability to capture what providers do rather than patients' characteristics. We assessed the performance of candidate indicators of ICU quality on these criteria. Indicators included ICU readmission, mortality, several length of stay outcomes, and the processes of venous-thromboembolism and stress ulcer prophylaxis provision.

DESIGN

Retrospective cohort study.

SETTING

One hundred thirty-eight U.S. ICUs from 2001-2008 in the Project IMPACT database.

PATIENTS

Two hundred sixty-eight thousand eight hundred twenty-four patients discharged from U.S. ICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed indicators' (1) variability across ICU-years; (2) degree of influence by patient vs. ICU and hospital characteristics using the Omega statistic; (3) sensitivity to severity adjustment by comparing the area under the receiver operating characteristic curve (AUC) between models including vs. excluding patient variables, and (4) correlation between risk adjusted quality indicators using a Spearman correlation. Large ranges of among-ICU variability were noted for all quality indicators, particularly for prolonged length of stay (4.7-71.3%) and the proportion of patients discharged home (30.6-82.0%), and ICU and hospital characteristics outweighed patient characteristics for stress ulcer prophylaxis (ω, 0.43; 95% CI, 0.34-0.54), venous thromboembolism prophylaxis (ω, 0.57; 95% CI, 0.53-0.61), and ICU readmissions (ω, 0.69; 95% CI, 0.52-0.90). Mortality measures were the most sensitive to severity adjustment (area under the receiver operating characteristic curve % difference, 29.6%); process measures were the least sensitive (area under the receiver operating characteristic curve % differences: venous thromboembolism prophylaxis, 3.4%; stress ulcer prophylaxis, 2.1%). None of the 10 indicators was clearly and consistently correlated with a majority of the other nine indicators.

CONCLUSIONS

No indicator performed optimally across assessments. Future research should seek to define and operationalize quality in a way that is relevant to both patients and providers.

Assessing the effects of the 2003 resident duty hours reform on internal medicine board scores

PURPOSE

To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents.

METHOD

The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform.

RESULTS

The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were -5.43 (-7.63, -3.23), -3.44 (-5.65, -1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores.

CONCLUSIONS

The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.

Arterial blood gas and spirometry parameters affect the length of stay in hospitalized asthmatic patients

BACKGROUND

Asthma is a common condition in general medical practice, and it accounts for about 1% of all ambulatory hospital visits. Nowadays, hospitalization rates for asthma have actually been increased in some demographic subgroups despite recent advances in treatment. Understanding the underlying factors that contribute to hospitalization and especially duration of the hospitalization of asthmatics could help elucidate the recent rise in morbidity and also reduce the high demand on health care systems of the disease. The aim of this study was to evaluate factors affecting the duration of hospitalization for Iranian patients with asthma.

METHODS

This study was conducted on 55 asthmatic patients (diagnosis of asthma was in accordance with the criteria of the American Thoracic Society). The study was performed on patients hospitalized in Rasoul-e-Akram hospital in Tehran, Iran during the period 2005-2006. During hospitalization, the patients' most common complaints were recorded as the symptoms and signs of the medical condition, results of physical examinations, spirometry, arterial blood gas analysis (ABG), and ICU admission.

RESULTS

There were 18(32.7%) male and 37(67.3%) female patients with a mean age of 54.96 (SD=17.54) years. The mean duration of hospitalization was 8.31(SD=4.69) days that ranged between 2 and 23 days. The mean baseline arterial PH (p=0.039, RPearso = -0.362), baseline arterial [HCO3] (p=0.042, RPearson = 0.361), changes of FEV1 after bronchodilator (p=0.041, RPearson= -0.363) and patient's age (p=0.002, RPearson=0.0433) were determined as factors affecting duration of hospitalization.

CONCLUSION

Our results showed that more attention needs to be given to the findings of arterial blood gas and spirometry which can potentially affect the duration of hospitalization of asthmatic patients.

Assessing efficient patient care: should length of stay be calculated independently of local admission rates?

OBJECTIVE

To compare the length of hospitalisation for infants with bronchiolitis across the Eastern region and to assess the impact of the varying admission rates in each hospital.

DESIGN

Data collection through the Hospital Episode Statistics (HES) using the ICD clinical coding for bronchiolitis across all hospitals in east of England for three winter seasons (October to March for the years 2009/10, 2010/11 and 2011/12).

MAIN OUTCOME MEASURE

Length of hospital stay, corrected to adjust for local population.

RESULTS

Seventeen hospitals across the east of England were included in this study. Overall admission rate (as a percentage of the population) for the region was 3.3% and consistent with national data, but rates within individual hospitals varied between 1.5% and 5.7% over the 3-year period. Bed days per 1000 population ('standardised bed days') per year varied almost fourfold, from 34.5 to 122.3 in different hospitals. Corrected length of stay showed high discordance when compared to average length of stay.

CONCLUSIONS

The average length of stay is substantially affected by admission rates, with hospitals who admit a greater proportion of infants appearing to have a shorter uncorrected length of stay. We propose that a single corrected measure for length of stay should be used when assessing the efficiency of care because it is unaffected by variations in local admission rates and is adjusted for local population size.

What brings children home? A prognostic study to predict length of hospitalisation

Adequate discharge planning could improve patient health and reduce readmissions. Increased accessibility and adequate use of hospital capacity are asking for an adequate discharge planning by means of efficient prediction of length of stay (LOS). Predictive factors of LOS for paediatric patients are lacking in the current available evidence. We aimed to identify these predictive factors in order to predict an optimal LOS. We conducted a prognostic study of all patients admitted to five different paediatric wards of Emma Children's Hospital, a tertiary university hospital in the Netherlands. We investigated possible predictive factors based on the literature and an expert panel categorised in patient characteristics and medical and non-medical factors. This preliminary list was scored for all patients at the moment of discharge. All significant or relevant factors were used in a linear regression model to predict the LOS. We included 142 patients and explored the relationship between 28 variables, reflecting a mix of patient characteristics, medical and non-medical factors and LOS. In a univariable analysis, 17 variables were significantly related with LOS. Multivariable analysis found seven independent variables: sex, age category, specialism, risk of malnutrition, complications, home care and the involvement of other disciplines. These seven variables explained 48 % of the LOS (R(2) of 0.476).

CONCLUSION

Predictors of LOS consist patient characteristics, medical factors as well as non-medical factors (i.e. the need for home care and other disciplines). The latter factors can be influenced by changes in hospital policies.

An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions

Background

Hospital patient-to-nurse staffing ratios are associated with quality outcomes in adult patient populations but little is known about how these factors affect paediatric care. We examined the relationship between staffing ratios and all-cause readmission (within 14 days, 15–30 days) among children admitted for common medical and surgical conditions.

Methods

We conducted an observational cross-sectional study of readmissions of children in 225 hospitals by linking nurse surveys, inpatient discharge data and information from the American Hospital Association Annual Survey. Registered Nurses (N=14 194) providing direct patient care in study hospitals (N=225) and children hospitalised for common conditions (N=90 459) were included.

Results

Each one patient increase in a hospital's average paediatric staffing ratio increased a medical child's odds of readmission within 15–30 days by a factor of 1.11, or by 11% (95% CI 1.02 to 1.20) and a surgical child's likelihood of readmission within 15–30 days by a factor of 1.48, or by 48% (95% CI 1.27 to 1.73). Children treated in hospitals with paediatric staffing ratios of 1 : 4 or less were significantly less likely to be readmitted within 15–30 days. There were no significant effects of nurse staffing ratios on readmissions within 14 days.

Discussion

Children with common conditions treated in hospitals in which nurses care for fewer patients each are significantly less likely to experience readmission between 15 and 30 days after discharge. Lower patient-to-nurse ratios hold promise for preventing unnecessary hospital readmissions for children through more effective predischarge monitoring of patient conditions, improved discharge preparation and enhanced quality improvement success.

Teaching hospital financial status and patient outcomes following ACGME duty hour reform

OBJECTIVE

To examine whether hospital financial health was associated with differential changes in outcomes after implementation of 2003 ACGME duty hour regulations.

DATA SOURCES/STUDY SETTING

Observational study of 3,614,174 Medicare patients admitted to 869 teaching hospitals from July 1, 2000 to June 30, 2005.

STUDY DESIGN

Interrupted time series analysis using logistic regression to adjust for patient comorbidities, secular trends, and hospital site. Outcomes included 30-day mortality, AHRQ Patient Safety Indicators (PSIs), failure-to-rescue (FTR) rates, and prolonged length of stay (PLOS).

PRINCIPAL FINDINGS

All eight analyses measuring the impact of duty hour reform on mortality by hospital financial health quartile, in postreform year 1 ("Post 1") or year 2 ("Post 2") versus the prereform period, were insignificant: Post 1 OR range 1.00-1.02 and Post 2 OR range 0.99-1.02. For PSIs, all six tests showed clinically insignificant effect sizes. The FTR rate analysis demonstrated nonsignificance in both postreform years (OR 1.00 for both). The PLOS outcomes varied significantly only for the combined surgical sample in Post 2, but this effect was very small, OR 1.03 (95% CI 1.02, 1.04).

CONCLUSIONS

The impact of 2003 ACGME duty hour reform on patient outcomes did not differ by hospital financial health. This finding is somewhat reassuring, given additional financial pressure on teaching hospitals from 2011 duty hour regulations.

Impact and determinants of nurse turnover: a pan-Canadian study

AIM

As part of a large study of nursing turnover in Canadian hospitals, the present study focuses on the impact and key determinants of nurse turnover and implications for management strategies in nursing units.

BACKGROUND

Nursing turnover is an issue of ever-increasing priority as work-related stress and job dissatisfaction are influencing nurses' intention to leave their positions.

METHODS

Data sources included the nurse survey, unit managers, medical records and human resources databases. A broad sample of hospitals was represented with nine different types of nursing units included.

RESULTS

Nurses turnover is a major problem in Canadian hospitals with a mean turnover rate of 19.9%. Higher levels of role ambiguity and role conflict were associated with higher turnover rates. Increased role conflict and higher turnover rates were associated with deteriorated mental health. Higher turnover rates were associated with lower job satisfaction. Higher turnover rate and higher level of role ambiguity were associated with an increased likelihood of medical error.

CONCLUSION

Managing turnover within nursing units is critical to high-quality patient care. A supportive practice setting in which role responsibilities are understood by all members of the caregiver team would promote nurse retention.

IMPLICATIONS FOR NURSING MANAGEMENT

Stable nurse staffing and adequate managerial support are essential to promote job satisfaction and high-quality patient care.

Trends in admissions for pediatric status asthmaticus in New Jersey over a 15-year period

OBJECTIVE

Status asthmaticus accounts for a large portion of the morbidity and mortality associated with asthma, but we know little about its epidemiology. We describe here the hospitalization characteristics of children with status asthmaticus, how they changed over time, and how they differed between hospitals with and without PICUs.

PATIENTS AND METHODS

We used administrative data from New Jersey that included all hospitalizations in the state from 1992, 1995, and 1999-2006. We identified children with status asthmaticus by using International Classification of Diseases, Ninth Revision, diagnosis codes that indicate status asthmaticus and the use of mechanical ventilation by using procedure codes. We designated hospitals with a PICU as "PICU hospitals" and those without as "adult hospitals."

RESULTS

We identified 28 309 admissions of children with status asthmaticus (22.8% of all asthma hospitalizations). From 1992 to 2006, the rate of hospital admissions decreased by half (from 1.98 in 1000 to 0.93 in 1000 children), and there was a 70% decrease in the number of children admitted to adult hospitals. The rate of ICU care in PICU hospitals more than tripled. However, the rate of mechanical ventilation remained low, and the number of deaths was small and unchanged (n=14 total). Hospital costs climbed from $6.6 million to $9.5 million.

CONCLUSIONS

Although fewer children are being admitted with status asthmaticus, the proportion of patients managed in PICUs is climbing. There has been no substantial change in rates of mechanical ventilation or death. Additional research is needed to better understand how patients and physicians decide on the appropriate site for hospital care and how that choice affects outcome.

Length of stay and imminent discharge probability distributions from multistage models: variation by diagnosis, severity of illness, and hospital

Multistage models have been effective at describing length of stay (LOS) distributions for diverse patient groups. Our study objective was to determine whether such models could be used for patient groups restricted by diagnosis, severity of illness, or hospital in order to facilitate comparisons conditioned on these factors. We performed a retrospective cohort study using data from 317,876 hospitalizations occurring over 2 years in 17 hospitals in a large, integrated health care delivery system. We estimated model parameters using data from the first year and validated them by comparing the predicted LOS distribution to the second year of data. We found that 3- and 4-stage models fit LOS data for either the entire hospital cohort or for subsets of patients with specific conditions (e.g. community-acquired pneumonia). Probability distributions were strongly influenced by the degree of physiologic derangement on admission, pre-existing comorbidities, or a summary mortality risk combining these with age, sex, and diagnosis. The distributions for groups with greater severity of illness were shifted slightly to the right, but even more notable was the increase in the dispersion, indicating the LOS is harder to predict with greater severity of illness. Multistage models facilitate computation of the hazard function, which shows the probability of imminent discharge given the elapsed LOS, and provide a unified method of fitting, summarizing, and studying the effects of factors affecting LOS distributions. Future work should not be restricted to expected LOS comparisons, but should incorporate examination of LOS probability distributions.

Global quantitative indices reflecting provider process-of-care: data-base derivation

Background

Controversy has attended the relationship between risk-adjusted mortality and process-of-care. There would be advantage in the establishment, at the data-base level, of global quantitative indices subsuming the diversity of process-of-care.

Methods

A retrospective, cohort study of patients identified in the Australian and New Zealand Intensive Care Society Adult Patient Database, 1993-2003, at the level of geographic and ICU-level descriptors (n = 35), for both hospital survivors and non-survivors. Process-of-care indices were established by analysis of: (i) the smoothed time-hazard curve of individual patient discharge and determined by pharmaco-kinetic methods as area under the hazard-curve (AUC), reflecting the integrated experience of the discharge process, and time-to-peak-hazard (TMAX, in days), reflecting the time to maximum rate of hospital discharge; and (ii) individual patient ability to optimize output (as length-of-stay) for recorded data-base physiological inputs; estimated as a technical production-efficiency (TE, scaled [0,(maximum)1]), via the econometric technique of stochastic frontier analysis. For each descriptor, multivariate correlation-relationships between indices and summed mortality probability were determined.

Results

The data-set consisted of 223129 patients from 99 ICUs with mean (SD) age and APACHE III score of 59.2(18.9) years and 52.7(30.6) respectively; 41.7% were female and 45.7% were mechanically ventilated within the first 24 hours post-admission. For survivors, AUC was maximal in rural and for-profit ICUs, whereas TMAX (≥ 7.8 days) and TE (≥ 0.74) were maximal in tertiary-ICUs. For non-survivors, AUC was maximal in tertiary-ICUs, but TMAX (≥ 4.2 days) and TE (≥ 0.69) were maximal in for-profit ICUs. Across descriptors, significant differences in indices were demonstrated (analysis-of-variance, P ≤ 0.0001). Total explained variance, for survivors (0.89) and non-survivors (0.89), was maximized by combinations of indices demonstrating a low correlation with mortality probability.

Conclusions

Global indices reflecting process of care may be formally established at the level of national patient data-bases. These indices appear orthogonal to mortality outcome.

Prolonged hospital stay and the resident duty hour rules of 2003

BACKGROUND

Resident duty hour reforms of 2003 had the potential to create a major impact on the delivery of inpatient care.

OBJECTIVE

We examine whether the reforms influenced the probability of a patient experiencing a prolonged hospital length of stay (PLOS), a measure reflecting either inefficiency of care or the development of complications that may slow the rate of discharge.

RESEARCH DESIGN

Conditional logistic models to compare PLOS in more versus less teaching-intensive hospitals before and after the reform, adjusting for patient comorbidities, common time trends, and hospital site.

SUBJECTS

Medicare (N = 6,059,015) and Veterans Affairs (VA) (N = 210,276) patients admitted for medical conditions (acute myocardial infarction, heart failure, stroke, or gastrointestinal bleeding) or surgical procedures (general, orthopedic, and vascular) from July 2000 to June 2005.

MEASURES

Prolonged length of stay.

RESULTS

Modeling all medical conditions together, the odds of prolonged stay in the first year post reform at more versus less teaching intensive hospitals was 1.01 (95% CI: 0.97-1.05) for Medicare and 1.07 (0.94-1.20) for the VA. Results were similarly negative in the second year post reform. For "combined surgery" the post year 1 odds ratios were 1.04 (0.98-1.09) and 0.94 (0.78-1.14) for Medicare and the VA respectively, and similarly unchanged in post year 2. Isolated increases in the probability of prolonged stay did occur for some vascular surgery procedures.

CONCLUSIONS

Hospitals generally found ways to cope with duty hour reform without increasing the prevalence of prolonged hospital stays, a marker of either inefficient care or complications.

Hospital readmissions for childhood asthma: the role of individual and neighborhood factors

OBJECTIVES

This study used a Cox proportional hazards model to determine whether neighborhood characteristics are associated with risk of readmission for childhood asthma independently of individual characteristics.

METHODS

Rhode Island Hospital Discharge Data from 2001 to 2005 were used to identify children younger than 19 years of age at the time of the index (i.e., first) asthma admission, defined as a primary diagnosis of asthma or a primary diagnosis of respiratory illness with a secondary or tertiary diagnosis of asthma (n=2,919). Hazard ratios of repeat hospitalizations for childhood asthma from 2001 to 2005 were estimated, controlling for individual- and neighborhood-level variables.

RESULTS

During the study period, 15% of the sample was readmitted for asthma (n=451). In the unadjusted cumulative hazard curves, children residing in the census tracts with the highest proportion of crowded housing conditions, racial minority residents, or neighborhood-level poverty had higher cumulative hospital readmission rates as compared with children who resided in less disadvantaged neighborhoods. In the fully adjusted models, children insured by Medicaid at the time of their index admission had readmission rates that were 33% higher than children who were privately insured.

CONCLUSION

Our findings suggest that differences in health-care coverage are associated with higher readmission rates for pediatric asthma, but the relationship between neighborhood inequality and repeat hospitalizations for pediatric asthma requires further exploration. Social indicators such as minority race, Medicaid health insurance, and neighborhood markers of economic disadvantage are tightly interwoven in the U.S. and teasing these relationships apart is important in asthma disparities research.

How well can hospital readmission be predicted in a cohort of hospitalized children? A retrospective, multicenter study

BACKGROUND

Children with complex chronic conditions depend on both their families and systems of pediatric health care, social services, and financing. Investigations into the workings of this ecology of care would be advanced by more accurate methods of population-level predictions of the likelihood for future hospitalization.

METHODS

This was a retrospective cohort study. Hospital administrative data were collected from 38 children's hospitals in the United States for the years 2003-2005. Participants included patients between 2 and 18 years of age discharged from an index hospitalization during 2004. Patient characteristics documented during the index hospitalization or any previous hospitalization during the preceding 365 days were included. The main outcome measure was readmission to the hospital during the 365 days after discharge from the index admission.

RESULTS

Among the cohort composed of 186856 patients discharged from the participating hospitals during 2004, the mean age was 9.2 years, with 54.4% male and 52.9% identified as non-Hispanic white. A total of 17.4% were admitted during the previous 365 days, and among those discharged alive (0.6% died during the admission), 16.7% were readmitted during the ensuing 365 days. The final readmission model exhibited a c statistic of 0.81 across all hospitals, with a range from 0.76 to 0.84 for each hospital. Bootstrap-based assessments demonstrated the stability of the final model.

CONCLUSIONS

Accurate population-level prediction of hospital readmissions is possible, and the resulting predicted probability of hospital readmission may prove useful for health services research and planning.

Use of prolonged travel to improve pediatric risk-adjustment models

OBJECTIVE

To determine whether travel variables could explain previously reported differences in lengths of stay (LOS), readmission, or death at children's hospitals versus other hospital types.

DATA SOURCE

Hospital discharge data from Pennsylvania between 1996 and 1998.

STUDY DESIGN

A population cohort of children aged 1-17 years with one of 19 common pediatric conditions was created (N=51,855). Regression models were constructed to determine difference for LOS, readmission, or death between children's hospitals and other types of hospitals after including five types of additional illness severity variables to a traditional risk-adjustment model.

PRINCIPAL FINDINGS

With the traditional risk-adjustment model, children traveling longer to children's or rural hospitals had longer adjusted LOS and higher readmission rates. Inclusion of either a geocoded travel time variable or a nongeocoded travel distance variable provided the largest reduction in adjusted LOS, adjusted readmission rates, and adjusted mortality rates for children's hospitals and rural hospitals compared with other types of hospitals.

CONCLUSIONS

Adding a travel variable to traditional severity adjustment models may improve the assessment of an individual hospital's pediatric care by reducing systematic differences between different types of hospitals.

Impact of admission-day crowding on the length of stay of pediatric hospitalizations

OBJECTIVE

Increased crowding may affect the care that is delivered to hospitalized patients, particularly around the time of admission. There is little information about the impact of admission-day crowding on the outcome of children who are hospitalized with common pediatric conditions.

METHODS

A population cohort was constructed of children who were aged 1 to 17 years and were hospitalized in Pennsylvania and New York between April 1, 1996, and June 30, 1998, with 1 of 19 common pediatric conditions (N = 116,235). Condition-specific Cox regression and logit models were developed to estimate the effect of admission-day occupancy on 4 outcome measures after controlling for illness severity and site of care: length of stay; 21-day readmission; prolonged stay or a stay longer than the typical, uncomplicated stay for that condition as a measure of care delivered to patients with uncomplicated courses; and conditional length of stay as a measure of care delivered to patients whose stays are prolonged.

RESULTS

For children who were admitted with respiratory disease, increasing admission-day occupancy from 60% to 100% was associated with a 0.25-day increase in the average length of stay. Increased admission-day occupancy above 60% was also associated with higher odds of a prolonged stay but not with a change in 21-day readmission rates or conditional length of stay. For children who were admitted with nonrespiratory conditions, increased admission-day occupancy was not associated with changes to any length-of-stay outcome.

CONCLUSIONS

Increased admission-day occupancy was associated with longer lengths of stay for less complicated respiratory admissions but not for children who were admitted with the most serious conditions. These results suggest that medical professionals, during times of increased workload, first focus their attention on more acutely ill children with a complicated course and thus delay treatment of children who have less complicated courses but require time-consuming management and treatment.

Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records

CONTEXT

Despite growing evidence in the US, little evidence has been available to evaluate whether internationally, hospitals in which nurses care for fewer patients have better outcomes in terms of patient survival and nurse retention.

OBJECTIVES

To examine the effects of hospital-wide nurse staffing levels (patient-to-nurse ratios) on patient mortality, failure to rescue (mortality risk for patients with complicated stays) and nurse job dissatisfaction, burnout and nurse-rated quality of care.

DESIGN AND SETTING

Cross-sectional analysis combining nurse survey data with discharge abstracts.

PARTICIPANTS

Nurses (N=3984) and general, orthopaedic, and vascular surgery patients (N=118752) in 30 English acute trusts.

RESULTS

Patients and nurses in the quartile of hospitals with the most favourable staffing levels (the lowest patient-to-nurse ratios) had consistently better outcomes than those in hospitals with less favourable staffing. Patients in the hospitals with the highest patient to nurse ratios had 26% higher mortality (95% CI: 12-49%); the nurses in those hospitals were approximately twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals.

CONCLUSIONS

Nurse staffing levels in NHS hospitals appear to have the same impact on patient outcomes and factors influencing nurse retention as have been found in the USA.

Communities with and without children's hospitals: Where do the sickest children receive care?

The author's purpose in this study was to examine whether children's hospitals treat more resource-intense children within their communities than do general acute-care hospitals in the same communities, and then to examine which general acute-care hospitals in communities without children's hospitals fill the role of caring for very sick children. In large communities without children's hospitals, at least one general hospital is likely to treat resource-intense children. Healthcare managers in community hospitals need to be prepared to meet the healthcare needs of resource-intense children, which includes having the appropriate specialized staff and technology to care for the sickest children.

Differences in characteristics of US hematopoietic stem cell transplantation centers by proportion of racial or ethnic minorities

Racial or ethnic minorities with leukemia who receive HLA-identical sibling hematopoietic stem cell transplants (HSCTs) are reported to have worse survival when compared with whites. Characteristics of US HSCT centers according to the proportion of ethnic minorities who undergo transplantation were compared to explore systematic differences among centers; the association with 100-day mortality was evaluated to determine whether center factors may explain the observed discrepant survival among ethnic minorities. One hundred sixteen US transplantation centers that performed HLA-identical sibling transplantations for leukemia were analyzed. We compared physician and health care provider staffing, transplantation unit procedure and resources, and medical center organization according to the volume procedure ratio of ethnic minorities who underwent transplantation and also according to the ratio of Hispanics who underwent transplantation. Centers that performed transplantation in a higher proportion of ethnic minorities were more likely to perform fewer transplantations per year, to have fewer devoted transplant beds, to be in an urban setting, to have a lower physician to patient volume ratio, and to follow up survivors 1 year after transplantation. Centers that performed transplantation in a higher proportion of Hispanics were more likely to perform fewer transplantations per year and to have fewer devoted transplantation beds, were less likely to perform outpatient transplantations, were more likely to be in an urban setting, and were less likely to have posttransplantation immunization protocols. Observed differences in center factors were not associated with 100-day mortality after adjustment for disease severity. Our results suggest that the inferior survival reported in ethnic minorities after HSCT may not be readily explained by center effects.

A Robustified Modeling Approach to Analyze Pediatric Length of Stay

PURPOSE

Length of stay (LOS) is an important measure of the cost of pediatric hospitalizations, but the guidelines developed so far are not rigorously evidence-based. This study demonstrates a robust gamma mixed regression approach to analyze the positively skewed LOS variable, which has implications for future studies of pediatric health care management.

METHODS

The robustified approach is applied to analyze hospital discharge data on childhood gastroenteritis in Western Australia (n=514). The model accounts for demographic characteristics and co-morbidities of the patients, as well as the dependency of LOS outcomes nested within the 58 hospitals in the State. The method is compared with the standard linear mixed regression with trimming of extreme observations.

RESULTS

For the empirical application, the linear mixed regression results are sensitive to the magnitude of trimming. The identified significant factors from the robust regression model, namely infection, failure to thrive, and iron deficiency anemia are resistant to high-LOS outliers.

CONCLUSIONS

Robust gamma mixed regression appears to be a suitable alternative to analyze the clustered and positively skewed pediatric LOS, without transforming and trimming the data arbitrarily.

Equivalent lengths of stay of pediatric patients hospitalized in rural and nonrural hospitals

BACKGROUND

Many children receive their care at local hospitals outside of a large urban area. There may be differences in the length of stay (LOS) between children hospitalized in rural versus urban hospitals. This study compared the differences in LOS, conditional LOS (CLOS), odds of prolonged stay, and 21-day readmission rates for children with 19 medical conditions and 9 surgical procedures admitted to rural, community, and large urban hospitals.

METHODS

Discharge records for the hospitalizations of children 1 to 17 years of age were obtained from the New York Department of Public Health Statewide Planning and Research Cooperative System and the Pennsylvania Health Care Cost Containment Council for April 1996 to July 1998. The 19 medical and 9 surgical conditions were identified with the principal condition and procedure codes. Hospitals were classified into 1 of 5 geographic categories on the basis of United States rural-urban continuum codes, ie, large urban, suburban, moderate urban, small urban, or rural. LOS was defined as the period of time between hospital admission and discharge. Readmission rates were calculated for 21 days after discharge from the hospital. A prolonged stay for each condition was defined as any admission lasting beyond the prolongation point, or the day at which the rate of discharge began to decline, as determined with the Hollander-Proschan statistic. This aspect of LOS describes the ability of providers to treat uncomplicated cases of that specific principle diagnosis. CLOS, as a marker for the management of complicated cases, was defined as the LOS beyond the prolongation point. Cox and logistic regression models were developed to describe the geographic effects on the 4 outcome variables, after severity adjustment with 32 demographic and 11 comorbidity variables and adjustment for hospital clustering.

RESULTS

Medical (N = 114,787) and surgical (N = 29,156) admissions to rural hospitals (N = 12,367) had similar outcomes, compared with all geographic categories except the large urban category. Medical patients admitted to rural hospitals had a shorter LOS (12% increase in discharge rate), a shorter CLOS (12% increase in discharge rate), and lower odds of prolonged stay (odds ratio: 0.80), compared with those in large urban hospitals. Surgical patients admitted to rural hospitals had a shorter LOS (12% increase in discharge rate) and lower odds of prolonged stay (odds ratio: 0.81), compared with those in large urban hospitals. For individual conditions, rural hospitals in general had similar or improved LOS, compared with all other hospitals in the 2 states. The addition of hospital-level variables failed to change the results of the primary models.

CONCLUSIONS

In their treatment of pediatric hospitalized patients, rural hospitals were not significantly different from hospitals in all geographic regions other than large urban areas. Rural hospitals appear to deliver similar care, compared with nonrural hospitals, for many of the common pediatric conditions included in this study. Additional research is needed to apply these results to other regions or states with different geographic distributions of hospitals and children, in order to determine the overall impact on the regionalization of pediatric care.