Insights from Definitive Healthcare based on most recent available CMS data, hospital cost report period, 2018 (accessed July 2019). Get free access to newly published articles. Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank. 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. Acquisition of data: Brasel. Forty percent of the patients had commercial insurance, 11% had Medicaid, 25% had Medicare, 16% were uninsured, and 9% had other insurance.  L The interaction of race/ethnicity and insurance is significant. 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). Should organizations that purport to measure quality of care abandon LOS as an indicator of effective and efficient care? We obtained 313 144 medical records. Discharge destination had the greatest effect on LOS. However, do you believe that any assessment of LOS is relevant if readmission rates are not included? title = "Length of stay: An appropriate quality measure? Longer stays result in higher costs and extra burdens on patients and their families. Hospital length of stay (LOS) has long been a crucial barometer of hospital efficiency and quality of 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).  G =mE�;��]f7���J� �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�  D Impact of pre-trauma center care on length of stay and hospital charges.Â, Holloway Ni���K*$��T,�v� m�*���/i�P���'�c. Drafting of the manuscript: Brasel, Lim, and Nirula. 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. Utilization of hospital services or procedures as measured by the hospital discharge rate or average length of stay.  AN While extended LOS certainly demonstrates holes in our health care system, is this an appropriate measure of quality of care in a trauma center?  DSMcGory Length of stay: an appropriate quality measure? Analysis and interpretation of data: Brasel, Lim, and Nirula. ��Q*�U}��p@4HP�N���ΗP6��}�"�����ϒ)���� 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. 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. Retrospective database analysis. Study supervision: Brasel and Weigelt. Some of this is moderated by race/ethnicity, inasmuch as interaction terms between groups were significant. Length of stayis thought to be a major indicator of efficiency of care. Adjustment for clinical factors, or risk adjustment, is also inadequate.  LW  et al.  Health-related quality of life and postoperative length of stay for patients with colorectal cancer.Â, Thomas 2011 Oct 1; 58(4):s266-s267. 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. Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons.  GKim Discharge destination had the greatest association with extended LOS.  RW Generalized linear models.Â, Shewhart 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. 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. The relationship of LOS, effectiveness, and efficiency may not always be direct. In the final regression model, we examined not only the significance of the risk coefficients but also the strength of association. Many facilities that submit data to the NTDB do not include financial information such as payer type. The average length of stay in hospitals (ALOS) is often used as an indicator of efficiency. 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. 0j�M��ٛ�&HcV�wAb'@���?��x��Ab�w�f�j�F��{��M���CG#Z�Υ����[$ԅ ^ u�`���u����:}o�%��ԩ=� �zm� Your study demonstrates that LOS is really process-related and not a quality outcome. Did you assess LOS for the various subcategories of discharge destination? 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. 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. Body region injured was categorized into the following 6 groups: head, face and neck, thorax, abdomen, spine, and upper or lower extremity. What is the UHC using as risk adjustments in a trauma population for LOS? The 2004 National Trauma Data Bank (NTDB) data set was used. Customize your JAMA Network experience by selecting one or more topics from the list below. doi:10.1001/archsurg.142.5.461. We obtained 313 144 medical records. I have 2 questions: Have you looked at the direct variable costs in your facility?  EHHerrin 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. What are you tracking now in your own facility insofar as LOS?  MALambert h�22�T0P���w�/�+Q0���L)�621�)�I3�RY�����Zlg` �v endstream endobj 406 0 obj <>stream 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. 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.  JAChristians  POdling-Smee STS measures have either been endorsed or are being considered for endorsement by the National Quality Forum. However, the large number of hospitals from different regions of the United States that do contribute allow many possible regional influences to be overcome. All Rights Reserved. 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. 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. Although injury severity was significantly associated with extended LOS, other factors had much stronger associations. Improving and reducing length of stay (LOS) improves financial, operational, and clinical outcomes by decreasing the costs of care for a patient. Your article has highlighted that LOS and indirectly controllable costs are not necessarily a provider-only outcome but a process of care. 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. Process involves the various steps involved in the delivery of health care. Different hospitals may have different inclusion criteria for patient inclusion in a trauma registry. Continued extended LOS might indicate an unmet LTACF bed need, which would need to be addressed at the system level. In addition, a multidisciplinary approach would be essential to improve the entire discharge process. 6�nlb�X��4Du$[����9�H�֗\{��)� xX�I endstream endobj 410 0 obj <>stream  PD Quality of health care, part 2: measuring quality of care.Â, Brasel 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. 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 … Author Contributions:Study concept and design: Brasel, Lim, Nirula, and Weigelt. 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. 266 Emergency Department Length of Stay as a Quality Measure: Will There Be Unintended Consequences for Safety-Net Emergency Departments?. Brasel KJ, Lim HJ, Nirula R, Weigelt JA. Length of stay (LOS) has been suggested as a meaningful outcome measure that is a potential target for quality improvement activities.  JA Reasons for delayed discharge of trauma patients.Â, Chan 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. 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 first slide, you showed that the UHC did have risk-adjusted LOS. Reducing length of stay Quality, Service Improvement and Redesign Tools: Reducing length of stay What is it? Quality | Quality improvement. © 2020 American Medical Association. 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. 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.  JrRue 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. 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. For each effect from the models, the odds ratio and 95% confidence interval were calculated.  SDMcClellan ����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$����.  SSarosi Arch Surg 2007 May;142(5):461-5; discussion 465-6 Date 05/23/2007 Pubmed ID 17515488 DOI 10.1001/archsurg.142.5.461 Abstract. Length of stay was longer for patients discharged to a nursing home (14.2 days) or rehabilitation facility (11.5 days) compared with those discharged to any other facility (9.6 days). Hospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care.  DLHopson 3g�h��ۖ�5��$eOS_�]C�Ҍ;t}����M�-^7��!������[������di��6ɘZ��y�$|')�[���k�2-�+������� ��� endstream endobj 409 0 obj <>stream This study has limitations. Results   KJRasmussen Did mechanism of injury, for example, blunt vs penetrating trauma or an assault vs a motor vehicle crash, have a significant effect on LOS? However, it becomes overwhelmed by those other nonclinical factors. 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. •They represent the properties of an object that we are interested in measuring. 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.  AAGoldberg Implementation of the weekly long length of stay patient reviews as set out in ‘reducing long length of stays’ 14 May 2019 Shared learning. 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). Nonclinical factors were defined as demographic and socioeconomic factors, including age, sex, race/ethnicity, payer status, and discharge status. We have case managers who work on that actively.  B 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. 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. Our website uses cookies to enhance your experience. 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. Something that can, and does, vary. 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. 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����:�� Main Outcome Measures  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. It would be equally interesting to have the same objective comparisons in patients who have a single pathologic condition. �� 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�  SL Effect of pre-existing disease on length of hospital stay in trauma patients.Â, McAleese Mean ± SD Injury Severity Score was 12.3 ± 9.3. Source: The user community  IKDavies There are a lot of nondesignated centers in the NTDB or centers that have chosen not to report a designation. An extended stay was defined as an LOS greater than the mean LOS. Clinical factors were defined as body region injured, Injury Severity Score, and Revised Trauma Score. Model of the correlation between Quality of care, Length of stay and patient satisfaction. 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. 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. The NHS has, for a long time, focused on attempting to reduce patient length of stay in hospital. 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. We hypothesized that nonclinical factors, specifically payer status, would similarly affect LOS in injured patients. There are several ways to meas… Mean ± SD LOS was 9.6 ± 12.8 days. Transfer agreements for rehabilitation and LTACF care could be incorporated into a trauma center's overall care plan.  LB The value of process measures in evaluating an evidence-based guideline.Â,  A resource from the Institute for Healthcare Improvement.Â, Spertus  MRosenblatt We did not overwhelm the model with interaction terms, but that interaction term was significant. This comparison between hospitals is used as one measure of the quality of care provided. 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.  JHenderson  MVFrankenfield Ninety percent of direct variable cost is directly related to LOS.  HT Beyond health outcomes: the advantages of measuring process.Â, Brook  M �#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}��?���� 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. Critical revision of the manuscript for important intellectual content: Brasel, Lim, Nirula, and Weigelt. There is hardly any research on how patients in general appreciate the actual length of a hospital stay.  AABroyles Some are relatively easy to measure, including mortality, perioperative myocardial infarction, and surgical site infection. Dr Brasel: We did not look at level of trauma center. Complication Rate:The percentage of patients who develop complications (typically surgical complications) as a result of care. 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. Clearly, age, physiologic status, and body region injured are also important. Discharge destination and insurance status are major factors in increased LOS in the injured patient. The analysis included 313 144 medical records. Conducted within the OhioHealth system, this relatively minor intervention suggests that oncologists can change their behavior and refer patients earlier to hospice care.  SNMcGwin 31 4.  EACleary 6 Although the influence of many clinical factors on LOS is both intuitive and supported by data, studies … Other papers that have examined LOS in surgical oncology have tried to relate it to high-volume centers and to complexity of cases.  JrEdelstein I do not think we are going to be able to throw out LOS.  GJMaier Patient days that were spent outside the period under calculation should not be counted. Dr Brasel: I am not sure I have a short or a simple answer to that question, but I do think it is important. Structure is simply the infrastructure of the health care system, which includes the individuals, the equipment, and the physical plant. 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. 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. 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. Dr Brasel: I would say, probably not. Charges. 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. David B. Hoyt, MD, Orange, Calif: Embedded in your data is this problem with access to rehabilitation. What is a variable? 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.  CJohantgen If LOS is used as a quality measure for injured patients, adjustment for these factors is necessary. 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.  WA The application of statistics as an aid in maintaining quality of a manufactured product.Â, Donabedian the Average Length Of Stay (ALOS) for patients under Hospitalist care exceed the benchmarks for large community non-teaching hospitals.  LMWoodward 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. Records were also excluded if any of the primary variables of interest were missing. Based on this work, the answer appears to be no. 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. 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. Measure Type: Process. However, there was a significant interaction effect between race/ethnicity × payer status on LOS (Table 2). Mean ± SD age of patients was 48.2 ± 21.1 years; 62.3% were men. 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. And that was not even because of some of these nonclinical factors.  LDoctor © 2020 American Medical Association.  GEJurkovich  KMKoch For example, discharge to home included the subcategories of home, home with health care assistance, psychiatric facility, and jail.  W The effect of complications on length of stay.Â, Case '|ⲻg��o�U��SO�b�ir�����oLK��$U�1�� Length of stay measurement can be used throughout a hospital or for a specific therapy area, such as acute myocardial infarctions (AMIs). In multivariate analysis, factors significantly associated with extended LOS included age, sex, race/ethnicity, insurance status, discharge destination, and Revised Trauma Score. For example, the percentage of uninsured patients, 16% in your study, seems small for a trauma population. 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 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. By continuing to use our site, or clicking "Continue," you are agreeing to our, 2020 American Medical Association. 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. u��z����m{]wK����ޓ`_]'��B�QЀ2�F��ѦȮ��j�����F������:���҇����҆�j*���R�Kn��,��� -h�  TCDaley 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.  C Outpatient mastectomy: clinical, payer, and geographic influences.Â, Kagan 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. ADDRESSING BARRIERS TO REDUCING LENGTH OF STAY IN HOSPITAL Design   RJJacobs It is so easy to measure and is such a part of the administrative culture. Nonclinical factors significantly influence LOS.  JARadford Privacy Policy| 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.  JCauley Length of stay is a commonly used outcome measure.  JElbel Arch Surg.  KJWeigelt h��W�n�8�>njkx'Ph�]$[�5��F�j�b�4�gđ-��,Z`_D�<3�9�� 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). Our data from the NTDB involving hospitalized injured patients suggest that nonclinical factors significantly affect LOS.  SHChalian Second, have you considered interaction between the variables used in your regression analyses? All Rights Reserved. Gregory J. Jurkovich, MD, Seattle, Wash: Two quick questions: First, do you know what the UHC uses as risk adjustment? 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.  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 While my teenage children may consider home the equivalent of incarceration, I am not sure this is true of trauma patients. Your categories of discharge destination were somewhat broad.  JTemkin 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. 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. 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. We have not been very successful. Discharge destination had the greatest effect on LOS. Dr Brasel and her colleagues have brought forward an important issue: How is quality measured? Medicaid patients and those designated as self-payers were associated with an extended LOS (Table 2). Scott R. Petersen, MD, Phoenix, Ariz: Hospital administrators are constantly looking at LOS and, subsequently, direct variable costs.  JDavis 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. 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� 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. Benchmarking & Reducing Length of Stay in Hospitals pMD prides itself on helping providers and practices accomplish their goals and measure their quality improvement initiatives. Length of hospital stay (LOS) following surgical cancer care is an important measure of short-term quality of care.  WM Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis.Â, Liu 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�]��  EJMorris 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. 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. In multivariate analysis, factors significantly associated with extended LOS included age, sex, race/ethnicity, insurance status, discharge destination, and Revised Trauma Score. 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. In hospitalized injured patients, LOS in an acute care hospital is clearly affected by the need for rehabilitation or long-term care. 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. 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 Accepted for Publication: December 31, 2006. 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.  N 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). 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). 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. "#|��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 The American College of Surgeons Committee on Trauma suggests the use of LOS as an example outcome measure in a performance improvement program. 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.  DJBockler  et al.  “Ideal” length of stay after colectomy: whose ideal?Â, Schwartz Results of the analysis of variance are given in Table 1; results of the generalized linear model analysis are given in Table 2.  et al.  Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short-term mortality.Â, Rocco  SE The type of payment was categorized into the following 5 groups: commercial, Medicaid, Medicare, uninsured, and other. �)g�rZ�"*g���*4N�")��ɠ���\Td�Ri�F��� �I� . The UHC adjusts for age and comorbidity. It comes down to realizing that hospital care usually costs more for patients and the organization than care in outpatient settings. 7}���u��N�_��r��[��'������ ���\ endstream endobj 408 0 obj <>stream 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. 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. Initial descriptive analyses were performed to determine whether to use parametric or nonparametric statistics. Nonclinical factors significantly influence LOS. Length of Stay: An Appropriate Quality Measure? 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). The organization embraced the …  RWRoberton In some communities, none of these beds may be available. Fig. Total patient days can be calculated by adding the length of stay of all patients during the period under calculation. We did look at some interaction terms.  MJEvery 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%.  GMFremes 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. 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. Mean LOS was 9.6 days. ", 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. 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. Longer than necessary LOS results in excess costs of $1,393,850 annually.  WHKhuri Patients   et al.  Impact of age on clinical care pathway length of stay after complex head and neck resection.Â, Nelder  MSteiner �� The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript. 2. In your database, did you look at high-volume trauma centers, different levels of trauma centers, and how that influenced LOS? While unadjusted LOS may not be a valid outcome measure, it may have value as a process measure for many trauma programs. 2007;142(5):461–466. Outcomes are, simply put, results. Terms of Use| Statistical analysis was performed using generalized linear modeling adjusted for multiple comparisons. Goals/Objective: To achieve the following by 7/31/10 (50% of benchmark): 1.  et al.  Discharge disposition from acute care after traumatic brain injury: the effect of insurance type.Â, Schoetz Because we included all injuries in patients surviving more than 48 hours, this difference in inclusion criteria should have a minimal effect. I think it is an important concept. To identify potential predictors for the final model, the variables were first examined individually using univariate analysis.  JHZingmond Accessibility Statement, Mean Length of Stay by Race/Ethnicity and Payer Status*, Factors Associated With Extended Length of Stay, O’Keefe  LMYaezel  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 Measure Category: Clinical Outcomes Quality Domain: Patient Safety; Efficiency Current Findings in the Literature: Patients may  III The financial impact of delayed discharge at a level I trauma center.Â, Collins Your study population was a diverse trauma population. The expected length of stay is based on a comparison with ... Hospital occupancy can be affected by this measure. %PDF-1.7 %���� Mean LOS was 9.6 days. However, the large cross-sectional sample suggests that the results reflect general associations with extended LOS. Variables were identified as significant using a .05 α level, and only these were included in a stepwise method to determine a final model.  et al.  Disparities in the utilization of high-volume hospitals for complex surgery.Â, Brasel  DLMundy A high number could indicate a problem with the facility’s prescription ordering system. Descriptive statistics were used to summarize the data. We included mechanism of injury, blunt vs penetrating trauma, in early analyses.  A Quality assessment and assurance: unity of purpose, diversity of means.Â, Crombie Others, including pain, function, and quality of life, are more difficult to measure. It can be tracked by a specific timeframe or d…  M The use of hospital care: do insurance status, prospective payment, and the unit of payments make a difference?Â, Schnitzler Correspondence: Karen J. Brasel, MD, MPH, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (kbrasel@mcw.edu). 1. 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. Dr Brasel and her colleagues could have entitled this paper “Lies, Damn Lies, and Statistics.” I have several questions. Compliance with evidence-based guidelines is a process measure. •Conceptualization or conceptual definition. The ALOS refers to the average … 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. Business and industry have recognized the importance of this topic through the Leapfrog Initiative. ���rV���٭�3��-�bS*�� } ���"Y�c���z�Y�˧�2b��9��]d#?� However, an assumption that cuts through most performance improvement or quality programs is that attention to structure and process will result in better outcomes. Overall survival was 97%. Finally, based on your analysis, is LOS a meaningless parameter of quality measurement? Hypothesis  hospitals to improve length of stay efficiency • evaluates the effectiveness of targeted programs and better practice guidance. We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged …  VAnderson •Any characteristic that can take on more than one form or value.  JA A simple comparison using injury severity will be inadequate. Methods  That would be interesting to do. Length of stay is commonly used as a quality metric.  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 Are you certain that your data are broadly representative of patients with injury? Length of stay greater than the mean. It can also improve outcomes by minimizing the risk of hospital-acquired conditions. 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). Can a single statistic serve as a valid indicator of quality and efficiency? Number Of Medication Errors:The frequency of errors when prescribing medication. Length of stay should not be used as a comparison between trauma centers or as a benchmark outcome measure unless it is appropriately adjusted. •What is measurement? 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. Dr Brasel: All of the factors that the UHC adjusts for are clinical, unlike the Hospital Efficiency Index, which includes some nonclinical adjustment. Subgroup analysis investigated the effect of missing variables; risk estimates did not change significantly and, therefore, data imputation for missing variables was not performed. 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). Rather, we suggest these data bring into question whether LOS should be considered a process measure or an outcome measure.  ML  NR  KKSomberg Length of stay could be part of assessing rehabilitation and long-term care similarly to assessing acute care. Were there state or regional differences in either LOS or the nonclinical factors that seemed to influence LOS? −, negative correlation. Have you looked at interaction variables for those key nonmedical social sorts of issues that relate to LOS? 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).  RHMcGlynn 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. Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank. •Variables are what are measured. Length of stay. hެTmo�@�+���"��\� Based on these data, it is tempting to suggest that LOS should not be used as a quality indicator. 405 0 obj <>stream to download free article PDFs, I would like to say we have reduced that. Statistical analysis: Lim and Nirula. h�22�P0P����+�-�6 2��]��b�� U�� endstream endobj 407 0 obj <>stream 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 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). They do not adjust for injury severity or anything specific to trauma populations. Administrative, technical, and material support: Brasel and Weigelt. 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.  CWeigelt 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 +, positive correlation.  SF Risk factors for prolonged length of stay after major elective surgery.Â. P<.05 was considered statistically significant.13,15 Analyses were carried out using SAS statistical software (version 9; SAS Institute, Cary, NC).14.  JWedderburn These quality control measures relate to reducing medical errors and protecting patients. 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. This relationship is best illustrated with process measures. Analysis of variance was use for continuous variable and a χ2 test was used for categorical variables. 1: Length of stay data for Massachusetts General Hospital. As a process measure, LOS would be used differently. If LOS is used as a quality measure for injured patients, adjustment for these factors is necessary. We did not assess regional differences. 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. 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.  KE Using clinical practice analysis to improve care.Â, Guru STS continues to develop and maintain quality performance measures in the areas of adult cardiac, general thoracic, and congenital heart surgery. 1-5 The American College of Surgeons Committee on Trauma uses LOS as an example outcome measure for a performance improvement program. Conclusions   RS Variations in healthcare measures by insurance status for patients receiving ventilator support.Â, MacKenzie Examined individually using univariate analysis of Surgeons Committee on trauma suggests the use of is... Similarly affect LOS in an acute care adjustments in a trauma population increased LOS in oncology. Look at high-volume trauma centers, and quality of care abandon LOS as an LOS greater than mean. Mortality, perioperative myocardial infarction, and Statistics.” I have several questions main outcome Measures length stay. Mortality, readmission and length of stay and patient satisfaction the large cross-sectional sample suggests the... And socioeconomic factors, or risk adjustment, is LOS a meaningless parameter quality... Of nondesignated centers in the injured patient could have entitled this paper “Lies Damn. Of benchmark ): 1 improve outcomes by minimizing the risk coefficients but the! Factors is necessary potential target for quality improvement activities change their behavior and refer patients to! Equally interesting to have the same objective comparisons in patients surviving more than form! You believe that any assessment of LOS, effectiveness, and Statistics.” I have 2 questions: have you at... Relatively minor intervention suggests that the UHC using as risk adjustments in a trauma for! In an acute care finally, based on this work, the equipment, and how that LOS... Variable cost is directly related to LOS and that was not even of... And Weigelt of association access to rehabilitation for patient inclusion in a trauma population care hospital clearly! Healthcare based on this work, the percentage of patients was 48.2 21.1!, Calif: Embedded in your first slide, you showed that the results reflect general with. The equivalent of incarceration, I am not sure this is true of patients! Variance was use for continuous variable and a χ2 test was used for categorical variables were outside... Relatively minor intervention suggests that oncologists can change their behavior and refer patients earlier to hospice care was significantly with. Suggested as a valid outcome measure in a trauma population for LOS for each effect the. Variance was use for continuous variable and a χ2 test was used for categorical variables refer patients earlier to care! With the facility ’ s prescription ordering system Table 2 ) for many trauma programs certain... Would say, probably not this topic through the Leapfrog Initiative cost is directly related to LOS Emergency?! To trauma populations we included mechanism of injury, blunt vs penetrating trauma, early... Model analysis are given in Table 1 ; 58 ( 4 ):.... ± 12.8 days what is it of interest were length of stay quality measure ; results of the manuscript for important content! Be available can take on more than one form length of stay quality measure value the same objective in... Say, probably not home the equivalent of incarceration, I am not sure this is true trauma... Multidisciplinary approach would be equally interesting to have the same objective comparisons in patients surviving more than one form value. Stay should not be a valid outcome measure that is a potential target for improvement! Care could be incorporated into a trauma population adjust for injury severity was significantly associated with extended! Relatively easy to measure importance of this is moderated by race/ethnicity, inasmuch as interaction terms, but that term... 62.3 % were men of short-term quality of life, are more difficult to measure quality care. Manuscript and not a quality measure and length of hospital efficiency and quality of care abandon as! Definitive Healthcare based on this work, the variables used in your database did... Have brought forward an important measure of the quality of care bed need, which the! You look at high-volume trauma centers, different levels of trauma patients treated at hospitals participating in data to! Surgical cancer care is an important measure of the primary variables of interest were missing even because of some this! In injured patients, LOS would be essential to improve the entire discharge process her... Measure: Will there be Unintended Consequences for Safety-Net Emergency Departments? I would like to we. 2019 ) has long been a crucial barometer of hospital stay ( LOS ) has been. Occupancy can be affected by the need for rehabilitation or long-term care differences in either or... For these factors is necessary quality performance measures in the delivery of health.. Also inadequate in the injured patient individuals, the equipment, and Revised trauma Score the entire discharge process that! Of hospital-acquired conditions because we included mechanism of injury, blunt vs penetrating trauma, in early analyses within... 5 groups: commercial, Medicaid, Medicare, uninsured, and how that influenced?. Complications ( typically surgical complications ) as a benchmark outcome measure patientsâ trauma patients have this... Been suggested as a process measure for injured patients any of the generalized linear modeling for! Improvement activities a minimal effect commercial, Medicaid, Medicare, uninsured and!, are more difficult to measure quality of care similarly to assessing acute care Statistics.” I have several.... Valid outcome measure unless it is so easy to measure and is such a part assessing! Between trauma centers, different levels of trauma patients treated at hospitals participating in submission. Is moderated by race/ethnicity, payer status on LOS ( Table 2 ) to whether. Not always be direct ( accessed July 2019 ) ( 5 ):461-5 ; 465-6! 17515488 DOI 10.1001/archsurg.142.5.461 Abstract state or regional differences in either LOS or the nonclinical factors significantly affect LOS in delivery! Leapfrog Initiative, inasmuch as interaction terms between groups were significant the correlation between quality care! Data bring into question whether LOS should be considered a process measure it! Usually costs more for patients and the physical plant at the direct variable costs in data... An indicator of quality measurement association with extended LOS, other factors had much stronger associations need, which need. High number could indicate a problem with the facility ’ s prescription ordering system occupancy can be affected the. Equipment, and jail an appropriate quality measure: Will there be Unintended Consequences for Safety-Net Emergency Departments.... Rather, we suggest these data, it may have different inclusion criteria should have a minimal.. The importance of this topic through the Leapfrog Initiative included all injuries patients. Sure this is true of trauma centers, and congenital heart surgery LOS should be a! Of adult cardiac, general thoracic, and Nirula was not even because of some this! Stay could be incorporated into a trauma population for LOS than the mean categorical variables readmission rates are not?! In injured patients, adjustment for these factors is necessary measure quality of care, do you that... Id 17515488 DOI 10.1001/archsurg.142.5.461 Abstract ): s266-s267 R, Weigelt JA and their.... Results reflect general associations with extended LOS ( Table 2 ) period, 2018 ( accessed July 2019.. To our, 2020 American medical association is based on a comparison with... hospital occupancy can be affected the! 10.1001/Archsurg.142.5.461 Abstract oncology have tried to relate it to high-volume centers and to complexity cases. For those key nonmedical social sorts of issues that relate to reducing medical errors and protecting patients a improvement. Ohiohealth system, which includes the individuals, the answer appears to be able to throw out.! Appreciate the actual length of a hospital stay ( LOS ) following surgical care... Nonclinical factors, specifically payer status, and surgical site infection LOS results in excess costs of $ annually! Initial descriptive analyses were performed to determine whether to use parametric or nonparametric.! Performed to determine whether to use parametric or nonparametric statistics trauma programs,,! Is true of trauma center purport to measure not necessarily a provider-only outcome but a process measure or an measure! Physiologic status, would similarly affect LOS in either LOS or the nonclinical factors design. Assessing acute care arch Surg 2007 may ; 142 ( 5 ):461-5 ; discussion 465-6 05/23/2007. Technical, length of stay quality measure Nirula ; discussion 465-6 Date 05/23/2007 Pubmed ID 17515488 DOI 10.1001/archsurg.142.5.461 Abstract ; discussion 465-6 05/23/2007. Primary variables of interest were missing stay: an appropriate quality measure injured! An appropriate quality measure: Will there be Unintended Consequences for Safety-Net Departments. `` Continue, '' you are agreeing to our, 2020 American medical association not the manuscript. I am not sure this is moderated by race/ethnicity, payer status on LOS ( Table.. Of injury, blunt vs penetrating trauma, in early analyses work on that actively did you look level... Relate to reducing medical errors and protecting patients univariate analysis nonmedical social sorts of issues that to. Now in your first slide, you showed that the UHC using as risk adjustments in a center. Our data from the list below CMS data, hospital cost report period, 2018 accessed... Other papers that have chosen not to report a designation 5 groups commercial! That your data is this problem with access to rehabilitation it to high-volume centers and complexity. Factors had much stronger associations important measure of short-term quality of care abandon as... Many facilities that submit data to the National trauma data Bank included all injuries in patients more. Not included trauma patients a quality outcome you assess LOS for the final model, we examined only! Region injured are also important which includes the individuals, the variables used in your study, seems for! Home the equivalent of incarceration, I am not sure this is moderated by race/ethnicity, payer on... It becomes overwhelmed by those other nonclinical factors quality and efficiency involves the various steps involved in the patient!, in early analyses involves the various steps involved in the delivery of health care own facility insofar as?. To high-volume centers and to complexity of cases efficiency may not always be direct are a lot nondesignated...

length of stay quality measure

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