Can practice guidelines safely reduce hospital length of stay? Results from a multicenter interventional study

BACKGROUND

Although practice guidelines about appropriate lengths of stay have been widely promulgated, their effects on patient outcomes are not clear. Our objective was to study the effects of length of stay practice guidelines on patient outcomes.

PATIENTS AND METHODS

We performed a prospective, nonrandomized, interventional trial in six geographically distributed hospitals, among consecutively hospitalized "low-risk" patients with total hip replacement, hip fracture, or knee replacement. Case managers provided physicians with patient risk information based on guideline recommendations. We measured length of stay, compliance with recommended guideline length of stay, health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction.

RESULTS

A total of 560 patients were included in the study. For patients with knee replacement, there was a statistically significant increase in practice guideline compliance (27% baseline versus 53% intervention, P <0.0001) and reduction in length of stay (5.2 days versus 4.6 days, P <0.001) when compared with the baseline period. For hip replacement patients, there similarly was an increase in practice guideline compliance (66% baseline versus 82% intervention, P = 0.01) and reduction in length of stay (5.1 days versus 4.8 days, P = 0.03). Significant reductions in length of stay were not observed for patients recovering after hip fracture despite a significant increase in guideline compliance. There were few statistically significant changes in patient outcomes related to reductions in lengths of stay, including health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction. For patients undergoing hip replacement, very short lengths of stay (shorter than the guideline recommendation) were associated with an increased rate of discharging patients to nursing homes and rehabilitation facilities (21% versus 7%, P = 0.01), and hip fracture patients with very short lengths of stay required more visits to the doctor after discharge (56% versus 25%, P = 0.04).

CONCLUSION

Reductions in lengths of stay were most often associated with no significant change in patient outcomes. However, very short lengths of stay were associated with increased intensity of care following discharge for patients undergoing hip surgery, indicating possible cost shifting (the cost incurred by transferring patients to rehabilitation facilities may have been greater than had the patients remained in the acute care hospital for an additional 1 or 2 days and been sent directly home). These results emphasize the importance of monitoring the effects of cost containment and other systematic efforts to change patient care at the local level.

Evaluation of a pneumonia practice guideline in an interventional trial

There are few available data to define the medically necessary duration of stay for patients hospitalized with pneumonia. Therefore, we investigated the safety and effectiveness of a practice guideline that provided information about switching patients from parenteral to oral antimicrobials and early hospital discharge. The study was a prospective controlled study with an alternate month design. The practice guideline was studied in 146 "low-risk" pneumonia patients hospitalized during a 22-month period. Medical care consistent with the practice guideline occurred in 64% and 76% of patients during control and intervention periods, respectively (p=0.15). There were no differences in patient outcomes in the control and intervention groups when measured 1 mo after hospital discharge, including hospital readmission rates, health-related quality of life, and patient satisfaction. Explicit and implicit review revealed that 98.6% (95% confidence interval [CI]: 95.1%, 99.8%) of low-risk patients would not have benefited from continued hospitalization after the fourth hospital day. The 30-d survival rate of the low-risk pneumonia patients was 99.3% (95% CI: 96.2%, 100%) and patient outcomes appeared to be favorable compared with previously published values. We conclude that duration of hospital stay was frequently consistent with the practice guideline in both study groups, and patient outcomes remained unchanged. The guideline will require additional testing before it can be recommended for use.

Salivary microflora and caries experience in 5-year-old children from two ethnic groups

The purposes of the study were threefold: to compare salivary levels of mutans streptococci and Lactobacillus in 140 5-year-old children from two ethnic groups, to correlate caries experience of each group with bacterial counts, and to determine levels of infectivity which could indicate high caries activity in young children. Pakistani-Muslim and white Caucasian children were paired, matched for age, gender and caries experience. There were no significant differences in mutans streptococci or Lactobacillus levels between the two ethnic groups. However, strong correlations were found between caries experience and levels of both mutans streptococci and Lactobacillus in each ethnic group. Furthermore, mutans streptococci and Lactobacillus levels correlated strongly with one another. For detection of high caries activity, the optimum screening levels of bacteria were > 10(5) cfu/ml for mutans streptococci (sensitivity 78% and specificity 86%) and > 10(4) cfu/ml for Lactobacillus (sensitivity 82% and specificity 89%).

Screening and monitoring coeliac disease: multicentre trial of a new serum antibody test kit

A multicentre trial was conducted to evaluate a new test for anti-gliadin antibodies (AGA) in serum (Coeliac Screening Kit, CSK, Medical Innovations Limited, Artarmon, NSW, Australia). The test showed excellent reproducibility for both anti-gliadin IgA and IgG detection. The average intraassay coefficient of variation (CV) was 3.0% for IgA and 2.4% for IgG (n = 6), while the average interassay CV was 6.4% for IgA and 4.3% for IgG (n = 3). By defining a positive test as both IgA and IgG elevated, a sensitivity of 93% in untreated coeliacs (n = 75) was observed. The corresponding specificities in healthy adults (n = 130) and healthy children (n = 77) were > 99% and 100% respectively, while in patients with other gastrointestinal disorders (disease controls) the specificity was 94% (n = 129). The test was also useful in monitoring patients, with anti-gliadin IgA and IgG falling for up to a year after commencing a gluten-free diet (GFD) (12 adults). In some patients however, antibody levels did not reach the normal cutpoint after many months on a GFD, which may reflect the patients' poor adherence to their gluten free diet. The test was superior to the Pharmacia anti-gliadin ELISA, and should be useful as an aid to the diagnosis of coeliac disease, as well as in the follow-up of treated patients.

Factors affecting the availability of sugar-free medicines for children--a survey in the UK

Because use of sugar-containing paediatric medicines is an aetiological factor in dental caries, sugar-free alternatives are slowly becoming more readily available. However, it is claimed that, for a variety of reasons, their production is difficult. This investigation was undertaken to determine whether problems exist in the formulation, production and availability of sugar-free medicines. A structured questionnaire was used with personnel involved in the production, marketing and wholesaling of paediatric medicines in the UK. Information was obtained from interviews with, or from questionnaires completed by, personnel of five pharmaceutical and five wholesale companies. The findings indicated that the only obstacle to producing sugar-free medicines is slightly higher cost, and that manufacturers are influenced to change mainly by consumer pressure. It was concluded that the dental profession should advise the public to demand sugar-free medicines and doctors to prescribe them.

An investigation into sugar-containing and sugar-free over-the-counter medicines stocked and recommended by pharmacists in the north western region of England

Sugar-containing paediatric medicines can contribute to the aetiology of dental caries, and as many are sold over-the-counter (OTC) as are prescribed. This study evaluated a dental health education initiative among pharmacists in the north-west of England in an effort to increase the sales of sugar-free preparations. It also investigated the stocks they held, their recommendations to their customers and their knowledge of, and attitudes to, sugar in medicine as a cause of dental caries. Following a baseline questionnaire, a randomly selected group of pharmacists were sent a dental health education leaflet informing them of the role of sugar-containing medicines in the aetiology of dental caries and a list of sugar-free alternatives which they were asked to stock and recommend. Twelve months later, a second questionnaire was completed by both the test and control groups of pharmacists. The most commonly stocked and recommended OTC paediatric medicines contained sugar. Of the 14 preparations stocked by over 90% of the pharmacists only two were sugar-free. During the year of the study the mean number of sugar-free medicines stocked by the pharmacists in the test group reduced from 7.70 to 7.12 (P < 0.05) and in the control group from 8.39 to 7.45 (P < 0.05). Seventy-seven per cent of the pharmacists thought that sugar in medicines could contribute to caries, but recommended sugar-containing preparations more frequently than sugar-free alternatives. The dental profession needs to actively promote medicines that are sugar-free if there is to be a change from the use of iatrogenic sugar-containing preparations.