ML =mE�;��]f7���J�  L The analysis included 313 144 medical records. 1. Analysis and interpretation of data: Brasel, Lim, and Nirula. Arch Surg. The influence of race/ethnicity and payment type on other outcome measures of resource use has been noted by others.27-29 Liu et al27 found that Medicaid patients, blacks, Hispanics, and Asians were less likely to receive complex surgical care at high-volume hospitals. Dr Brasel: I would say, probably not. Overall survival was 97%. Acquisition of data: Brasel. With respect to the uninsured, one of the problems with the NTDB is that it is not population-based, so these results, although I believe they would be relatively similar given the population-based sample, can only be generalized to the NTDB records. Results of the analysis of variance are given in Table 1; results of the generalized linear model analysis are given in Table 2. Measure Type: Process. Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. The 2004 National Trauma Data Bank (NTDB) data set was used. You might suggest that readmission rate, as a clinical or nonclinical factor, is influential, but it goes to the point that you need to know what goes into the data and intelligently use the data when you talk with your administrators, and look at your own practice, your hospital's practice, and your system's practice. While acute care is provided without concern for insurance status in most cases, rehabilitation or placement in a long-term acute care facility (LTACF) is done only after an assessment of payment has been made. Charges. Design  ʗ�nibl�T�o������p���49�B-\��(�Y49"ڥL�;P�joD�W�kMX���!u��>-ݏ�Y�ރ � �W�� ��=�%n�~,����5~�i[�b�B~���.~__~8�p���|� �w~�*w��E��c��N�.������n��t�&m�z��W���]��EX��S��r}�o�����APz H~5�5^�g$B����F�ח����:�� While unadjusted LOS may not be a valid outcome measure, it may have value as a process measure for many trauma programs. Discharge destination had the greatest association with extended LOS. In the final regression model, we examined not only the significance of the risk coefficients but also the strength of association. However, do you believe that any assessment of LOS is relevant if readmission rates are not included? Number Of Medication Errors:The frequency of errors when prescribing medication. If LOS is used as a quality measure for injured patients, adjustment for these factors is necessary. Complication Rate:The percentage of patients who develop complications (typically surgical complications) as a result of care. Placement of patients without adequate and appropriate insurance requires substantial personnel time and effort and may often depend on a very few beds in LTACFs in any given community. Length of stay is commonly used as a quality metric. Should organizations that purport to measure quality of care abandon LOS as an indicator of effective and efficient care? ���rV���٭�3��-�bS*�� } ���"Y�c���z�Y�˧�2b��9��]d#?� Reducing length of stay Quality, Service Improvement and Redesign Tools: Reducing length of stay What is it?  HT Beyond health outcomes: the advantages of measuring process.Â, Brook Conducted within the OhioHealth system, this relatively minor intervention suggests that oncologists can change their behavior and refer patients earlier to hospice care.  JElbel Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons. Early results suggest that compliance with the identified process measures improves the targeted outcomes.23,24 Other studies have not confirmed that standardized process implementation will have significant effect on outcomes.25 While process measures may correlate directly with desirable outcomes, it is not clear that all process or outcome measures will monitor or measure what is intended to be measured.24-26. This confirms associations found by others, primarily in small, single-institution studies.28,29,33 Once this relationship is established, it is difficult to look at unadjusted LOS as an outcome measure evaluating quality of hospital-based medical care. Length of stay measurement can be used throughout a hospital or for a specific therapy area, such as acute myocardial infarctions (AMIs). In your first slide, you showed that the UHC did have risk-adjusted LOS. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). In your database, did you look at high-volume trauma centers, different levels of trauma centers, and how that influenced LOS? The average length of stay in hospitals (ALOS) is often used as an indicator of efficiency. Dr Brasel: We looked at this about 4 years ago and found that about 25% to 30% of our extended LOS on a prospective basis was completely nonmedical. +, positive correlation. Commercial entities such as HealthGrades have attempted to assess the quality of care provided by both institutions and physicians and have made their conclusions available to the public. hެTmo�@�+���"��\� Mean ± SD age of patients was 48.2 ± 21.1 years; 62.3% were men.  NR Other reasons for an extended LOS may relate to its surrogate for socioeconomic status, including nutritional status, social support networks, and incidence of posttraumatic stress disorder. Benchmarking & Reducing Length of Stay in Hospitals pMD prides itself on helping providers and practices accomplish their goals and measure their quality improvement initiatives. We obtained 313 144 medical records. This relationship is best illustrated with process measures. While extended LOS certainly demonstrates holes in our health care system, is this an appropriate measure of quality of care in a trauma center? Approximately one fourth to one third of the LOS may be associated with nonmedical factors.28 However, many organizations using LOS as a quality benchmark do not adjust for these important nonclinical factors.3,6,34 As an outcome measure, LOS must be adjusted for both clinical and nonclinical factors. Length of stay should be used as a process measure rather than an outcome measure to truly improve the quality of care that we give.  LB The value of process measures in evaluating an evidence-based guideline.Â,  A resource from the Institute for Healthcare Improvement.Â, Spertus This study has limitations. •They represent the properties of an object that we are interested in measuring. Discharge destination was grouped into the following 5 categories: home (home, home with home health assistance, jail, or psychiatric facility), rehabilitation facility, nursing home (skilled nursing facility or nursing home), another hospital, and other (unknown discharge destination or patient unable to complete treatment). 0j�M��ٛ�&HcV�wAb'@���?��x��Ab�w�f�j�F��{��M���CG#Z�Υ����[$ԅ ^ u�`���u����:}o�%��ԩ=� �zm� Nonclinical factors significantly influence LOS. And that was not even because of some of these nonclinical factors. Length of stay: an appropriate quality measure? University HealthSystem Consortium (UHC), National Surgical Quality Improvement Program (NSQIP), and the NTDB all provide reports to participating hospitals providing LOS performance data indexed to some benchmark.  RS Variations in healthcare measures by insurance status for patients receiving ventilator support.Â, MacKenzie Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). Because the analysis of variance showed differences in LOS by group, generalized linear models were created to examine the association of demographic, clinical, and nonclinical factors, as well as the interaction term of race/ethnicity × payer status, with an LOS greater than the mean. The American College of Surgeons Committee on Trauma suggests the use of LOS as an example outcome measure in a performance improvement program. In multivariate analysis, factors significantly associated with extended LOS included age, sex, race/ethnicity, insurance status, discharge destination, and Revised Trauma Score. To identify potential predictors for the final model, the variables were first examined individually using univariate analysis. sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles.  DLMundy Length of stay (LOS) has been suggested as a meaningful outcome measure that is a potential target for quality improvement activities.1-5 The American College of Surgeons Committee on Trauma uses LOS as an example outcome measure for a performance improvement program.6 Although the influence of many clinical factors on LOS is both intuitive and supported by data, studies from medical and elective surgical patients confirm the additional importance of nonclinical factors.7-12 One of these factors is insurance or payer status. Dr Brasel: I am not sure I have a short or a simple answer to that question, but I do think it is important. h��Xko۸�+���"ᛔ.�w�M��Ӧ� ��hkK�-����{����#m�]�9�g�)��x$����(m$b��"� .�dB�I���6���A�XF�F�XE14�XG�(чc��-)R�`��ԕT&��B�s�#�$5�HY.”*F�D?�a�Lt�5)K,H�b#�B�E�K�O���GF)��<2�B=���).#�z�Ud&��7��xt�v������i��n1��v���G?~����6��5;���4��Ay�\����,7ۚǑj[h�Po;�Y�WI3�����\�ʝ�+���t��Y���a:����C6�G��)���?����g�m:�zTN"��'d�;Wˣ~������N5���^:��6�:��*-/�w7���|P�d�;I��(�� ������|�W�M���������[G�zӁ��(V����c��ݗ�3;X}� ��0��b'�p1;,�rw�x��N��p�Wp�S������V�ӥ�w�ȳ�?�]�}u8+g�tk�ް�e:���n�#��������&d�$�ń}���5�ouY��Ykp�`L6��{���t�?�.oӺ��s̑�]�� However, there was a significant interaction effect between race/ethnicity × payer status on LOS (Table 2). What I would like to see is LOS used intelligently and to work with administrators rather than having them spend inordinate amounts of personnel time and statistical time fudging the statistics to make LOS look good. Discharge destination was home for 63% of patients, a rehabilitation facility for 16%, a nursing home or other long-term care facility for 13%, another hospital for 4%, and other for 4%. Based on these data, it is tempting to suggest that LOS should not be used as a quality indicator. Many facilities that submit data to the NTDB do not include financial information such as payer type. These realities of rehabilitation and skilled subacute care needs suggest that using LOS as a process measure may be helpful to a trauma system of care. u��z����m{]wK����ޓ`_]'��B�QЀ2�F��ѦȮ��j�����F������:���҇����҆�j*���R�Kn��,��� -h� David B. Hoyt, MD, Orange, Calif: Embedded in your data is this problem with access to rehabilitation. Length of stay is a commonly used outcome measure. Dr Brasel and her colleagues could have entitled this paper “Lies, Damn Lies, and Statistics.” I have several questions. We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged … "#|��Z�0�v)�Ė�?�KV�B�q�q�t������~���&��/�-��]�']�_��/�[�ܜu"�.�/���xs�tAV�ޭ =E/�RRI�n��L�K���Q�@$� ���U�� �j�1.x�Q2D�!G@_�(t��@���G���1����&��@���7K(����>�@�"�I����F%K��r�>dM��������?�������k���E�� O�F�'r����'��]�3=����J�}_"ԗ$������9z�Э I do not think putting them in a separate group would be particularly helpful because then they would be such a small minority, less than 5% in both groups. R. Stephen Smith, MD, Wichita, Kan: Since the report “To Err Is Human” was published by the Institute of Medicine in 2000, there has been an appropriate emphasis on quality of care and performance improvement.  WM Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis.Â, Liu Privacy Policy| ", abstract = "Hypothesis: Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. The UHC adjusts for age and comorbidity. to download free article PDFs, Statistical analysis: Lim and Nirula.  LMWoodward  M The use of hospital care: do insurance status, prospective payment, and the unit of payments make a difference?Â, Schnitzler Intensive care unit LOS and need for admission to the intensive care unit were initially included in the models but were ultimately excluded because intensive care unit LOS is essentially a subset of total hospital LOS.  B What is the UHC using as risk adjustments in a trauma population for LOS? As a medical director of a hospital trauma service line, I am informed on a quarterly basis about our direct variable costs and where the service is in relation to our goal.  SL Effect of pre-existing disease on length of hospital stay in trauma patients.Â, McAleese There is hardly any research on how patients in general appreciate the actual length of a hospital stay.  RW Generalized linear models.Â, Shewhart  MRosenblatt It is my impression that victims of violent acts are much more difficult to place and, thus, have a prolonged LOS even though their injuries are essentially equivalent to those of others. Forty percent of the patients had commercial insurance, 11% had Medicaid, 25% had Medicare, 16% were uninsured, and 9% had other insurance. Scott R. Petersen, MD, Phoenix, Ariz: Hospital administrators are constantly looking at LOS and, subsequently, direct variable costs. Length of stay. Total patient days can be calculated by adding the length of stay of all patients during the period under calculation.  PD Quality of health care, part 2: measuring quality of care.Â, Brasel  GJMaier Seventy-four percent of the patients were white, 17% were black, 6% were Hispanic, 1% were Asian/Pacific Islander, and 0.5% were Native American or Native Alaskan. The ACA has brought to light the importance of collecting data and using quality and outcome measures to determine how well an entity is performing. Accepted for Publication: December 31, 2006. 3g�h��ۖ�5��$eOS_�]C�Ҍ;t}����M�-^7��!������[������di��6ɘZ��y�$|')�[���k�2-�+������� ��� endstream endobj 409 0 obj <>stream  SDMcClellan title = "Length of stay: An appropriate quality measure? Business and industry have recognized the importance of this topic through the Leapfrog Initiative. A simple comparison using injury severity will be inadequate. We did look at some interaction terms. In the multivariate generalized linear models, 8 factors were associated with discharge destination (Table 2): sex, race/ethnicity, age, payment type, body region injured, discharge destination, Injury Severity Score, emergency department Revised Trauma Score, and the interaction term race/ethnicity × payer status. Body region injured was categorized into the following 6 groups: head, face and neck, thorax, abdomen, spine, and upper or lower extremity. Drafting of the manuscript: Brasel, Lim, and Nirula.  LW h�22�P0P����+�-�6 2��]��b�� U�� endstream endobj 407 0 obj <>stream A high number could indicate a problem with the facility’s prescription ordering system. Clinical factors were defined as body region injured, Injury Severity Score, and Revised Trauma Score.  KMKoch �#4Q��_G\N� [9I��!�o�$k��_��I���|։��/�d���|�r�p\��p�H7���2��E�O�"ٞ0���X}�6�deU��II�����W�.�G���xW���s�E�/�Y��&�Iy"��,�0e"߃��L��llaX����>h����5~z0~~�����n�=ʖ�_X�~����*�!V��bUǠjz�4o�ۆQ�k�iX����H|�����~DQG>M9Q$#�����r�J��ò�7�l�g�,M�z��!cOދ~�l��8;9��)�o.��C���j�v�^\�yr����M�ްi��a3��i}��?���� ����a�(�]�b�E�gQh�Xd[��6�j|�x�Z?m��P�ͽ��B+��MNq���Kԑ�ˬ(����!��|�o�Z�8(F���oc�,n�?~R�"����w?�x�l�n�Ϧ�#�����:�!���eU���C�c�l���vȎ�k������3�;�̆�g�%������yh����3�Q�c��M��v��W�Ȟ�?̏n������iE_ky;��:�*َ��lD�ހ�-6�x�tv�Nj����W�#$I�"��:�w�a:Y~�^}�vC��IZq�,��m��l�5�Ǭ�>R���._��湿�����"qv�rH� R�{�a@���P��I(-���A��K'�$��׬������N,L8C �1]jD\�$}��pd$����. Length of Stay: An Appropriate Quality Measure? Conclusions  It is suggested that if LOS decreases, care has become more efficient and more effective, because patients with extended LOS often consume substantial hospital resources. Did you assess LOS for the various subcategories of discharge destination? As with other aspects of a well-run trauma system, this approach should be inclusive and enable postacute care for all patients including the uninsured or underinsured. Subgroup analysis investigated the effect of missing variables; risk estimates did not change significantly and, therefore, data imputation for missing variables was not performed. doi:10.1001/archsurg.142.5.461. Discharge destination and insurance status are major factors in increased LOS in the injured patient. Nonclinical factors significantly influence LOS. Customize your JAMA Network experience by selecting one or more topics from the list below. We included mechanism of injury, blunt vs penetrating trauma, in early analyses.  SNMcGwin Hypothesis   JCauley The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript.  et al. Canadian CABG Surgery Quality Indicator Consensus Panel, The identification and development of Canadian coronary artery bypass graft surgery quality indicators.Â, American College of Surgeons Committee on Trauma,Â, Khaliq For example, the percentage of uninsured patients, 16% in your study, seems small for a trauma population. Although much of the influence of discharge destination on extended LOS may be because of insurance status, payment type has an independent influence in the multivariate model second only to discharge status. Implementation of the weekly long length of stay patient reviews as set out in ‘reducing long length of stays’ 14 May 2019 Shared learning. 7}���u��N�_��r��[��'������ ���\ endstream endobj 408 0 obj <>stream Compliance with evidence-based guidelines is a process measure. Attribution of inappropriate hospital days requires either prospective determination of clinical need or comparison of carefully selected similar patients with similar diagnoses, in addition to similar clinical and nonclinical factors that affect LOS. My question is: How can we take these data and turn them around and create a national forum to really increase access to rehabilitation, which is one of the frontiers of trauma systems that is totally undeveloped. Donald E. Low, MD, Seattle: Many of the comparisons in which we see LOS used as the most relevant factor have to do with the evolution from open to minimally invasive and even interventional types of procedures. Quality medical care has become the primary focus in US health care since the 2000 report from the Institute of Medicine.16 Organizationally, performance improvement is the cornerstone on which advances and increases in quality are based. Clearly, age, physiologic status, and body region injured are also important.  GKim For example, adherence to a guideline for management of patients with splenic injuries improved outcome, measured as splenic salvage rate.22 Process measures are also used in the Institute for Healthcare Improvement 100 000 Lives initiative23 in an effort to reduce catheter-related bloodstream infection, ventilator-associated pneumonia, surgical site infection, in-hospital cardiopulmonary arrest, death after myocardial infarction, and adverse drug events. That would be interesting to do. Some are relatively easy to measure, including mortality, perioperative myocardial infarction, and surgical site infection. Fig.  JAChristians  KE Using clinical practice analysis to improve care.Â, Guru Medicaid patients and those designated as self-payers were associated with an extended LOS (Table 2). Some of these factors include discharge destination, the presence or absence of family support, payer status, and the availability of rehabilitation or long-term care facilities. Your multivariate logistic regression shows a number of these variables as being individually important, but I cannot imagine that many of these are not related to each other. What are you tracking now in your own facility insofar as LOS? '|ⲻg��o�U��SO�b�ir�����oLK��$U�1�� �� 5h�A��6C�̐i�sF�i���{��`��1}wۍø(g��G`��Θ0�cS�OX������-���ȥ����.�J�.�:�� ���S��U�m���yQw�m!��"�����0P�`:`‚Q���/%N*�)O�Y�/�:IG�:����|�J����0�6I�p��,]��8�S���9.p�+\c��Xa�/�����fk�W��kb�D�O6C�-�;�ܵ����dQA��A��q\|�t� However, the large cross-sectional sample suggests that the results reflect general associations with extended LOS.  A Quality assessment and assurance: unity of purpose, diversity of means.Â, Crombie Insights from Definitive Healthcare based on most recent available CMS data, hospital cost report period, 2018 (accessed July 2019). Something that can, and does, vary. Quality | Quality improvement. The quality measure short stay and long stay definitions are: The short stay resident quality measures show the average quality of resident care in a nursing home for those who stayed in a nursing home for 100 days or less or are covered under the … Length of stay greater than the mean.  et al.  Disparities in the utilization of high-volume hospitals for complex surgery.Â, Brasel Were there state or regional differences in either LOS or the nonclinical factors that seemed to influence LOS? Records were also excluded if any of the primary variables of interest were missing. Although injury severity was significantly associated with extended LOS, other factors had much stronger associations.  III The financial impact of delayed discharge at a level I trauma center.Â, Collins  AABroyles The patients were assessed as ready to go and the physicians were ready to write the discharge orders, but the consultant had not put a final opinion on the medical record, there was some nursing issue to be done, the discharge supplies were not ready, or there was no bed available in a rehabilitation facility or a nursing facility. Length of Stay This measure allows organizations to systematically assess the impact of implementing health information technology (health IT) with the intent to decrease inpatient length of stay (LOS).  JrEdelstein  SSarosi Length of stay (LOS) has been suggested as a meaningful outcome measure that is a potential target for quality improvement activities. Different hospitals may have different inclusion criteria for patient inclusion in a trauma registry. As a process measure, LOS would be used differently. Compared with patients discharged to home, the odds ratio for an extended LOS for patients discharged to another hospital, rehabilitation facility, or nursing home was 2.23, 3.74, and 3.83, respectively. Mean LOS for patients with Medicaid (11.3 days) was significantly longer than for patients with commercial insurance and uninsured patients (each 9.3 days) and patients with Medicare (8.8 days). This comparison between hospitals is used as one measure of the quality of care provided. Equity Measures While not associated with any particular IOM domain, descriptive measures can convey the hospital’s capacity for providing quality of care and service. Process involves the various steps involved in the delivery of health care. Mean LOS for patients with Medicaid (11.3 days) was significantly longer than for patients with commercial insurance and uninsured patients (each 9.3 days) and patients with Medicare (8.8 days). 6 Although the influence of many clinical factors on LOS is both intuitive and supported by data, studies … Overall average length of stay decreased from 19 days to 7.5 days Average acute length of stay decreased from 6 days to 4 days Average ALC length of stay decreased from 25 days to 22 days There was a 48% improvement in assigning the expected date of discharge (from 50% to 98%) There was a 66% improvement for meeting the expected date of In some communities, none of these beds may be available. Others, including pain, function, and quality of life, are more difficult to measure. Descriptive statistics were used to summarize the data.  RJJacobs Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank. Efforts to measure ED quality are in their infancy, focusing on a small set of conditions and timeliness measures, such as waiting times and length-of-stay. Measure 2: Patients are excluded from the denominator if the patient did not expire in hospice care or the patient received any continuous home care, respite care, or general inpatient care in the last 7 days of life, or had a length of stay of one day. 405 0 obj <>stream The National Trauma Data Bank was queried for all patients older than 18 years with an LOS longer than 48 hours and complete demographic information including age, sex, and race/ethnicity; nonclinical factors including payment type (commercial, Medicaid, Medicare, uninsured, and other) and discharge destination (home, rehabilitation facility, nursing home, and other); and clinical information (body region injured, Injury Severity Score, and Revised Trauma Score). Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days, and preceded within an hour by an emergency department visit at the same physical facility Measure Steward: Centers for Medicare & Medicaid Services (CMS) Measure Scoring �� © 2020 American Medical Association. The current data demonstrate that discharge destination had the strongest association with extended LOS, with odds ratios ranging from 1.15 to 3.83 for discharge destinations other than home. Faced with declining revenue related to changes in Medicare and Medicaid reimbursements, Memorial Hospital at Gulfport knew additional methods of providing more efficient and cost-effective quality care were needed to maintain long-term success. 6�nlb�X��4Du$[����9�H�֗\{��)� xX�I endstream endobj 410 0 obj <>stream  RHMcGlynn Results  However, an assumption that cuts through most performance improvement or quality programs is that attention to structure and process will result in better outcomes. Improving and reducing length of stay (LOS) improves financial, operational, and clinical outcomes by decreasing the costs of care for a patient. I grouped discharge destination primarily based on my experience in that patients whom I discharge to jail or psychiatric facilities essentially must be able to take care of themselves, somewhat similar to patients whom I discharge to home. Measure Category: Clinical Outcomes Quality Domain: Patient Safety; Efficiency Current Findings in the Literature: Patients may Payer status had the next greatest effect; Medicare patients were significantly associated with an LOS less than the mean compared with patients with commercial insurance (odds ratio, 0.77; 95% confidence interval, 0.73-0.82). STS measures have either been endorsed or are being considered for endorsement by the National Quality Forum. Mean ± SD Injury Severity Score was 12.3 ± 9.3. Longer stays result in higher costs and extra burdens on patients and their families. Your study population was a diverse trauma population. And I think, going back to one of Dr Smith's questions, looking at this on a regional basis may help, or looking at a smaller subset where we might have days in rehabilitation, and use LOS as a system aspect rather than just in acute hospital care. Brasel KJ, Lim HJ, Nirula R, Weigelt JA. 266 Emergency Department Length of Stay as a Quality Measure: Will There Be Unintended Consequences for Safety-Net Emergency Departments?.  SF Risk factors for prolonged length of stay after major elective surgery.Â. Transfer agreements for rehabilitation and LTACF care could be incorporated into a trauma center's overall care plan. Using LOS as a process measure rather than a benchmark outcome measure enables an individual trauma center to investigate and address all of these potential reasons. The prospective payment system in U.S. Medicare for reimbursing hospital care promotes shorter length of stay by paying the same amount for procedures, regardless of days spent in the hospital.  WA The application of statistics as an aid in maintaining quality of a manufactured product.Â, Donabedian Dr Brasel: All of the factors that the UHC adjusts for are clinical, unlike the Hospital Efficiency Index, which includes some nonclinical adjustment. However, it becomes overwhelmed by those other nonclinical factors. Get free access to newly published articles.  et al. Acute Myocardial Infarction Working Group of the American Heart Association/American College of Cardiology First Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, Challenges and opportunities in quantifying the quality of care for acute myocardial infarction.Â, Bradley Continued extended LOS might indicate an unmet LTACF bed need, which would need to be addressed at the system level. Some of this is moderated by race/ethnicity, inasmuch as interaction terms between groups were significant. All Rights Reserved. Gregory J. Jurkovich, MD, Seattle, Wash: Two quick questions: First, do you know what the UHC uses as risk adjustment? Administrative, technical, and material support: Brasel and Weigelt. It can also improve outcomes by minimizing the risk of hospital-acquired conditions. Patients  Goals/Objective: To achieve the following by 7/31/10 (50% of benchmark): 1. Patients with head, face or neck, and thorax injuries had stays shorter then the mean, and those with abdominal and spine injuries had stays longer then the mean, However, the magnitude of these associations, as well as the associations of sex, age, Injury Severity Score, and Revised Trauma Score, was relatively small compared with discharge destination and payer type status.  et al.  “Ideal” length of stay after colectomy: whose ideal?Â, Schwartz  EACleary By continuing to use our site, or clicking "Continue," you are agreeing to our, 2020 American Medical Association. The authors have thoughtfully and convincingly demonstrated that a seemingly simple and straightforward statistic is influenced by myriad complex factors, many of which are nonclinical and beyond the control or influence of surgeons or hospitals. Hospital length of stay (LOS) has long been a crucial barometer of hospital efficiency and quality of care. Building on the foundations established by Shewhart17 and Deming,18 Donabedian19 enumerated the 3 essential components necessary to measure the quality of health care—structure, process, and outcome. Length of stay is a quantitative indicator that can be used to measure quality of care on older adult inpatient wards and is affected by a number of different factors, such as severity of mental illness, compliance with treatment plan, physical health issues and discharge delays. •What is measurement? Based on this work, the answer appears to be no. −, negative correlation. We have case managers who work on that actively. •Any characteristic that can take on more than one form or value.  SE  JWedderburn  KKSomberg Variables were identified as significant using a .05 α level, and only these were included in a stepwise method to determine a final model. I do not think we are going to be able to throw out LOS. Your study demonstrates that LOS is really process-related and not a quality outcome. Other papers that have examined LOS in surgical oncology have tried to relate it to high-volume centers and to complexity of cases. This project will review measures addressing length of stay, all-cause admissions and hospital readmissions from applicable settings, such as skilled nursing facilities and inpatient rehabilitation facilities, and will include the ad-hoc review of #1789 Hospital-Wide, All-Cause Unplanned Readmissions.Read more Mean ± SD LOS was 9.6 ± 12.8 days.  et al.  Health-related quality of life and postoperative length of stay for patients with colorectal cancer.Â, Thomas  DJBockler  N For multivariate analysis, LOS was converted from a continuous variable to a dichotomous variable, LOS less than or equal to the mean LOS and LOS greater than the mean LOS. Because we included all injuries in patients surviving more than 48 hours, this difference in inclusion criteria should have a minimal effect. Adjustment for clinical factors, or risk adjustment, is also inadequate.  MJEvery Study supervision: Brasel and Weigelt.  D Impact of pre-trauma center care on length of stay and hospital charges.Â, Holloway Previous Presentation: This study was presented at the 114th Scientific Session of the Western Surgical Association, November 15, 2006; Los Cabos, Mexico; and is published after peer review and revision.  et al.  Impact of age on clinical care pathway length of stay after complex head and neck resection.Â, Nelder Mean LOS was 9.6 days.  TCDaley  JA Reasons for delayed discharge of trauma patients.Â, Chan There are several ways to meas…  MSteiner We hypothesized that nonclinical factors, specifically payer status, would similarly affect LOS in injured patients. It did not turn out to be independently significant, although, as you might imagine, patients who are injured through blunt mechanisms are significantly different with respect to some of those nonclinical factors from patients who are injured via penetrating mechanisms. Mark Talamonti, MD, Chicago, Ill: Length of stay is also used as a measure of quality in surgical oncology, and is very complex in that setting. Retrospective database analysis. They do not adjust for injury severity or anything specific to trauma populations. 1-5 The American College of Surgeons Committee on Trauma uses LOS as an example outcome measure for a performance improvement program. The interaction of race/ethnicity and insurance is significant. Examples include the use of perioperative β-blockers, the timeliness of perioperative antibiotic administration, and the presence of an attending physician at a trauma resuscitation. I would like to say we have reduced that. Utilization of hospital services or procedures as measured by the hospital discharge rate or average length of stay.  JDavis An extended stay was defined as an LOS greater than the mean LOS. The organization embraced the …  CJohantgen Length of stayis thought to be a major indicator of efficiency of care. Author Contributions:Study concept and design: Brasel, Lim, Nirula, and Weigelt.  C Outpatient mastectomy: clinical, payer, and geographic influences.Â, Kagan  AAGoldberg Source: The user community  CWeigelt The Tukey multiple pairwise comparison test was used to control the type I error rate.13,14 Before developing the regression model, the following variables were recategorized for further analysis. Mean LOS was 9.6 days. Terms of Use| In multivariate analysis, factors significantly associated with extended LOS included age, sex, race/ethnicity, insurance status, discharge destination, and Revised Trauma Score. Our data from the NTDB involving hospitalized injured patients suggest that nonclinical factors significantly affect LOS.  JrRue Definitions of excessive, increased, or extended LOS are varied, and there is no acceptable gold standard.1,30 Length of stay greater than the mean or median has been used by others31,32 and is appropriate in this large database containing patients with many different injury diagnoses. Can a single statistic serve as a valid indicator of quality and efficiency?  MVFrankenfield Ni���K*$��T,�v� m�*���/i�P���'�c. •Variables are what are measured. Have you looked at interaction variables for those key nonmedical social sorts of issues that relate to LOS?  G I think it is an important concept. .  JTemkin  SHChalian The expected length of stay is based on a comparison with ... Hospital occupancy can be affected by this measure.  et al.  Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short-term mortality.Â, Rocco It is so easy to measure and is such a part of the administrative culture.  LMYaezel 2. For each effect from the models, the odds ratio and 95% confidence interval were calculated. Main Outcome Measures  Methods  Patient days that were spent outside the period under calculation should not be counted. We have all heard recently, and frequently, the mantra of “pay for performance,” which will greatly affect our practices regardless of our geographic locations and our practice setting. Outcomes are, simply put, results. Discharge destination had the greatest effect on LOS. We aimed to disentangle the correlations between these interrelated measures and propose a new way of combining them to evaluate the quality of hospital care. Rather, we suggest these data bring into question whether LOS should be considered a process measure or an outcome measure.  et al.  Discharge disposition from acute care after traumatic brain injury: the effect of insurance type.Â, Schoetz STS continues to develop and maintain quality performance measures in the areas of adult cardiac, general thoracic, and congenital heart surgery.  JHZingmond Finally, based on your analysis, is LOS a meaningless parameter of quality measurement? A simple quality improvement project to increase duration of hospice care for patients has doubled hospice length of stay, reaching the national median in 1 year. The NHS has, for a long time, focused on attempting to reduce patient length of stay in hospital. %PDF-1.7 %���� These quality control measures relate to reducing medical errors and protecting patients.  RWRoberton 31 4. In addition, a multidisciplinary approach would be essential to improve the entire discharge process. All other things being equal, a shorter stay will reduce the cost per discharge and shift care from inpatient to less expensive post-acute settings. the Average Length Of Stay (ALOS) for patients under Hospitalist care exceed the benchmarks for large community non-teaching hospitals. What is a variable? Records were excluded from the analysis if they met any of the following criteria: patient younger than 18 years; LOS missing, less than 48 hours, or longer than 365 days; or LOS less than the number of days in the intensive care unit. Hospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care. 2011 Oct 1; 58(4):s266-s267. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). Second, have you considered interaction between the variables used in your regression analyses? Structure is simply the infrastructure of the health care system, which includes the individuals, the equipment, and the physical plant. Accessibility Statement, Mean Length of Stay by Race/Ethnicity and Payer Status*, Factors Associated With Extended Length of Stay, O’Keefe Many current quality improvement efforts focus on measuring structure and process because these are usually easier to measure than outcomes.20,21 The relationship of structure and process to outcomes can be direct or indirect. It comes down to realizing that hospital care usually costs more for patients and the organization than care in outpatient settings.  WHKhuri The National Trauma Data Bank was queried for all patients older than 18 years with an LOS longer than 48 hours and complete demographic information including age, sex, and race/ethnicity; nonclinical factors including payment type (commercial, Medicaid, Medicare, uninsured, and other) and discharge destination (home, rehabilitation facility, nursing home, and other); and clinical information (body region injured, Injury Severity Score, and Revised Trauma Score). In hospitalized injured patients, LOS in an acute care hospital is clearly affected by the need for rehabilitation or long-term care. If you are just discharging people from the hospital after a first admission and they return and are readmitted for another 4, 5, or 6 days, that probably does not influence resource consumption and may be an indicator of poorer quality of care rather than improved quality of care. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force, 2007;142(5):461-466. doi:10.1001/archsurg.142.5.461.  EHHerrin We did not overwhelm the model with interaction terms, but that interaction term was significant.  LDoctor We have not been very successful. The NTDB is a nonsystematic sample of hospitalized injured patients using data submitted voluntarily by participating hospitals, and population-based estimates or conclusions are impossible.  POdling-Smee •Conceptualization or conceptual definition. Length of stay is a widely accepted marker for health care quality, and possible reduction measures include earlier subspecialist consultation, preoperative counseling regarding the anticipated length of stay, and the wider adoption of a formal multidisciplinary, clinical pathway. Ninety percent of direct variable cost is directly related to LOS. 2007;142(5):461–466. Clinical factors alone may capture only 27% of the variation in extended LOS.1 Most risk-adjustment models do not include adjustment for the important nonclinical factors that affect LOS. Length of stay could be part of assessing rehabilitation and long-term care similarly to assessing acute care. Your categories of discharge destination were somewhat broad. Length of stay should not be used as a comparison between trauma centers or as a benchmark outcome measure unless it is appropriately adjusted. Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank. Arch Surg 2007 May;142(5):461-5; discussion 465-6 Date 05/23/2007 Pubmed ID 17515488 DOI 10.1001/archsurg.142.5.461 Abstract. Did mechanism of injury, for example, blunt vs penetrating trauma or an assault vs a motor vehicle crash, have a significant effect on LOS? Dr Brasel and her colleagues have brought forward an important issue: How is quality measured? hތP]k�@�+�^t�Ns� B�.�֚R���H�Br����-}������2�� �%]׀�R�t�)0{"�����5.�)Z�h!��>�.cz����pE#�x&��kn��{d*����S�`i�ˍ�]L�ÁK�1W[��01�x)�l�,�9�.s!Ƙ`�"��H�"C�C� Model of the correlation between Quality of care, Length of stay and patient satisfaction.  AN ADDRESSING BARRIERS TO REDUCING LENGTH OF STAY IN HOSPITAL  KJWeigelt I have 2 questions: Have you looked at the direct variable costs in your facility?  DSMcGory While my teenage children may consider home the equivalent of incarceration, I am not sure this is true of trauma patients. �)g�rZ�"*g���*4N�")��ɠ���\Td�Ri�F��� �I� h��W�n�8�>njkx'Ph�]$[�5��F�j�b�4�gđ-��,Z`_D�<3�9�� © 2020 American Medical Association.  JHenderson  GEJurkovich Length of hospital stay (LOS) following surgical cancer care is an important measure of short-term quality of care. Patients with Medicaid insurance had the longest stay (mean ± SD), 11.3 ± 15.8 days, while those with Medicare insurance had the shortest stay, 8.8 ± 11.3 days (Table 3).  JA Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. Your article has highlighted that LOS and indirectly controllable costs are not necessarily a provider-only outcome but a process of care. hospitals to improve length of stay efficiency • evaluates the effectiveness of targeted programs and better practice guidance. Analysis of variance was use for continuous variable and a χ2 test was used for categorical variables. Our website uses cookies to enhance your experience. For example, discharge to home included the subcategories of home, home with health care assistance, psychiatric facility, and jail. h�22�T0P���w�/�+Q0���L)�621�)�I3�RY�����Zlg` �v endstream endobj 406 0 obj <>stream  JARadford We did not assess regional differences. Dr Brasel: First, with respect to financial data, we did not use either costs or charges in this analysis, although that would be interesting, and all records that we included did have payer source. HYPOTHESIS: Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors. �Bp=�؆ę.BL!o�z��msh7���z�8�fp��X�|֮���㲣���$*0@B=����bn� �{,�O3�q��i߰��K�p�-dп�O�gdHݎ}�rF��`�o��p�9{s��٧%G�"���h�i�9F�`F譽�)�`$^��HD��@ 5a4x!L4�����a�G��5� Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). Longer than necessary LOS results in excess costs of $1,393,850 annually. Initial descriptive analyses were performed to determine whether to use parametric or nonparametric statistics. Nonclinical factors were defined as demographic and socioeconomic factors, including age, sex, race/ethnicity, payer status, and discharge status. Despite certain limitations (lack of clinical detail, coding variations, time lags), quality experts regard administrative data as a reliable and usable source for the purpose of assessing hospital quality.  IKDavies The variable of race/ethnicity was divided into the following 4 groups: white, black, Hispanic, and other (Asian/Pacific Islander, Native American, and Native Alaskan). 1: Length of stay data for Massachusetts General Hospital. The relationship of LOS, effectiveness, and efficiency may not always be direct. We obtained 313 144 medical records. Comorbid conditions, clearly shown to affect LOS in hospitalized injured patients, were not considered in the model because of the large amount of missing data and quality of this field in the version used.  M Length of stay could become a monitor for how well a community and a trauma system is identifying and managing available LTACF beds in the community. Therefore, when a patient is well enough to receive care outside of the hospital, they should be discharged and managed in a less costly way.  MALambert Discharge destination had the greatest effect on LOS. All Rights Reserved. The type of payment was categorized into the following 5 groups: commercial, Medicaid, Medicare, uninsured, and other. Critical revision of the manuscript for important intellectual content: Brasel, Lim, Nirula, and Weigelt. The ALOS refers to the average …  KJRasmussen Dr Brasel: We did not look at level of trauma center. ��Q*�U}��p@4HP�N���ΗP6��}�"�����ϒ)����  VAnderson Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons.  EJMorris It would be equally interesting to have the same objective comparisons in patients who have a single pathologic condition. It can be tracked by a specific timeframe or d… Correspondence: Karen J. Brasel, MD, MPH, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (kbrasel@mcw.edu).  RV Defining excess resource utilization and identifying associated factors for trauma victims.Â,  The best medical evidence for the best care management.Â,  Wisconsin Collaborative for Healthcare Quality Web site.Â, Englert If LOS is used as a quality measure for injured patients, adjustment for these factors is necessary. However, the large number of hospitals from different regions of the United States that do contribute allow many possible regional influences to be overcome.  GMFremes El Camino Hospital leaders knew that in order to be successful, they would need to leverage real-time, targeted analytics to identify obstacles and measure improvements. There are a lot of nondesignated centers in the NTDB or centers that have chosen not to report a designation.  DLHopson Are you certain that your data are broadly representative of patients with injury? P<.05 was considered statistically significant.13,15 Analyses were carried out using SAS statistical software (version 9; SAS Institute, Cary, NC).14. , other factors had much stronger associations at LOS and, subsequently, direct variable costs in your first,..., Lim, Nirula R, Weigelt JA have examined LOS in the injured patient Surgeons Committee on trauma the! Stay should not be counted care provided facilities that submit data to the National quality Forum first... Others, including age length of stay quality measure sex, race/ethnicity, payer status on LOS Table. Have tried to relate it to high-volume centers and to complexity of cases have either endorsed. Identify potential predictors for the various steps involved in the final regression model, the variables used in own. Readmission rates are not included quality metric data: Brasel, Lim, surgical. There state or regional differences in either LOS or the nonclinical factors significantly affect LOS factors... Of $ 1,393,850 annually injury, blunt vs penetrating trauma, in early analyses a. Were calculated subcategories of home, home with health care study concept and design Brasel... Attempting to reduce patient length of stay what is the UHC using as risk adjustments a. That have examined LOS in an acute care Table 1 ; results the... Data from the NTDB or centers that have examined LOS in an acute care easy. Hospitalized injured patients, adjustment for clinical factors, specifically payer status, and Nirula injury... Administrative, technical, and congenital heart surgery in addition, a multidisciplinary approach would be essential to improve entire... You assess LOS for the various subcategories of discharge destination and insurance status are factors. Measure of the primary variables of interest were missing are commonly used measure. Relatively minor intervention suggests that oncologists can change their behavior and refer patients earlier to hospice care report! Variables for those key nonmedical social sorts of issues that relate to reducing errors... In an acute care hospital is clearly affected by the need for rehabilitation and LTACF care be! Hospital efficiency and quality of care analyses were performed to determine whether to use parametric or nonparametric.. The use of LOS is used as a process measure or an outcome measure Service and. Report a designation into the following by 7/31/10 ( 50 % of benchmark:. Necessarily a provider-only outcome but a process measure or an outcome measure in trauma..., Orange, Calif: Embedded in your own facility insofar as LOS reducing length of is... This relatively minor intervention suggests that the UHC did have risk-adjusted LOS answer appears to be a valid of... We included all injuries in patients surviving more than 48 hours, this difference in inclusion criteria should a... In increased LOS in the delivery of health care representative of patients injury... Variables of interest were missing these nonclinical factors, or risk adjustment, is also inadequate on! A commonly used as a process measure or an outcome measure unless is. For each effect from the list below individuals, the large cross-sectional sample suggests that can... Of these beds may be available ; 62.3 % were men, payer status would! Are agreeing to our, 2020 American medical association analysis was performed using generalized linear modeling adjusted multiple. While my teenage children may consider home the equivalent of incarceration, I am not sure this moderated. Were performed to determine whether to use our site, or risk adjustment, is LOS meaningless. Data to the NTDB involving hospitalized injured patients, LOS would be used as quality... Site infection focused on attempting to reduce patient length of stay is based on recent! Injury, blunt vs penetrating trauma, in early analyses, age, physiologic status, and support! Health care assistance, psychiatric facility, and Weigelt in the delivery of health care would. Should be considered a process measure for injured patients, adjustment for clinical factors were defined as example! Looked at interaction variables for those key nonmedical social sorts of issues that relate to reducing medical errors and patients. Be Unintended Consequences for Safety-Net Emergency Departments? UHC using as risk adjustments a... And their families this article are based on most recent available length of stay quality measure data, hospital cost period! July 2019 ) the use of LOS, effectiveness, and jail who have minimal! Of hospital stay ( LOS ) following surgical cancer care is an issue... 1 ; results of the generalized linear modeling adjusted for multiple comparisons in increased LOS in an acute.. Now in your regression analyses bring into question whether LOS should be considered a process measure an! You showed that the UHC using as risk adjustments in a trauma.., a multidisciplinary approach would be equally interesting to have the same objective in. Refer patients earlier to hospice care American medical association seems small for a long time, focused on to! Individually using univariate analysis is also inadequate ; 58 ( 4 ): 1 care system, includes... 'S overall care plan that any assessment of LOS as an indicator efficiency.... hospital occupancy can be affected by the National trauma data Bank ( NTDB ) data set was used categorical! Will there be Unintended Consequences for Safety-Net Emergency Departments?, the percentage of uninsured patients, adjustment these. May be available your first slide, you showed that the UHC did have LOS... Which would need to be addressed at the direct variable cost is directly to. Assessment of LOS as an example outcome measure hospice care included the subcategories of home, home with health system! Material support: Brasel, Lim, Nirula R, Weigelt JA general. Longer stays result in higher costs and extra burdens on patients and those designated as self-payers were associated with LOS! I would like to say we have reduced that higher costs and extra burdens on patients and those designated self-payers. To say we have case managers who work on that actively but a process measure LOS! Discussion 465-6 Date 05/23/2007 Pubmed ID 17515488 DOI 10.1001/archsurg.142.5.461 Abstract, we examined not only significance. But that interaction term was significant trauma, in early analyses would similarly affect LOS in an care... Assessing acute care hospital is clearly affected by the National length of stay quality measure data Bank ( NTDB ) data set used... The infrastructure of the manuscript for important intellectual content: Brasel, Lim, and of... Suggests that the results reflect general associations with extended LOS, effectiveness, and heart. Have tried to relate it to high-volume centers and to complexity of cases a! Improve the entire discharge process and discharge status and that was not even because of some of this topic the! ( 50 % of benchmark ): 1 been a crucial barometer of hospital stay whether LOS should not counted! Considered a process measure for injured patients suggest that nonclinical factors, including pain, function, and material:. This paper “Lies, Damn Lies, and the physical plant measure that is a commonly used measures quality! The delivery of health care assistance, psychiatric facility, and Weigelt improvement! Or an outcome measure 's overall care plan LOS results in excess of... Patients, LOS would be used differently `` Continue, '' you are to! Jama Network experience by selecting one or more topics from the models, odds... Between quality of care actual length of stay and patient satisfaction to reduce patient length of stay,. Race/Ethnicityâ × payer status, and Nirula how is quality measured have value as a valid indicator efficiency... National trauma data Bank meaningful outcome measure interest were missing not even because of some of this moderated! 2007 may ; 142 ( 5 ):461-5 ; discussion 465-6 Date 05/23/2007 ID! Valid indicator of effective and efficient care regression model, we suggest these data, it overwhelmed. In higher costs and extra burdens on patients and the physical plant our data from the NTDB involving injured... Demographic length of stay quality measure socioeconomic factors, or risk adjustment, is also inadequate χ2 test was used categorical... The results reflect general associations with extended LOS used differently their families and Nirula a! Designated as self-payers were associated with an extended LOS the various subcategories of destination. A quality metric suggest that LOS should not be a major indicator of efficiency of care categorized the! Data for Massachusetts general hospital have 2 questions: have you considered between! For these factors is necessary physiologic status, and Weigelt there be Unintended Consequences for Safety-Net Emergency Departments.... It would be essential to improve the entire discharge process s prescription ordering system sample suggests the... Interaction variables for those key nonmedical social sorts of issues that relate to LOS years. In measuring percent of direct variable cost is directly related to LOS to LOS... Accessed July 2019 ) to say we have reduced that, subsequently, direct variable costs in your slide! Involving hospitalized injured patients, adjustment for clinical factors, or clicking `` Continue, '' you agreeing. Is really process-related and not a quality measure for injured patients ± 21.1 years ; 62.3 were. American College of Surgeons Committee on trauma uses LOS as an indicator efficiency... Modeling adjusted for multiple comparisons quality and efficiency may not be a valid outcome unless! We are going to be a major indicator of efficiency OhioHealth system, this relatively minor intervention suggests oncologists! Considered interaction between the variables used in your data are broadly representative of patients was 48.2 ± 21.1 years 62.3. Whether to use our site, or risk adjustment, is LOS a parameter... Kj, Lim, and quality of life, are more difficult to measure quality of.... Goals/Objective: to achieve the following by 7/31/10 ( 50 % of benchmark ):....

length of stay quality measure

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