van de Vijsel Aart R, Heijink Richard, Schipper Maarten
National Institute for Public Health and the Environment, Richard Heijink, P.O. Box 1, 3720, BA, Bilthoven, The Netherlands.
BMC Health Serv Res. 2015 Sep 30;15:438. doi: 10.1186/s12913-015-1087-6.
We aimed to get better insight into the development of the variation in length of stay (LOS) between and within hospitals over time, in order to assess the room for efficiency improvement in hospital care.
Using Dutch national individual patient-level hospital admission data, we studied LOS for patients in nine groups of diagnoses and procedures between 1995 and 2010. We fitted linear mixed effects models to the log-transformed LOS to disentangle within and between hospital variation and to evaluate trends, adjusted for case-mix.
We found substantial differences between diagnoses and procedures in LOS variation and development over time, supporting our disease-specific approach. For none of the diagnoses, relative variance decreased on the log scale, suggesting room for further LOS reduction. Except for two procedures in the same specialty, LOS of individual hospitals did not correlate between diagnoses/procedures, indicating the absence of a hospital wide policy. We found within-hospital variance to be many times greater than between-hospital variance. This resulted in overlapping confidence intervals across most hospitals for individual hospitals' performances in terms of LOS.
The results suggest room for efficiency improvement implying lower costs per patient treated. It further implies a possibility to raise the number of patients treated using the same capacity or to downsize the capacity. Furthermore, policymakers and health care purchasers should take into account statistical uncertainty when benchmarking LOS between hospitals and identifying inefficient hospitals.
我们旨在更深入地了解不同医院之间以及同一医院内部住院时间（LOS）随时间的变化发展情况，以便评估医院护理服务中提高效率的空间。
利用荷兰全国个体患者层面的医院入院数据，我们研究了1995年至2010年间九组诊断和治疗程序患者的住院时间。我们对经对数转换后的住院时间拟合线性混合效应模型，以区分医院内部和医院之间的差异，并评估趋势，同时对病例组合进行了调整。
我们发现不同诊断和治疗程序在住院时间变化及随时间发展方面存在显著差异，这支持了我们针对特定疾病的研究方法。对于所有诊断，对数尺度上的相对方差均未降低，这表明进一步缩短住院时间仍有空间。除了同一专科的两个治疗程序外，各医院在不同诊断/治疗程序之间的住院时间并无关联，这表明缺乏全院范围的政策。我们发现医院内部方差比医院之间的方差大很多倍。这导致大多数医院在住院时间方面的个体表现的置信区间相互重叠。
结果表明存在提高效率的空间，这意味着每位接受治疗患者的成本更低。这还意味着有可能在相同规模下增加接受治疗的患者数量或缩减规模。此外，政策制定者和医疗保健购买者在对医院之间的住院时间进行基准比较以及识别低效医院时应考虑统计不确定性。
