Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston.
JAMA Surg. 2013 Oct;148(10):956-61. doi: 10.1001/jamasurg.2013.2148.
Reduction in length of hospital stay is a veritable target in reducing the overall costs of health care. However, many existing approaches are flawed because the assumptions of what cause excessive length of stay are incorrect; we methodically identified the right targets in this study.
To identify the causes of excessively prolonged hospitalization (ExProH) in trauma patients.
The trauma registry, billing databases, and medical records of trauma admissions were reviewed. Excessively prolonged hospitalization was defined by the standard method used by insurers, which is a hospital stay that exceeds the Diagnosis Related Group-based trim point. The causes of ExProH were explored in a unique potentially avoidable days database, used by our hospital's case managers to track discharge delays.
Level I academic trauma center.
Adult trauma patients admitted between January 1, 2006, and December 31, 2010.
Excessively prolonged hospitalization and hospital cost.
Of 3237 patients, 155 (5%) had ExProH. The patients with ExProH compared with non-ExProH patients were older (mean [SD] age, 53 [21] vs 47 [22] years, respectively; P = .001), were more likely to have blunt trauma (92% vs 84%, respectively; P = .03), were more likely to be self-payers (16% vs 11%, respectively; P = .02) or covered by Medicare/Medicaid (41% vs 30%, respectively; P = .002), were more likely to be discharged to post-acute care facilities than home (65% vs 35%, respectively; P < .001), and had higher hospitalization cost (mean, $54 646 vs $18 444, respectively; P < .001). Both groups had similar Injury Severity Scores, Revised Trauma Scores, baseline comorbidities, and in-hospital complication rates. Independent predictors of mortality were discharge to a rehabilitation facility (odds ratio = 4.66; 95% CI, 2.71-8.00; P < .001) or other post-acute care facility (odds ratio = 5.04; 95% CI, 2.52-10.05; P < .001) as well as insurance type that was Medicare/Medicaid (odds ratio = 1.70; 95% CI, 1.06-2.72; P = .03) or self-pay (odds ratio = 2.43; 95% CI, 1.35-4.37; P = .003). The reasons for discharge delays were clinical in only 20% of the cases. The remaining discharges were excessively delayed because of difficulties in rehabilitation facility placement (47%), in-hospital operational delays (26%), or payer-related issues (7%).
System-related issues, not severity of illness, prolong hospital stay excessively. Cost-reduction efforts should target operational bottlenecks between acute and postacute care.
降低住院时间是降低医疗保健总成本的一个真正目标。然而，许多现有的方法都存在缺陷，因为导致住院时间过长的假设是不正确的；我们在这项研究中系统地确定了正确的目标。
确定创伤患者住院时间过长（ExProH）的原因。
回顾了创伤登记处、计费数据库和创伤入院的病历。过长的住院时间是由保险公司使用的标准方法定义的，即住院时间超过诊断相关组的修剪点。在我们医院的病例管理员用来跟踪出院延迟的独特潜在可避免天数数据库中，探讨了 ExProH 的原因。
一级学术创伤中心。
2006 年 1 月 1 日至 2010 年 12 月 31 日期间入院的成年创伤患者。
住院时间过长和医院费用。
在 3237 名患者中，有 155 名（5%）存在 ExProH。与非 ExProH 患者相比，ExProH 患者年龄更大（平均[标准差]年龄分别为 53[21]岁和 47[22]岁，P<0.001），更有可能遭受钝性创伤（92%比 84%，分别为 P=0.03），更有可能是自付者（16%比 11%，分别为 P=0.02）或医疗保险/医疗补助覆盖（41%比 30%，分别为 P<0.001），更有可能出院到康复设施而不是家庭（65%比 35%，分别为 P<0.001），并且住院费用更高（平均分别为 54646 美元和 18444 美元，分别为 P<0.001）。两组患者的损伤严重程度评分、修订创伤评分、基线合并症和院内并发症发生率相似。出院到康复机构（比值比=4.66；95%置信区间，2.71-8.00；P<0.001）或其他康复设施（比值比=5.04；95%置信区间，2.52-10.05；P<0.001）以及医疗保险类型为医疗保险/医疗补助（比值比=1.70；95%置信区间，1.06-2.72；P=0.03）或自付（比值比=2.43；95%置信区间，1.35-4.37；P=0.003）是死亡率的独立预测因素。只有 20%的病例中出院延迟的原因是临床原因。其余的出院时间过长是由于康复设施安置困难（47%）、院内运营延迟（26%）或支付方相关问题（7%）所致。
系统相关问题而不是疾病严重程度导致住院时间过长。降低成本的努力应针对急性和康复后护理之间的运营瓶颈。
