Weingarten S, Riedinger M S, Sandhu M, Bowers C, Ellrodt A G, Nunn C, Hobson P, Greengold N
Department of Health Services Research, Cedars-Sinai Health System, Beverly Hills, CA 90211, USA.
Am J Med. 1998 Jul;105(1):33-40. doi: 10.1016/s0002-9343(98)00129-6.
Although practice guidelines about appropriate lengths of stay have been widely promulgated, their effects on patient outcomes are not clear. Our objective was to study the effects of length of stay practice guidelines on patient outcomes.
We performed a prospective, nonrandomized, interventional trial in six geographically distributed hospitals, among consecutively hospitalized "low-risk" patients with total hip replacement, hip fracture, or knee replacement. Case managers provided physicians with patient risk information based on guideline recommendations. We measured length of stay, compliance with recommended guideline length of stay, health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction.
A total of 560 patients were included in the study. For patients with knee replacement, there was a statistically significant increase in practice guideline compliance (27% baseline versus 53% intervention, P <0.0001) and reduction in length of stay (5.2 days versus 4.6 days, P <0.001) when compared with the baseline period. For hip replacement patients, there similarly was an increase in practice guideline compliance (66% baseline versus 82% intervention, P = 0.01) and reduction in length of stay (5.1 days versus 4.8 days, P = 0.03). Significant reductions in length of stay were not observed for patients recovering after hip fracture despite a significant increase in guideline compliance. There were few statistically significant changes in patient outcomes related to reductions in lengths of stay, including health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction. For patients undergoing hip replacement, very short lengths of stay (shorter than the guideline recommendation) were associated with an increased rate of discharging patients to nursing homes and rehabilitation facilities (21% versus 7%, P = 0.01), and hip fracture patients with very short lengths of stay required more visits to the doctor after discharge (56% versus 25%, P = 0.04).
Reductions in lengths of stay were most often associated with no significant change in patient outcomes. However, very short lengths of stay were associated with increased intensity of care following discharge for patients undergoing hip surgery, indicating possible cost shifting (the cost incurred by transferring patients to rehabilitation facilities may have been greater than had the patients remained in the acute care hospital for an additional 1 or 2 days and been sent directly home). These results emphasize the importance of monitoring the effects of cost containment and other systematic efforts to change patient care at the local level.
尽管关于适当住院时长的实践指南已广泛发布，但其对患者预后的影响尚不清楚。我们的目的是研究住院时长实践指南对患者预后的影响。
我们在六家地理位置分散的医院进行了一项前瞻性、非随机、干预性试验，纳入连续住院的接受全髋关节置换术、髋部骨折或膝关节置换术的“低风险”患者。病例管理人员根据指南建议向医生提供患者风险信息。我们测量了住院时长、对推荐的指南住院时长的依从性、健康状况、医院再入院率、返回急诊科情况、恢复工作和娱乐情况以及患者满意度。
共有560例患者纳入研究。与基线期相比，膝关节置换患者的实践指南依从性有统计学显著提高（基线期为27%，干预期为53%，P<0.0001），住院时长缩短（5.2天对4.6天，P<0.001）。髋关节置换患者同样如此，实践指南依从性提高（基线期为66%，干预期为82%，P = 0.01），住院时长缩短（5.1天对4.8天，P = 0.03）。尽管髋部骨折患者的指南依从性显著提高，但未观察到住院时长有显著缩短。与住院时长缩短相关的患者预后方面几乎没有统计学显著变化，包括健康状况、医院再入院率、返回急诊科情况、恢复工作和娱乐情况以及患者满意度。对于接受髋关节置换术的患者，极短的住院时长（短于指南推荐时长）与将患者转至疗养院和康复机构的出院率增加相关（21%对7%，P = 0.01），住院时长极短的髋部骨折患者出院后需要更多次看医生（56%对25%，P = 0.04）。
住院时长的缩短通常与患者预后无显著变化相关。然而，极短的住院时长与髋关节手术患者出院后护理强度增加相关，这表明可能存在成本转移（将患者转至康复机构产生的成本可能高于患者在急症医院再额外住1或2天然后直接回家的成本）。这些结果强调了在地方层面监测成本控制及其他改变患者护理的系统性努力效果的重要性。
