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Vinci A, Furia G, Cammalleri V, Colamesta V, Chierchini P, Corrado O, Mammarella A, Ingravalle F, Bardhi D, Malerba RM, Carnevale E, Gentili S, Damiani G, De Vito C, Maurici M. Burden of delayed discharge on acute hospital medical wards: A retrospective ecological study in Rome, Italy. PLoS One 2024; 19:e0294785. [PMID: 38265995 PMCID: PMC10807762 DOI: 10.1371/journal.pone.0294785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/09/2023] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION Delayed discharge represents the difficulty in proceeding with discharge of patients who do not have any further benefit from prolonged stay. A quota of this problem is related to organizational issues. In the Lazio region in Italy, a macro service re-organization in on the way, with a network of hospital and territorial centers engaged in structuring in- and out- of hospital patient pathways, with a special focus on intermediate care structures. Purpose of this study is to quantify the burden of delayed discharge on a single hospital structure, in order to estimate costs and occurrence of potential resource misplacement. MATERIAL AND METHODS Observational Retrospective study conducted at the Santo Spirito Hospital in Rome, Italy. Observation period ranged from 1/09/2022, when the local database was instituted, to 1/03/2023 (6 months). Data from admissions records was anonymously collected. Data linkage with administrative local hospital database was performed in order to identify the date a discharge request was fired for each admission. Surgical discharges and Intensive Care Unit (ICU) discharges were excluded from this study. A Poisson hierarchical regression model was employed to investigate for the role of ward, Severity of Disease (SoD) and Risk of Mortality (RoM) on elongation of discharge time. RESULTS 1222 medical ward admissions were recorded in the timeframe. 16% of them were considered as subject to potentially elongated stay, and a mean Delay in discharge of 6.3 days (SD 7.9) was observed. DISCUSSION AND CONCLUSIONS Delayed discharge may cause a "bottleneck" in admissions and result in overcrowded Emergency Department, overall poor performance, and increase in overall costs. A consisted proportion of available beds can get inappropriately occupied, and this inflates both direct and indirect costs. Clinical conditions on admission are not a good predictor of delay in discharge, and the root causes of this phenomenon likely lie in organizational issues (on structure\system level) and social issues (on patient's level).
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Affiliation(s)
- Antonio Vinci
- Hospital Health Management Area, Local Health Authority “ASL Roma 1”, Rome, Italy
- Doctoral School of Nursing Sciences and Public Health, University of Rome “Tor Vergata”, Rome, Italy
| | - Giuseppe Furia
- Hospital Health Management Area, Local Health Authority “ASL Roma 1”, Rome, Italy
- Department of Public Health and Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - Vittoria Cammalleri
- Department of Public Health and Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - Vittoria Colamesta
- Hospital Health Management Area, Local Health Authority “ASL Roma 1”, Rome, Italy
| | - Patrizia Chierchini
- Hospital Health Management Area, Local Health Authority “ASL Roma 1”, Rome, Italy
| | - Ornella Corrado
- Hospital Health Management Area, Local Health Authority “ASL Roma 1”, Rome, Italy
| | - Assunta Mammarella
- Hospital Health Management Area, Local Health Authority “ASL Roma 1”, Rome, Italy
| | - Fabio Ingravalle
- Doctoral School of Nursing Sciences and Public Health, University of Rome “Tor Vergata”, Rome, Italy
- Hospital Health Management Area, Local Health Authority “ASL Roma 6”, Albano Laziale, Italy
| | - Dorian Bardhi
- Post-Graduate School of Hygiene and Preventive Medicine, University of L’Aquila, L’Aquila, Italy
| | - Rosa Maria Malerba
- School of Specialization in Hygiene and Public Health, University of Rome “Tor Vergata”, Rome, Italy
| | - Edoardo Carnevale
- School of Specialization in Hygiene and Public Health, University of Rome “Tor Vergata”, Rome, Italy
| | - Susanna Gentili
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Gianfranco Damiani
- Department of Health Sciences and Public Health, Section of Hygiene, Catholic University of the Sacred Heart, Rome, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - Massimo Maurici
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy
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Benevides Santos Paiva M, de Gouvêa Viana L, Melo de Andrade MV. Reduction of hospital length of stay through the implementation of SAFER patient flow bundle and Red2Green days tool: a pre-post study. BMJ Open Qual 2024; 13:e002399. [PMID: 38191217 PMCID: PMC10806560 DOI: 10.1136/bmjoq-2023-002399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND In 2018, the National Health System released the 'Guide to reducing long hospital stays' to stimulate improvement and decrease length of stay (LOS) in England hospitals. The SAFER patient flow bundle and Red2Green tool were described as strategies to be implemented in inpatient wards to reduce discharge delays. OBJECTIVE To verify if implementing the SAFER patient flow bundle and Red2Green days tool is associated with LOS reduction in the internal medicine unit (IMU) wards of a university hospital in Brazil. METHODS In this pre post study, we compared the LOS of patients discharged from the IMU wards in 2019, during the implementation of the SAFER bundle and Red2Green tool, to the LOS of patients discharged in the same period in 2018. The Diagnosis-Related Group Brazil algorithm compared groups according to complexity and resource requirements. In-hospital mortality, readmission rates, the number of hospital acquired conditions and the number and causes of inappropriate hospital days were also evaluated. RESULTS Two hundred and eight internal medicine patients were discharged in 2018, and 252 were discharged in 2019. The median hospital LOS was significantly lower during the intervention period (14.2 days (IQR, 8-23) vs 19 days (IQR, 12-32); p<0.001). In-hospital mortality, 30-day mortality, readmission in 30 days and the number of hospital acquired conditions were the same between groups. Of the 3350 patient days analysed, 1482 (44.2%) were classified as green and 1868 (55.8%) as red. The lack of senior review was the most frequent cause of a red day (42.4%). CONCLUSION The SAFER patient flow bundle and Red2Green days tool implementation were associated with a significant decrease in hospital LOS in a university hospital IMU ward. There is a considerable improvement opportunity for hospital LOS reduction by changing the multidisciplinary team's attitude during patient hospitalisation using these strategies.
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Affiliation(s)
| | - Luciana de Gouvêa Viana
- Departamento de Propedeutica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marcus Vinícius Melo de Andrade
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Hospital Sirio-Libanes, Sao Paulo, Brazil
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Chantra S, Chotcomwongse P, Jittreprasert S, Senarak W, Amornpetchsathaporn A, Kemchoknatee P, Ruamviboonsuk P. Assessment of Direct Costs of Admission Due to Presumed Microbial Keratitis in a Tertiary Referral Hospital in Thailand: A 7-Year Retrospective Study. Clin Ophthalmol 2023; 17:2845-2860. [PMID: 37794953 PMCID: PMC10547063 DOI: 10.2147/opth.s425058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/22/2023] [Indexed: 10/06/2023] Open
Abstract
Objective To evaluate the direct healthcare cost of admission and examine the effects of cost drivers of treating presumed microbial keratitis (MK) at a tertiary referral hospital. Design Retrospective study. Methods A total of 741 patients who presented with MK were included. All information regarding costs was collected, and demographic data were employed for risk factor analysis. Results The total cost of treating MK over a 7-year period at Rajavithi Hospital was US$14,514,625.04, while the median cost was US$10,840.17 per patient (Q1-3, US$5866.56-24,172.28). The medical professional services were the highest cost category in terms of both total cost of treatment over 7 years and median cost per patient, accounting for US$6,474,718.43 and US$5235.20 (Q1-3, US$2582.79-10,474.24) respectively. In 2020, the total cost of treatment declined, corresponding with fewer hospitalized patients; however, the median cost per patient was the highest of all years, amounting to US$15,089.90 (Q1-3, US$8064.17-29102.50), while the median cost per patient from 2014 to 2019 was US$9969.96 (Q1-3, US$5177.98-21,942.68). Statistical significance was found in the median cost per patient in 2020 compared to the median cost per patient in 2014-2019 (p-value 0.019). Risk factors associated with the more expensive cost of treatment were longer length of stay (LOS); age more than 60 years old; readmission; diabetes mellitus (DM); hypertension; and heart disease. Conclusion There were several key factors impacting the direct healthcare costs of severe MK treatment. Medical professional services emerged as the most substantial cost category, while longer hospital stays, older age groups, readmission cases, and comorbidities such as diabetes mellitus, hypertension, and heart disease were all linked to elevated treatment expenses. There were no statistically significant differences in the direct medical expenses during hospitalization associated with treating severe MK, whether the culture results were positive or negative, or regardless of the type of cultured organism utilized.
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Affiliation(s)
- Somporn Chantra
- Department of Ophthalmology, Rajavithi Hospital, Bangkok, Thailand
- College of Medicine, Rangsit University, Bangkok, Thailand
| | | | | | - Wirapha Senarak
- Department of Ophthalmology, Rajavithi Hospital, Bangkok, Thailand
| | | | - Parinee Kemchoknatee
- Department of Ophthalmology, Rajavithi Hospital, Bangkok, Thailand
- College of Medicine, Rangsit University, Bangkok, Thailand
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, Rajavithi Hospital, Bangkok, Thailand
- College of Medicine, Rangsit University, Bangkok, Thailand
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Durante-Mangoni E, Riccardi A, Guarino M, Cesaro F, Lugarà M, Mascolo S, Morelli L, Natale V, Andreoni M. Emergency department care of ABSSSI with dalbavancin infusion, direct discharge, and outpatient telemedicine follow up: a study protocol. J Chemother 2023; 35:397-403. [PMID: 36264157 DOI: 10.1080/1120009x.2022.2134616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 08/05/2022] [Accepted: 10/06/2022] [Indexed: 10/24/2022]
Abstract
Novel therapeutic strategies such as the long-acting lipoglycopeptide antibiotics allow for the treatment and discharge of selected emergency department (ED) patients with Acute Bacterial Skin and Skin Structure Infections (ABSSSI), who require intravenous antibiotics and would otherwise be hospitalized. The COVID-19 pandemic highlighted the need to develop strategies that may reduce hospitalization. The telehealth approach has shown success in remote management of cellulitis patients and could aid in the remote follow up of overall ABSSSI patients. This article describes a study protocol for the telemedicine follow up of patients diagnosed with ABSSSI in the ED, requiring intravenous treatment, receiving a single dalbavancin dose, and directly discharged. A telehealth system for remote follow up is evaluated as well as the possible inclusion of point-of-care ultrasound for the appropriate diagnosis of ABSSSI. The study will be conducted in compliance with regulatory requirements; and all collected data will be kept strictly confidential and in accordance with all relevant legislation on the control and protection of personal information. Dissemination of the study protocol may help increasing knowledge and awareness on this topic, with the aim of optimizing patient management, reducing hospitalization and lower the impact on healthcare associated costs.
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Affiliation(s)
- Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli" and Unit of Infectious & Transplant Medicine, A.O.R.N. Ospedali dei Colli - Ospedale Monaldi, Napoli, Italy
| | | | - Mario Guarino
- Unit of Emergency Medicine, Ospedale CTO, A.O.R.N. Ospedali dei Colli, Napoli, Italy
| | - Flavio Cesaro
- Unit of Emergency Medicine, Ospedale CTO, A.O.R.N. Ospedali dei Colli, Napoli, Italy
| | - Marina Lugarà
- Unit of General Medicine, Ospedale del Mare, ASL Napoli 1 Centro, Napoli, Italy
| | - Silvia Mascolo
- Unit of Immunodeficiency and Gender Infectious Diseases, A.O.R.N. Ospedali dei Colli - Ospedale Cotugno, Napoli, Italy
| | - Lucia Morelli
- Unit of Emergency Medicine, Ospedale San Paolo, ASL Napoli 1 Centro, Napoli, Italy
| | - Vincenzo Natale
- Unit of Emergency Medicine, ASP Vibo Valenzia, and SIMEU Calabria, Vibo Valentia, Italy
| | - Massimo Andreoni
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Infectious Diseases Unit, University Hospital "Tor Vergata", Roma, Italy
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Correoso Castellanos S, Blay Domínguez E, Veracruz Gálvez EM, Muela Pérez B, Puertas García-Sandoval JP, Ricón Recarey FJ, Salinas Gilabert JE, Mira Viudes V, Lajara Marco F. [Translated article] Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T365-T370. [PMID: 37364723 DOI: 10.1016/j.recot.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/08/2023] [Indexed: 06/28/2023] Open
Abstract
INTRODUCTION Pre-operative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge. MATERIAL AND METHODS A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA≤II were included for analysis and divided according to their post-operative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year post-operative mortality rates; 30-day post-operative hospital readmission rate; and medical or surgical cause were recorded. RESULTS In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% versus 4.1%, p=.16) and 1-year post-operative (4.3% versus 16.3%, p=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% versus 16.3%, p=.037). CONCLUSIONS In the present study, the early discharge group obtained better results 30-day and 1-year post-operative mortality indicators, as well as readmission for medical reasons.
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Correoso Castellanos S, Blay Domínguez E, Veracruz Gálvez EM, Muela Pérez B, Puertas García-Sandoval JP, Ricón Recarey FJ, Salinas Gilabert JE, Mira Viudes V, Lajara Marco F. Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:365-370. [PMID: 36801250 DOI: 10.1016/j.recot.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Preoperative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge. MATERIAL AND METHODS A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA ≤II were included for analysis and divided according to their postoperative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year postoperative mortality rates; 30-day postoperative hospital readmission rate; and medical or surgical cause were recorded. RESULTS In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% vs 4.1%, P=.16) and 1-year postoperative (4.3% vs 16.3%, P=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% vs 16.3%, P=.037). CONCLUSIONS In the present study, the early discharge group obtained better results 30-day and 1-year postoperative mortality indicators, as well as readmission for medical reasons.
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Neugaard B, Politi R, McCay C. Level of Care Appropriateness in VA Inpatient Surgery Cases. Prof Case Manag 2023; 28:98-109. [PMID: 36999758 DOI: 10.1097/ncm.0000000000000609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
PURPOSE OF STUDY Within the Veterans Health Administration, utilization management (UM) focuses on reducing unnecessary or inappropriate hospitalizations by applying evidence-based criteria to evaluate whether the patient is placed in the right level of care. This study examined inpatient surgery cases to classify reasons for not meeting criteria and to identify the appropriate level of care for admissions and subsequent bed days of care. PRIMARY PRACTICE SETTINGS There were 129 VA Medical Centers in which inpatient UM reviews were performed during that time, of which 109 facilities had UM reviews conducted in Surgery Service. METHODOLOGY AND SAMPLE All admissions to surgery service during fiscal year 2019 (October 1, 2018 to September 30, 2019) that had a UM review entered in the national database were extracted, including current level of care, recommended level of care, and reasons for not meeting criteria. The following demographic and diagnostic fields were supplemented from a national data warehouse: age, gender, marital status, race, ethnicity, and service connection status. Data were analyzed with descriptive statistics. Characteristics of patient demographics were compared using the χ2 test for categorical variables and the Student's t test. RESULTS A total of 363,963 reviews met conditions to be included in the study: 87,755 surgical admission reviews and 276,208 continued stay reviews. There were 71,274 admission reviews (81.22%) and 198,521 (71.87%) continued stay reviews that met the InterQual criteria. The primary reason for not meeting admission criteria was clinical variance (27.70%), followed by inappropriate level of care (26.85%). The leading reason for not meeting continued stay criteria was inappropriate level of care (27.81%), followed by clinical instability (25.67%). Of the admission reviews not meeting admission criteria, 64.89% were in the wrong level of care and 64.05% of continued stay reviews were also in the wrong level of care. Half of the admission reviews not meeting criteria had a recommended level of care as home/outpatient (43.51%), whereas nearly one-third (28.81%) continued stay reviews showed a recommended level of care of custodial care or skilled nursing. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE This study identified system inefficiencies through admission and continued stay reviews of surgical inpatients. Patients admitted for ambulatory surgery or for preoperative testing prior to day of surgery resulted in avoidable bed days of care that may have contributed to patient flow issues and limited the available hospital beds for other patients. Through early collaboration with case management and care coordination professionals, alternatives can be explored that safely address the patient needs, such as temporary lodging options. There may be conditions or complications that can be anticipated on the basis of patient history. Proactive efforts to address these conditions may help avoid unnecessary bed days and extended lengths of stay.
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Affiliation(s)
- Britta Neugaard
- Britta Neugaard, PhD, MPH, is director of UM Data & Statistics in the VA Utilization Management Program Office. She has conducted extensive research on quality management and health outcomes. She received her master's degree in public health from the University of South Florida and doctorate in health service research from the University of Florida
- Ruth Politi, PhD, MSN, RN, CNE , currently works for the Veterans Health Administration in the National Center for Patient Safety. She also teaches graduate nursing students where she shares her 35 years of nursing experience, which includes 15 years in the areas of case management and utilization review
- Christy McCay, BSBME, is a health systems specialist with the Department of Veterans Affairs. She received a bachelor's degree in biomedical engineering with a minor in mathematics from Tulane University. She has extensive experience with relational database extraction techniques for the purposes of data synthesis with primary interest in health care data
| | - Ruth Politi
- Britta Neugaard, PhD, MPH, is director of UM Data & Statistics in the VA Utilization Management Program Office. She has conducted extensive research on quality management and health outcomes. She received her master's degree in public health from the University of South Florida and doctorate in health service research from the University of Florida
- Ruth Politi, PhD, MSN, RN, CNE , currently works for the Veterans Health Administration in the National Center for Patient Safety. She also teaches graduate nursing students where she shares her 35 years of nursing experience, which includes 15 years in the areas of case management and utilization review
- Christy McCay, BSBME, is a health systems specialist with the Department of Veterans Affairs. She received a bachelor's degree in biomedical engineering with a minor in mathematics from Tulane University. She has extensive experience with relational database extraction techniques for the purposes of data synthesis with primary interest in health care data
| | - Christy McCay
- Britta Neugaard, PhD, MPH, is director of UM Data & Statistics in the VA Utilization Management Program Office. She has conducted extensive research on quality management and health outcomes. She received her master's degree in public health from the University of South Florida and doctorate in health service research from the University of Florida
- Ruth Politi, PhD, MSN, RN, CNE , currently works for the Veterans Health Administration in the National Center for Patient Safety. She also teaches graduate nursing students where she shares her 35 years of nursing experience, which includes 15 years in the areas of case management and utilization review
- Christy McCay, BSBME, is a health systems specialist with the Department of Veterans Affairs. She received a bachelor's degree in biomedical engineering with a minor in mathematics from Tulane University. She has extensive experience with relational database extraction techniques for the purposes of data synthesis with primary interest in health care data
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Cesare M, D’agostino F, Maurici M, Zega M, Zeffiro V, Cocchieri A. Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data. SAGE Open Nurs 2023; 9:23779608231158157. [PMID: 36824318 PMCID: PMC9941607 DOI: 10.1177/23779608231158157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/06/2022] [Accepted: 01/30/2023] [Indexed: 02/22/2023] Open
Abstract
Introduction In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs. Objectives The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes. Methods A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs. Results The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred. Conclusion NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.
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Affiliation(s)
- Manuele Cesare
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Fabio D’agostino
- Unicamillus, Saint Camillus International University of Health Sciences, Rome, Italy
| | - Massimo Maurici
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Maurizio Zega
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Valentina Zeffiro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Antonello Cocchieri
- Section of Hygiene, Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Antonello Cocchieri, Section of Hygiene, Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito 1, 00168 Rome, Italy.
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Yusefi AR, Mehralian G, Khodamoradi A, Abbasi R, Vatankhah F, Heaidari F, Bastani P. Out-of-pocket payments for treatment of COVID-19 in Iran. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:12. [PMID: 35305664 PMCID: PMC8934129 DOI: 10.1186/s12962-022-00350-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/10/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Out-of-pocket (OOP) is among the payment methods in Iran's health system. The present study aimed to examine the OOP treatment costs for patients with COVID-19 in Iran. METHODS A descriptive-analytical, cross-sectional study was conducted in 2021. In this study, the cost records of 550 patients with COVID-19 hospitalized in a referral center of COVID-19 were selected using the stratified random sampling method. The required data were collected using a researcher-made questionnaire. Data were analyzed by t-test, ANOVA, and Pearson's correlation coefficient in SPSS software version 23 at p = 0.05. RESULTS The total direct costs were 1,037,992.15 US $. Moreover, the shares of patients (OOP), basic insurance, government subsidy, supplementary insurance, discounts, and out-of-government subsidy in the total direct costs were US $ 92,231.21, 746,932.99 US $, 155,127.08 US $, 39,690.25 US $ and 4010.61 US $, respectively. In addition, the results confirmed that there was a positive and significant relationship between the patients' OOP payments and the length of stay. It also found that the patients' OOP payments are subject to the type of insurance program and discharge method. CONCLUSION According to the results, 8.89% of the total direct costs were directly paid out of the patients' pockets. The research findings confirm the urgent need to make decisions and implement effective interventions for COVID-19 disease by controlling risk factors and exploiting other countries' successful experiences and international organizations' recommendations to decrease the prevalence of the infected and consequently reduce the financial pressure of the disease on patients by approving the expansion of the insurance organizations' role.
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Affiliation(s)
- Ali Reza Yusefi
- Department of Public Health, School of Health, Jiroft University of Medical Sciences, Jiroft, Iran
| | | | - Abdolvahed Khodamoradi
- Department of Health Policy and Economics, Social Security Research Institute, Tehran, Iran
| | - Roghaye Abbasi
- Student Research Committee, School of Health, Jiroft University of Medical Sciences, Jiroft, Iran
| | - Fatemeh Vatankhah
- Student Research Committee, School of Health, Jiroft University of Medical Sciences, Jiroft, Iran
| | - Fatemeh Heaidari
- Student Research Committee, School of Health, Jiroft University of Medical Sciences, Jiroft, Iran
| | - Peivand Bastani
- Faculty of Health and Behavioral Sciences, School of Dentistry, University of Queensland, Brisbane, QLD 4072 Australia
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Hou XL, Liu JY, Fan XH, Zhang N, Cao GL, Guo ZB, Zhang YY, Yu YH, Tian YQ, Sun XX, Tian FM. Secular trends of incidence and hospitalization cost of hip fracture in Tangshan, China. Osteoporos Int 2022; 33:89-96. [PMID: 34235549 DOI: 10.1007/s00198-021-06050-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 06/24/2021] [Indexed: 11/25/2022]
Abstract
We investigated the secular trends of the incidence and hospitalization cost of hip fracture in Tangshan, China. The incidence of hip fracture and the hospitalization cost were both increasing during the observation period. INTRODUCTION The present study aimed to determine sex-, age-, and fracture type-specific incidence and annual changes in hip fractures in Tangshan, China, between 2007 and 2018. METHODS We analyzed annual hip fracture incidence using urban hospital data during 2007-2018 and calculated incidence rate/100,000 person years in each age group and sex. We assessed annual changes in incidence among people aged >60 years using linear-by-linear association tests and evaluated hospitalization costs with the Kruskal-Wallis test. RESULTS During the study period, we observed an increasing proportion of hip fractures in people >60 years old from 14.2 to 22.79%. Crude hip fracture incidence increased markedly from 140.87 to 306.56/100,000 in women (p < 0.01) and from 124.83 to 167.19/100,000 in men (p < 0.01) in the age group >60 years. Type-specific analysis indicated significantly increased trends in incidence of cervical and trochanteric fractures among women and cervical fracture among men (p < 0.01). In people aged 36-60 years, the trend of hip fracture increased significantly in both sexes. The total and cervical-to-trochanteric ratio in men increased, with significant upward trends (p < 0.01). The proportion of cervical fracture was higher than that for trochanteric fracture in women, with stable levels from 2007 to 2018. Hospitalization costs for cervical and trochanteric fractures increased by 51.91% and 53.20%, respectively, during 2011-2018. CONCLUSION Tangshan will have an increasing burden on health care resources attributable to a considerable rise in hip fracture incidence and the older population. Further investigation of risk factors and subsequent implementation of effective measures to prevent hip fracture are needed.
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Affiliation(s)
- X-L Hou
- School of Public Health, North China University of Science and Technology, Bohai Road 21, Caofeidian Dis, Tangshan, 063210, People's Republic of China
| | - J-Y Liu
- The Second Hospital of Tangshan City, Tangshan, People's Republic of China
| | - X-H Fan
- Kailuan General Hospital, Tangshan, People's Republic of China
| | - N Zhang
- Kailuan General Hospital, Tangshan, People's Republic of China
| | - G-L Cao
- Gongren Hospital, Tangshan, People's Republic of China
| | - Z-B Guo
- Kailuan General Hospital, Tangshan, People's Republic of China
| | - Y-Y Zhang
- School of Public Health, North China University of Science and Technology, Bohai Road 21, Caofeidian Dis, Tangshan, 063210, People's Republic of China
| | - Y-H Yu
- School of Public Health, North China University of Science and Technology, Bohai Road 21, Caofeidian Dis, Tangshan, 063210, People's Republic of China
| | - Y-Q Tian
- School of Public Health, North China University of Science and Technology, Bohai Road 21, Caofeidian Dis, Tangshan, 063210, People's Republic of China
| | - X-X Sun
- Department of Orthopedic Surgery, Affiliated Hospital of North China University of Science and Technology, Jianshe South Road 73, Tangshan, 063000, People's Republic of China.
| | - F-M Tian
- School of Public Health, North China University of Science and Technology, Bohai Road 21, Caofeidian Dis, Tangshan, 063210, People's Republic of China.
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11
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Patel PD, Kelly KA, Chen H, Greeno A, Shannon CN, Naftel RP. Measuring the effects of institutional pediatric traumatic brain injury volume on outcomes for rural-dwelling children. J Neurosurg Pediatr 2021; 28:638-646. [PMID: 34598145 DOI: 10.3171/2021.7.peds21159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rural-dwelling children may suffer worse pediatric traumatic brain injury (TBI) outcomes due to distance from and accessibility to high-volume trauma centers. This study aimed to compare the impacts of institutional TBI volume and sociodemographics on outcomes between rural- and urban-dwelling children. METHODS This retrospective study identified patients 0-19 years of age with ICD-9 codes for TBI in the 2012-2015 National Inpatient Sample database. Patients were characterized as rural- or urban-dwelling using United States Census classification. Logistic and linear (in log scale) regressions were performed to measure the effects of institutional characteristics, patient sociodemographics, and mechanism/severity of injury on occurrence of medical complications, mortality, length of stay (LOS), and costs. Separate models were built for rural- and urban-dwelling patients. RESULTS A total of 19,736 patients were identified (median age 11 years, interquartile range [IQR] 2-16 years, 66% male, 55% Caucasian). Overall, rural-dwelling patients had higher All Patient Refined Diagnosis Related Groups injury severity (median 2 [IQR 1-3] vs 1 [IQR 1-2], p < 0.001) and more intracranial monitoring (6% vs 4%, p < 0.001). Univariate analysis showed that overall, rural-dwelling patients suffered increased medical complications (6% vs 4%, p < 0.001), mortality (6% vs 4%, p < 0.001), and LOS (median 2 days [IQR 1-4 days ] vs 2 days [IQR 1-3 days], p < 0.001), but multivariate analysis showed rural-dwelling status was not associated with these outcomes after adjusting for injury severity, mechanism, and hospital characteristics. Institutional TBI volume was not associated with medical complications, disposition, or mortality for either population but was associated with LOS for urban-dwelling patients (nonlinear beta, p = 0.008) and cost for both rural-dwelling (nonlinear beta, p < 0.001) and urban-dwelling (nonlinear beta, p < 0.001) patients. CONCLUSIONS Overall, rural-dwelling pediatric patients with TBI have worsened injury severity, mortality, and in-hospital complications, but these disparities disappear after adjusting for injury severity and mechanism. Institutional TBI volume does not impact clinical outcomes for rural- or urban-dwelling children after adjusting for these covariates. Addressing the root causes of the increased injury severity at hospital arrival may be a useful path to improve TBI outcomes for rural-dwelling children.
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Affiliation(s)
- Pious D Patel
- 1Vanderbilt University School of Medicine
- 2Surgical Outcomes Center for Kids, Vanderbilt Monroe Carell Jr. Children's Hospital; and
| | - Katherine A Kelly
- 1Vanderbilt University School of Medicine
- 2Surgical Outcomes Center for Kids, Vanderbilt Monroe Carell Jr. Children's Hospital; and
| | | | - Amber Greeno
- 2Surgical Outcomes Center for Kids, Vanderbilt Monroe Carell Jr. Children's Hospital; and
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Vanderbilt Monroe Carell Jr. Children's Hospital; and
- 4Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- 4Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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12
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Cadel L, Guilcher SJT, Kokorelias KM, Sutherland J, Glasby J, Kiran T, Kuluski K. Initiatives for improving delayed discharge from a hospital setting: a scoping review. BMJ Open 2021; 11:e044291. [PMID: 33574153 PMCID: PMC7880119 DOI: 10.1136/bmjopen-2020-044291] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The overarching objective of the scoping review was to examine peer reviewed and grey literature for best practices that have been developed, implemented and/or evaluated for delayed discharge involving a hospital setting. Two specific objectives were to review what the delayed discharge initiatives entailed and identify gaps in the literature in order to inform future work. DESIGN Scoping review. METHODS Electronic databases and websites of government and healthcare organisations were searched for eligible articles. Articles were required to include an initiative that focused on delayed discharge, involve a hospital setting and be published between 1 January 2004 and 16 August 2019. Data were extracted using Microsoft Excel. Following extraction, a policy framework by Doern and Phidd was adapted to organise the included initiatives into categories: (1) information sharing; (2) tools and guidelines; (3) practice changes; (4) infrastructure and finance and (5) other. RESULTS Sixty-six articles were included in this review. The majority of initiatives were categorised as practice change (n=36), followed by information sharing (n=19) and tools and guidelines (n=19). Numerous initiatives incorporated multiple categories. The majority of initiatives were implemented by multidisciplinary teams and resulted in improved outcomes such as reduced length of stay and discharge delays. However, the experiences of patients and families were rarely reported. Included initiatives also lacked important contextual information, which is essential for replicating best practices and scaling up. CONCLUSIONS This scoping review identified a number of initiatives that have been implemented to target delayed discharges. While the majority of initiatives resulted in positive outcomes, delayed discharges remain an international problem. There are significant gaps and limitations in evidence and thus, future work is warranted to develop solutions that have a sustainable impact.
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Affiliation(s)
- Lauren Cadel
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Sara J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Rehabiliation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Quality Division, Ontario Health, Toronto, Ontario, Canada
| | | | - Jason Sutherland
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jon Glasby
- School of Social Policy, University of Birmingham, Edgbaston, Birmingham, UK
| | - Tara Kiran
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Quality Division, Ontario Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kerry Kuluski
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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13
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Khalife J, Ammar W, Emmelin M, El-Jardali F, Ekman B. Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon. Wellcome Open Res 2020; 5:95. [PMID: 33437874 PMCID: PMC7780336 DOI: 10.12688/wellcomeopenres.15810.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 11/25/2022] Open
Abstract
Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.
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Affiliation(s)
- Jade Khalife
- Faculty of Medicine at Lund University, Lund, Sweden
- Ministry of Public Health, Beirut, Lebanon
| | - Walid Ammar
- Ministry of Public Health, Beirut, Lebanon
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Maria Emmelin
- Faculty of Medicine at Lund University, Lund, Sweden
| | - Fadi El-Jardali
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Bjorn Ekman
- Faculty of Medicine at Lund University, Lund, Sweden
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14
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Public spending on adult social care and delayed transfers of care in England. QUALITY IN AGEING AND OLDER ADULTS 2020. [DOI: 10.1108/qaoa-11-2019-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This paper aims to whether current public expenditure on adult social care services might be associated with the number of delayed days of care attributable to the social care system in England.
Design/methodology/approach
Panel econometric models on data from local authorities with adult social care responsibilities in England between 2013–2014 and 2018–2019.
Findings
After controlling for other organisational sources of inefficiency, the level of demand in the area and the income poverty amongst the resident older population, this paper finds that a 4.5% reduction in current spending per head on adult social care per older person in one year is associated with an increase by 0.01 delayed days per head the following year.
Social implications
Given the costs of adverse outcomes of delayed transfers of care reported in the literature, this paper suggests that budgetary constraints to adult social care services would represent a false economy of public funds.
Originality/value
This is the first paper that models the association between public spending on adult social care and delayed transfers of care due to issues originating in the social care system in England.
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15
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Elsamna ST, Hasan S, Shapiro ME, Merchant AM. Factors Contributing to Extended Hospital Length of Stay in Emergency General Surgery †. J INVEST SURG 2020; 34:1399-1406. [PMID: 32791866 DOI: 10.1080/08941939.2020.1805829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) is a field characterized by disproportionately high costs, post-operative mortality, and complications. We attempted to identify independent factors predictive of an increased postoperative length of stay (LOS), a key contributor to economic burden and worse outcomes. METHODS The ACS-NSQIP database was queried for data from2005 to 2017. Current procedural terminology (CPT) codes were used to identify the most commonly performed EGS procedures: appendectomy, bowel resection, colectomy, and cholecystectomy. Cohorts above and below 75th percentile LOS were determined, compared by preoperative variables, and evaluated with univariate and multivariate logistic regression to quantify risk. RESULTS Of 267,495 cases, 70,703 cases were above the 75th percentile for LOS. A larger proportion of patients in the extended LOS group were 41 years or older (88.6% vs 45.7%). More Blacks (10.3% vs 6.7%) were observed in the extended LOS group. Age, race, cardiopulmonary, hepatic, and renal disease, diabetes, recent weight loss, steroid use, and sepsis history were significant factors on multivariate analysis but varied in terms of risk proportion by procedure. Age (61+), Black race, hypertension, sepsis, and cancer were significant for all 4 procedures. CONCLUSIONS Several factors are independently associated with extended LOS for those undergoing the most common EGS procedures. Five of these were associated with an increased LOS for all four procedures. These included, age (61+), hypertension, sepsis, cancer, and Black race.
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Affiliation(s)
- Samer T Elsamna
- Department of General Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Saif Hasan
- Department of General Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Michael E Shapiro
- Department of General Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Aziz M Merchant
- Department of General Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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16
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Lim J. Big Data-Driven Determinants of Length of Stay for Patients with Hip Fracture. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17144949. [PMID: 32659953 PMCID: PMC7400185 DOI: 10.3390/ijerph17144949] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022]
Abstract
It is important that length of stay (LOS) management for alleviating health care financial burdens and improving patient outcomes. The aim of this study was to report the differences of LOS and the factors affecting LOS of hip fracture patients using big data. A total of 463,194 data were collected from 2016 to 2017 KNHDS. Of those, 2238 patients with the hip fracture primary diagnosis were included in the study population. As independent variables were used gender, age, type of insurance, admission route, result of treatment, number of hospital beds, the presence of surgery, and comorbidities. Statistical analysis performed using the IBM SPSS Statistics for Windows, version 25.0. A statistically significant difference was observed in the length of stay of hip fracture patients according to the healthcare insurance type. The difference in LOS associated with comorbidities was statistically significant for hypertension, peptic ulcer disease, coagulopathy, and alcohol abuse (p < 0.05). Independent variables that affected LOS of hip fracture patients with national health insurance were the treatment result, operation presence, comorbidity count, and hospital beds (p < 0.001). The factors associated with the length of stay for hip fracture patients were the difference according to the healthcare insurance type. The results of this study can be used as a basic data for the national health policy for the proper distribution and utilization of medical resources.
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Affiliation(s)
- Jihye Lim
- Department of Healthcare Management, Youngsan University, Yangsan 50510, Korea
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17
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Khalife J, Ammar W, Emmelin M, El-Jardali F, Ekman B. Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon. Wellcome Open Res 2020; 5:95. [PMID: 33437874 PMCID: PMC7780336 DOI: 10.12688/wellcomeopenres.15810.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 09/20/2023] Open
Abstract
Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.
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Affiliation(s)
- Jade Khalife
- Faculty of Medicine at Lund University, Lund, Sweden
- Ministry of Public Health, Beirut, Lebanon
| | - Walid Ammar
- Ministry of Public Health, Beirut, Lebanon
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Maria Emmelin
- Faculty of Medicine at Lund University, Lund, Sweden
| | - Fadi El-Jardali
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Bjorn Ekman
- Faculty of Medicine at Lund University, Lund, Sweden
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18
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Nouvenne A, Caminiti C, Diodati F, Iezzi E, Prati B, Lucertini S, Schianchi P, Pascale F, Starcich B, Manotti P, Brianti E, Fabi M, Ticinesi A, Meschi T. Implementation of a strategy involving a multidisciplinary mobile unit team to prevent hospital admission in nursing home residents: protocol of a quasi-experimental study (MMU-1 study). BMJ Open 2020; 10:e034742. [PMID: 32071189 PMCID: PMC7045229 DOI: 10.1136/bmjopen-2019-034742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Nursing home residents represent a particularly vulnerable population experiencing high risk of unplanned hospital admissions, but few interventions have proved effective in reducing this risk. The aim of this research will be to verify the effects of a hospital-based multidisciplinary mobile unit (MMU) team intervention delivering urgent care to nursing home residents directly at their bedside. METHODS AND ANALYSIS Four nursing homes based in the Parma province, in Northern Italy, will be involved in this prospective, pragmatic, multicentre, 18-month quasiexperimental study (sequential design with two cohorts). The residents of two nursing homes will receive the MMU team care intervention. In case of urgent care needs, the nursing home physician will contact the hospital physician responsible for the MMU team by phone. The case will be triaged as (a) manageable by phone advice, (b) requiring urgent assessment by the MMU team or (c) requiring immediate emergency department (ED) referral. MMU team is composed of one senior physician and one emergency-medicine resident chosen within the staff of Internal Medicine and Critical Subacute Care Unit of Parma University-Hospital, usually with different specialty background, and equipped with portable ultrasound, set of drugs and devices useful in urgency. The MMU visits patients in nursing homes, with the mission to stabilise clinical conditions and avoid hospital admission. Residents of the other two nursing homes will receive usual care, that is, ED referral in every case of urgency. Study endpoints include unplanned hospital admissions (primary), crude all-cause mortality, hospital mortality, length of stay and healthcare-related costs (secondary). ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of Area Vasta Emilia Nord (Emilia-Romagna region). Informed consent will be collected from patients or legal representatives. The results will be actively disseminated through peer-reviewed journals and conference presentations, in compliance with the Italian law. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04085679); Pre-results.
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Affiliation(s)
- Antonio Nouvenne
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Caterina Caminiti
- Research and Innovation Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Francesca Diodati
- Research and Innovation Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Elisa Iezzi
- Research and Innovation Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Beatrice Prati
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Stefano Lucertini
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Paolo Schianchi
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Federica Pascale
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Bruno Starcich
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Pietro Manotti
- Medical Direction, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Ettore Brianti
- Medical Direction, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Massimo Fabi
- General Management, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Andrea Ticinesi
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Tiziana Meschi
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
- Department of Medicine and Surgery, Università degli studi di Parma, Parma, Italy
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Landeiro F, Roberts K, Gray AM, Leal J. Delayed Hospital Discharges of Older Patients: A Systematic Review on Prevalence and Costs. THE GERONTOLOGIST 2019; 59:e86-e97. [PMID: 28535285 DOI: 10.1093/geront/gnx028] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Indexed: 11/12/2022] Open
Abstract
PURPOSE OF THE STUDY To determine the prevalence of delayed discharges of elderly inpatients and associated costs. DESIGN AND METHODS We searched Medline, Embase, Global Health, CAB Abstracts, Econlit, Web of Knowledge, EBSCO - CINAHL, The Cochrane Library, Health Management Information Consortium, and SCIE - Social Care Online for evidence published between 1990 and 2015 on number of days or proportion of delayed discharges for elderly inpatients in acute hospitals. Descriptive and regression analyses were conducted. Data on proportions of delayed discharges were pooled using a random effects logistic model and the association of relevant factors was assessed. Mean costs of delayed discharge were calculated in USD adjusted for Purchasing Power Parity (PPP). RESULTS Of 64 studies included, 52 (81.3%) reported delayed discharges as proportions of total hospital stay and 9 (14.1%) estimated the respective costs for these delays. Proportions of delayed discharges varied widely, from 1.6% to 91.3% with a weighted mean of 22.8%. This variation was also seen in studies from the same country, for example, in the United Kingdom, they ranged between 1.6% and 60.0%. No factor was found to be significantly associated with delays. The mean costs of delayed discharge also varied widely (between 142 and 31,935 USD PPP adjusted), reflecting the variability in mean days of delay per patient. IMPLICATIONS Delayed discharges occur in most countries and the associated costs are significant. However, the variability in prevalence of delayed discharges and available data on costs limit our knowledge of the full impact of delayed discharges. A standardization of methods is necessary to allow comparisons to be made, and additional studies are required-preferably by disease area-to determine the postdischarge needs of specific patient groups and the estimated costs of delays.
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Affiliation(s)
- Filipa Landeiro
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - Kenny Roberts
- Department of Physiology, Anatomy and Genetics, University of Oxford, UK
| | - Alastair Mcintosh Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - José Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
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20
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Smith CG, Davenport DL, Gorski J, McDowell A, Burgess BT, Fredericks TI, Baldwin LA, Miller RW, DeSimone CP, Dietrich CS, Gallion HH, Pavlik EJ, van Nagell JR, Ueland FR. Clinical Factors Associated with Longer Hospital Stay Following Ovarian Cancer Surgery. Healthcare (Basel) 2019; 7:E85. [PMID: 31277282 PMCID: PMC6787623 DOI: 10.3390/healthcare7030085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Ovarian cancer (OC) is the leading cause of death from gynecologic malignancy and is treated with a combination of cytoreductive surgery and platinum-based chemotherapy. Extended length of stay (LOS) after surgery can affect patient morbidity, overall costs, and hospital resource utilization. The primary objective of this study was to identify factors contributing to prolonged LOS for women undergoing surgery for ovarian cancer. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify women from 2012-2016 who underwent hysterectomy for ovarian, fallopian tube and peritoneal cancer. The primary outcome was LOS >50th percentile. Preoperative and intraoperative variables were examined to determine which were associated with prolonged LOS. Results: From 2012-2016, 1771 women underwent elective abdominal surgery for OC and were entered in the ACS-NSQIP database. The mean and median LOS was 4.6 and 4.0 days (IQR 0-38), respectively. On multivariate analysis, factors associated with prolonged LOS included: American Society of Anesthesiologists (ASA) Classification III (aOR 1.71, 95% CI 1.38-2.13) or IV (aOR 1.88, 95% CI 1.44-2.46), presence of ascites (aOR 1.88, 95% CI 1.44-2.46), older age (aOR 1.23, 95% CI 1.13-1.35), platelet count >400,000/mm3 (aOR 1.74, 95% CI 1.29-2.35), preoperative blood transfusion (aOR 11.00, 95% CI 1.28-94.77), disseminated cancer (aOR 1.28, 95% CI 1.03-1.60), increased length of operation (121-180 min, aOR 1.47, 95% CI 1.13-1.91; >180 min, aOR 2.78, 95% CI 2.13-3.64), and postoperative blood transfusion within 72 h of incision (aOR 2.04, 95% CI 1.59-2.62) (p < 0.05 for all). Conclusions: Longer length of hospital stay following surgery for OC is associated with many patient, disease, and treatment-related factors. The extent of surgery, as evidenced by perioperative blood transfusion and length of surgical procedure, is a factor that can potentially be modified to shorten LOS, improve patient outcomes, and reduce hospital costs.
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Affiliation(s)
- Christopher G Smith
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA.
| | - Daniel L Davenport
- Department of Surgery, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Justin Gorski
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Anthony McDowell
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Brian T Burgess
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Tricia I Fredericks
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Lauren A Baldwin
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Rachel W Miller
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Christopher P DeSimone
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Charles S Dietrich
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Holly H Gallion
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Edward J Pavlik
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - John R van Nagell
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Frederick R Ueland
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
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Singh S, Sparapani R, Wang MC. Variations in 30-day readmissions and length of stay among spine surgeons: a national study of elective spine surgery among US Medicare beneficiaries. J Neurosurg Spine 2018; 29:286-291. [DOI: 10.3171/2018.1.spine171064] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPay-for-performance programs are targeting hospital readmissions. These programs have an underlying assumption that readmissions are due to provider practice patterns that can be modified by a reduction in reimbursement. However, there are limited data to support the role of providers in influencing readmissions. To study this, the authors examined variations in readmission rates by spine surgeon within 30 days among Medicare beneficiaries undergoing elective lumbar spine surgery for degenerative conditions.METHODSThe authors applied validated ICD-9-CM algorithms to 2003–2007 Medicare data to select beneficiaries undergoing elective inpatient lumbar spine surgery for degenerative conditions. Mixed models, adjusting for patient demographics, comorbidities, and surgery type, were used to estimate risk of 30-day readmission by the surgeon. Length of stay (LOS) was also studied using these same models.RESULTSA total of 39,884 beneficiaries were operated on by 3987 spine surgeons. The mean readmission rate was 7.2%. The mean LOS was 3.1 days. After adjusting for patient characteristics and surgery type, 1 surgeon had readmission rates significantly below the mean, and only 5 surgeons had readmission rates significantly above the mean. In contrast, for LOS, the patients of 288 surgeons (7.2%) had LOS significantly lower than the mean, and the patients of 397 surgeons (10.0%) had LOS significantly above the mean. These findings were robust to adjustments for surgeon characteristics and clustering by hospital. Similarly, hospital characteristics were not significantly associated with readmission rates, but LOS was associated with hospital for-profit status and size.CONCLUSIONSThe authors found almost no variations in readmission rates by surgeon. These findings suggest that surgeon practice patterns do not affect the risk of readmission. Likewise, no significant variation in readmission rates by hospital characteristics were found. Strategies to reduce readmissions would be better targeted at factors other than providers.
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Affiliation(s)
| | | | - Marjorie C. Wang
- 3Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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22
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Hospital and Intensive Care Unit Length of Stay for Injury Admissions: A Pan-Canadian Cohort Study. Ann Surg 2017; 267:177-182. [PMID: 27735821 DOI: 10.1097/sla.0000000000002036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To assess the variation in hospital and intensive care unit (ICU) length of stay (LOS) for injury admissions across Canadian provinces and to evaluate the relative contribution of patient case mix and treatment-related factors (intensity of care, complications, and discharge delays) to explaining observed variations. BACKGROUND Identifying unjustified interprovider variations in resource use and the determinants of such variations is an important step towards optimizing health care. METHODS We conducted a multicenter, retrospective cohort study on admissions for major trauma (injury severity score >12) to level I and II trauma centers across Canada (2006-2012). We used data from the Canadian National Trauma Registry linked to hospital discharge data to compare risk-adjusted hospital and ICU LOS across provinces. RESULTS Risk-adjusted hospital LOS was shortest in Ontario (10.0 days) and longest in Newfoundland and Labrador (16.1 days; P < 0.001). Risk-adjusted ICU LOS was shortest in Québec (4.4 days) and longest in Alberta (6.1 days; P < 0.001). Patient case-mix explained 32% and 8% of interhospital variations in hospital and ICU LOS, respectively, whereas treatment-related factors explained 63% and 22%. CONCLUSIONS We observed significant variation in risk-adjusted hospital and ICU LOS across trauma systems in Canada. Provider ranks on hospital LOS were not related to those observed for ICU LOS. Treatment-related factors explained more interhospital variation in LOS than patient case-mix. Results suggest that interventions targeting reductions in low-value procedures, prevention of adverse events, and better discharge planning may be most effective for optimizing LOS for injury admissions.
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Tardif PA, Moore L, Boutin A, Dufresne P, Omar M, Bourgeois G, Bonaventure PL, Kuimi BLB, Turgeon AF. Hospital length of stay following admission for traumatic brain injury in a Canadian integrated trauma system: A retrospective multicenter cohort study. Injury 2017; 48:94-100. [PMID: 27839794 DOI: 10.1016/j.injury.2016.10.042] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/18/2016] [Accepted: 10/28/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is the leading cause of disability in children and young adults and costs CAD$3 billion annually in Canada. Stakeholders have expressed the urgent need to obtain information on resource use for TBI to improve the quality and efficiency of acute care in this patient population. We aimed to assess the components and determinants of hospital and ICU LOS for TBI admissions. METHODS We performed a retrospective multicenter cohort study on 11,199 adults admitted for TBI between 2007 and 2012 in an inclusive Canadian trauma system. Our primary outcome measure was index hospital LOS (admission to the hospital with the highest designation level). Index LOS was compared to total LOS (all consecutive admissions related to the injury). Expected LOS was calculated by matching TBI admissions to all-diagnosis hospital admissions by age, gender, and year of admission. LOS determinants were identified using multilevel linear regression. RESULTS Geometric mean total LOS was 1day longer than geometric mean index LOS (12.6 versus 11.7 days). Observed index and ICU LOS were respectively 4.2days and 2.5days longer than that expected according to all-diagnosis admissions. The six most important determinants of LOS were discharge destination, severity of concomitant injuries, extracranial complications, GCS, TBI severity, and mechanical ventilation, accounting for 80% of explained variation. CONCLUSIONS Results of this multicenter retrospective cohort study suggest that hospital and ICU LOS for TBI admissions are 56% and 119% longer than expected according to all-diagnosis admissions, respectively. In addition, hospital LOS is underestimated when only the index visit is considered and is largely influenced by discharge destination and extracranial complications, suggesting that improvements could be achieved with better discharge planning and interventions targeting prevention of in-hospital complications. This study highlights the importance of considering TBI patients as a distinct population when allocating resources or planning quality improvement interventions.
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Affiliation(s)
- Pier-Alexandre Tardif
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Québec (QC), Canada; Department of Social and Preventative Medicine, Université Laval, Québec (QC), Canada.
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Québec (QC), Canada; Department of Social and Preventative Medicine, Université Laval, Québec (QC), Canada.
| | - Amélie Boutin
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Québec (QC), Canada; Department of Social and Preventative Medicine, Université Laval, Québec (QC), Canada.
| | - Philippe Dufresne
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Québec (QC), Canada; Department of Social and Preventative Medicine, Université Laval, Québec (QC), Canada.
| | - Madiba Omar
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Québec (QC), Canada; Department of Social and Preventative Medicine, Université Laval, Québec (QC), Canada.
| | - Gilles Bourgeois
- Institut National d'Excellence en Santé et en Services Sociaux, Montréal, Québec, Canada.
| | - Paule Lessard Bonaventure
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Québec (QC), Canada; Department of Neurological Sciences, Division of Neurosurgery, Université Laval, Québec (QC), Canada.
| | - Brice Lionel Batomen Kuimi
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Québec (QC), Canada.
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Québec (QC), Canada; Department of Anesthesiology, Division of Critical Care Medicine, Université Laval, Québec (QC), Canada.
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Langton JM, Wong ST, Johnston S, Abelson J, Ammi M, Burge F, Campbell J, Haggerty J, Hogg W, Wodchis WP, McGrail K. Primary Care Performance Measurement and Reporting at a Regional Level: Could a Matrix Approach Provide Actionable Information for Policy Makers and Clinicians? Healthc Policy 2016; 12:33-51. [PMID: 28032823 PMCID: PMC5221710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Primary care services form the foundation of modern healthcare systems, yet the breadth and complexity of services and diversity of patient populations may present challenges for creating comprehensive primary care information systems. Our objective is to develop regional-level information on the performance of primary care in Canada. METHODS A scoping review was conducted to identify existing initiatives in primary care performance measurement and reporting across 11 countries. The results of this review were used by our international team of primary care researchers and clinicians to propose an approach for regional-level primary care reporting. RESULTS We found a gap between conceptual primary care performance measurement frameworks in the peer-reviewed literature and real-world primary care performance measurement and reporting activities. We did not find a conceptual framework or analytic approach that could readily form the foundation of a regional-level primary care information system. Therefore, we propose an approach to reporting comprehensive and actionable performance information according to widely accepted core domains of primary care as well as different patient population groups. CONCLUSIONS An approach that bridges the gap between conceptual frameworks and real-world performance measurement and reporting initiatives could address some of the potential pitfalls of existing ways of presenting performance information (i.e., by single diseases or by age). This approach could produce meaningful and actionable information on the quality of primary care services.
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Affiliation(s)
- Julia M. Langton
- Research Associate, Centre for Health Services and Policy Research, University of British, Columbia Vancouver, BC
| | - Sabrina T. Wong
- Professor, Centre for Health Services and Policy Research & School of Nursing, University of British Columbia, Vancouver, BC
| | - Sharon Johnston
- Associate Professor, Department of Family Medicine, University of Ottawa & Bruyere Research Institute, Ottawa, ON
| | - Julia Abelson
- Professor, Department of Clinical Epidemiology & Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON
| | - Mehdi Ammi
- Assistant Professor, School of Public Policy & Administration, Carleton University, Ottawa, ON
| | - Fred Burge
- Professor, Faculty of Medicine, Dalhousie University, Halifax, NS
| | - John Campbell
- Professor, Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | | | - William Hogg
- Professor, Department of Family Medicine, University of Ottawa & Bruyere Research Institute, Ottawa, ON
| | - Walter P. Wodchis
- Associate Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Kimberlyn McGrail
- Associate Professor, Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC
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Cox JC, Sadiraj V, Schnier KE, Sweeney JF. Higher Quality and Lower Cost from Improving Hospital Discharge Decision Making. JOURNAL OF ECONOMIC BEHAVIOR & ORGANIZATION 2016; 131:1-16. [PMID: 28239219 PMCID: PMC5319446 DOI: 10.1016/j.jebo.2015.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This paper reports research on improving decisions about hospital discharges - decisions that are now made by physicians based on mainly subjective evaluations of patients' discharge status. We report an experiment on uptake of our clinical decision support software (CDSS) which presents physicians with evidence-based discharge criteria that can be effectively utilized at the point of care where the discharge decision is made. One experimental treatment we report prompts physician attentiveness to the CDSS by replacing the default option of universal "opt in" to patient discharge with the alternative default option of "opt out" from the CDSS recommendations to discharge or not to discharge the patient on each day of hospital stay. We also report results from experimental treatments that implement the CDSS under varying conditions of time pressure on the subjects. The experiment was conducted using resident physicians and fourth-year medical students at a university medical school as subjects.
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Affiliation(s)
- James C. Cox
- Corresponding author: James C. Cox. Experimental Economics Center (ExCEN) and Department of Economics, Andrew Young School of Policy Studies, Georgia State University. Phone: 404-413-0200 FAX: 404-413-0195
| | - Vjollca Sadiraj
- Experimental Economics Center (ExCEN) and Department of Economics, Andrew Young School of Policy Studies, Georgia State University
| | - Kurt E. Schnier
- School of Social Sciences, Humanities and Arts, University of California, Merced
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Meschi T, Ticinesi A, Prati B, Montali A, Ventura A, Nouvenne A, Borghi L. A novel organizational model to face the challenge of multimorbid elderly patients in an internal medicine setting: a case study from Parma Hospital, Italy. Intern Emerg Med 2016; 11:667-76. [PMID: 26846233 DOI: 10.1007/s11739-016-1390-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 01/09/2016] [Indexed: 11/25/2022]
Abstract
Continuous increase of elderly patients with multimorbidity and Emergency Department (ED) overcrowding are great challenges for modern medicine. Traditional hospital organizations are often too rigid to solve them without consistently rising healthcare costs. In this paper we present a new organizational model achieved at Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, a 106-bed internal medicine area organized by intensity of care and specifically dedicated to such patients. The unit is partitioned into smaller wards, each with a specific intensity level of care, including a rapid-turnover ward (mean length of stay <4 days) admitting acutely ill patients from the ED, a subacute care ward for chronic critically ill subjects and a nurse-managed ward for stable patients who have socio-economic trouble preventing discharge. A very-rapid-turnover ("come'n'go") ward has also been instituted to manage sudden ED overflows. Continuity, effectiveness, safety and appropriateness of care are guaranteed by an innovative figure called "flow manager," with skilled clinical experience and managerial attitude, and by elaboration of an early personalized discharge plan anticipating every patient's needs according to lean methodology principles. In 2012-2014, this organizational model, compared with other peer units of the hospital and of other teaching hospitals of the region, showed a better performance, efficacy and effectiveness indexes calculated on Regional Hospital Discharge Records database system, allowing a capacity to face a massive (+22 %) rise in medical admissions from the ED. Further studies are needed to validate this model from a patient outcome point of view.
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Affiliation(s)
- Tiziana Meschi
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy.
| | - Andrea Ticinesi
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
| | - Beatrice Prati
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
| | | | - Antonio Ventura
- Business Management Control Unit, General Management Direction, Parma University Hospital, Parma, Italy
| | - Antonio Nouvenne
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
| | - Loris Borghi
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
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Moore L, Cisse B, Batomen Kuimi BL, Stelfox HT, Turgeon AF, Lauzier F, Clément J, Bourgeois G. Impact of socio-economic status on hospital length of stay following injury: a multicenter cohort study. BMC Health Serv Res 2015; 15:285. [PMID: 26204932 PMCID: PMC4513757 DOI: 10.1186/s12913-015-0949-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 07/14/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Injury is second only to cardiovascular disease in terms of acute care costs in North America. One key to improving injury care efficiency is to generate knowledge on the determinants of resource use. Socio-economic status (SES) is a documented risk factor for injury severity and mortality but its impact on length of stay (LOS) for injury admissions is unknown. This study aimed to examine the relationship between SES and LOS following injury. This multicenter retrospective cohort study was based on adults discharged alive from any trauma center (2007-2012; 57 hospitals; 65,486 patients) in a Canadian integrated provincial trauma system. SES was determined using ecological indices of material and social deprivation. Mean differences in LOS adjusted for age, gender, comorbidities, and injury severity were generated using multivariate linear regression. RESULTS Mean LOS was 13.5 days. Patients in the highest quintile of material/social deprivation had a mean LOS 0.5 days (95 % CI 0.1-0.9)/1.4 days (1.1-1.8) longer than those in the lowest quintile. Patients in the highest quintiles of both social and material deprivation had a mean LOS 2.6 days (1.8-3.5) longer than those in the lowest quintiles. CONCLUSIONS Results suggest that patients admitted for traumatic injury who suffer from high social and/or material deprivation have longer acute care LOS in a universal-access health care system. The reasons behind observed differences need to be further explored but may indicate that discharge planning should take patient SES into consideration.
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Affiliation(s)
- Lynne Moore
- Department of social and preventive medicine, Laval University, Quebec, QC, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
| | - Brahim Cisse
- Department of social and preventive medicine, Laval University, Quebec, QC, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
| | - Brice Lionel Batomen Kuimi
- Department of social and preventive medicine, Laval University, Quebec, QC, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
| | - Henry T Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, Institute for Public Health, University of Calgary, Calgary, AB, Canada.
| | - Alexis F Turgeon
- Department of social and preventive medicine, Laval University, Quebec, QC, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Laval University, Québec, QC, Canada.
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
- Department of Medicine, Laval University, Québec, QC, Canada.
| | - Julien Clément
- Department of Surgery, Laval University, Québec, QC, Canada.
| | - Gilles Bourgeois
- Institut National d'Excellence en Santé et en Services Sociaux, Montréal, Qc, Canada.
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Intensive Care Unit Rounding Checklist Implementation. Effect of Accountability Measures on Physician Compliance. Ann Am Thorac Soc 2015; 12:533-8. [DOI: 10.1513/annalsats.201410-494oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Buist MD, Jaffray L, Bell E, Hanna L, Weinstein P, Kumar S, Grimmer K. Utilisation of beds on the general medical unit by 'non-acute medical' patients: a retrospective study of incidence and cost in two Tasmanian regional medical hospital units. Intern Med J 2015; 44:171-7. [PMID: 24320789 DOI: 10.1111/imj.12335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 11/22/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Demand for healthcare services threatens to overwhelm the Australian healthcare system. Public hospitals have the largest component of expenditure growth and as such represent the largest opportunity for efficiency gains. Utilisation of inpatient hospital beds and in particular those on general medical units has not been studied in Australia. AIM To undertake a retrospective patient medical record review of 200 sequential admissions to the medical wards in two regional Tasmanian hospitals to determine the incidence of non-acute medical patient admission to the medical unit, and the subsequent days in hospital that were not required for medical reasons. The cost of these days was estimated. RESULTS Sixteen patient admissions (8%) could not be justified on medical grounds. Forty-eight (24%) patient admissions had at least one day hospital day that could not be justified on medical grounds. Of the 1438 total bed days, 475 (33%) were for non-medical reasons. The estimated cost of those non-medical bed days for this cohort was $764 800. CONCLUSIONS The incidence of non-acute medical admissions and non-acute medical bed days to the medical unit and associated cost was significant. Further research is needed to design alternative care provision for such patients particularly in regional Australia. The potential savings to the Australian healthcare system could be significant.
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Affiliation(s)
- M D Buist
- Centre for Health Services Research, University of Tasmania, Hobart, Tasmania, Australia
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Derivation and validation of a quality indicator of acute care length of stay to evaluate trauma care. Ann Surg 2015; 260:1121-7. [PMID: 24743606 DOI: 10.1097/sla.0000000000000648] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To derive and internally validate a quality indicator (QI) for acute care length of stay (LOS) after admission for injury. BACKGROUND Unnecessary hospital days represent an estimated 20% of total LOS implying an important waste of resources as well as increased patient exposure to hospital-acquired infections and functional decline. METHODS This study is based on a multicenter, retrospective cohort from a Canadian provincial trauma system (2005-2010; 57 trauma centers; n = 57,524). Data were abstracted from the provincial trauma registry and the hospital discharge database. Candidate risk factors were identified by expert consensus and selected for model derivation using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting. RESULTS The risk adjustment model explains 37% of the variation in LOS. The QI discriminates well across trauma centers (coefficient of variation = 0.02, 95% confidence interval: 0.011-0.028) and is correlated with the QI on processes of care (r = -0.32), complications (r = 0.66), unplanned readmissions (r = 0.38), and mortality (r = 0.35). Performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.80). CONCLUSIONS We have developed a QI on the basis of risk-adjusted LOS to evaluate trauma care that can be implemented with routinely collected data. The QI is based on a robust risk adjustment model with good internal and temporal validity, and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This QI can be used to target interventions to reduce LOS, which will lead to more efficient resource use and may improve patient outcomes after injury.
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Pannick S, Beveridge I, Wachter RM, Sevdalis N. Improving the quality and safety of care on the medical ward: A review and synthesis of the evidence base. Eur J Intern Med 2014; 25:874-87. [PMID: 25457434 DOI: 10.1016/j.ejim.2014.10.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/13/2014] [Accepted: 10/13/2014] [Indexed: 11/17/2022]
Abstract
Despite its place at the heart of inpatient medicine, the evidence base underpinning the effective delivery of medical ward care is highly fragmented. Clinicians familiar with the selection of evidence-supported treatments for specific diseases may be less aware of the evolving literature surrounding the organisation of care on the medical ward. This review is the first synthesis of that disparate literature. An iterative search identified relevant publications, using terms pertaining to medical ward environments, and objective and subjective patient outcomes. Articles (including reviews) were selected on the basis of their focus on medical wards, and their relevance to the quality and safety of ward-based care. Responses to medical ward failings are grouped into five common themes: staffing levels and team composition; interdisciplinary communication and collaboration; standardisation of care; early recognition and treatment of the deteriorating patient; and local safety climate. Interventions in these categories are likely to improve the quality and safety of care in medical wards, although the evidence supporting them is constrained by methodological limitations and inadequate investment in multicentre trials. Nonetheless, with infrequent opportunities to redefine their services, institutions are increasingly adopting multifaceted strategies that encompass groups of these themes. As the literature on the quality of inpatient care moves beyond its initial focus on the intensive care unit and operating theatre, physicians should be mindful of opportunities to incorporate evidence-based practice at a ward level.
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Affiliation(s)
- Samuel Pannick
- NIHR Patient Safety Translational Research Centre, Imperial College London, and West Middlesex University Hospital NHS Trust, UK.
| | | | - Robert M Wachter
- Division of Hospital Medicine, University of CA, San Francisco, USA.
| | - Nick Sevdalis
- NIHR Patient Safety Translational Research Centre, Imperial College London, UK.
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Campbell S, Campbell M, Shah C, Djuricich AM. Educational Conference Scheduling, Patient Discharge Time, and Resident Satisfaction. J Grad Med Educ 2014; 6:574-6. [PMID: 26279788 PMCID: PMC4535227 DOI: 10.4300/jgme-d-13-00400.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 03/31/2014] [Accepted: 04/07/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Limits on resident duty hours instituted in 2003 and 2011 have compressed medical resident daily workload. Despite this compression, residents must gain competence to practice medicine without supervision. OBJECTIVE We sought to determine whether moving the time our educational conference is scheduled affects the time when patient discharges are completed on an internal medicine teaching service. METHODS The study was conducted at a county hospital within a large internal medicine residency program. During the 4-month study period, the morning report conference for internal medicine residents was shifted from 8:30 am to 2 pm. Patient discharge times, defined as the time the discharge order set was signed, were obtained for the service via the electronic health record. The outcomes measured were patient discharge time variation and internal medicine resident preference for conference time. RESULTS Survey response rate was 82% (42 of 51). Of the residents who responded, 64% (27 of 42) preferred the 8:30 am report time, and 74% (31 of 42) felt the 8:30 am time was also better for education and timing of teaching rounds. There was no difference in discharge times for 2999 patients on the medicine teaching service, whether educational case conference morning report occurred at 8:30 am or at 2 pm. CONCLUSIONS Medical patient average discharge time was not influenced by time of educational conference. Factors other than the timing of educational conference appear to influence hospital discharge times on an inpatient internal medicine service.
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Derivation and validation of a quality indicator for 30-day unplanned hospital readmission to evaluate trauma care. J Trauma Acute Care Surg 2014; 76:1310-6. [DOI: 10.1097/ta.0000000000000202] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Epstein NE. A review article on the benefits of early mobilization following spinal surgery and other medical/surgical procedures. Surg Neurol Int 2014; 5:S66-73. [PMID: 24843814 PMCID: PMC4023009 DOI: 10.4103/2152-7806.130674] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 01/02/2014] [Indexed: 11/04/2022] Open
Abstract
Background: The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in other medical/surgical subspecialties. However, few spinal series have specifically focused on the “pros” of early mobilization for spinal surgery, other than in acute spinal cord injury. Here we reviewed how early mobilization and other adjunctive measures reduced morbidity and LOS in both medical and/or surgical series, and focused on how their treatment strategies could be applied to spinal patients. Methods: We reviewed studies citing protocols for early mobilization of hospitalized patients (day of surgery, first postoperative day/other) in various subspecialties, and correlated these with patients’ perioperative morbidity and LOS. As anticipated, multiple comorbid factors (e.g. hypertension, high cholesterol, diabetes, hypothyroidism, obesity/elevated body mass index hypothyroidism, osteoporosis, chronic obstructive pulmonary disease, coronary artery disease and other factors) contribute to the risks and complications of immobilization for any medical/surgical patient, including those undergoing spinal procedures. Some studies additionally offered useful suggestions specific for spinal patients, including prehabilitation (e.g. rehabilitation that starts prior to surgery), preoperative and postoperative high protein supplements/drinks, better preoperative pain control, and early tracheostomy, while others cited more generalized recommendations. Results: In many studies, early mobilization protocols reduced the rate of complications/morbidity (e.g. respiratory decompensation/pneumonias, deep venous thrombosis/pulmonary embolism, urinary tract infections, sepsis or infection), along with the average LOS. Conclusions: A review of multiple medical/surgical protocols promoting early mobilization of hospitalized patients including those undergoing spinal surgery reduced morbidity and LOS.
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Affiliation(s)
- Nancy E Epstein
- Chief of Neurosurgical Research and Education, Winthrop University Hospital, Mineola, NY 11501, USA
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Sociodemographic, clinical and organisational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res 2014; 14:128. [PMID: 24628917 PMCID: PMC3985597 DOI: 10.1186/1472-6963-14-128] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 03/12/2014] [Indexed: 11/10/2022] Open
Abstract
Background Evidence from studies conducted in Western countries indicates that a significant proportion of hospital beds are occupied by patients who experience a delayed hospital discharge (DHD). However, evidence about this topic is lacking in Italy, and little is known on the patients’ and organisational characteristics that influence DHDs. Therefore, we carried out a survey in all the hospitals of a Northern Italian region to analyse the prevalence and the determinants of DHD. Methods A cross-sectional study was carried out during an index period of 15 days in 256 operative units in Emilia-Romagna, a Northern Italian region with 4.4 million inhabitants, to identify patients medically fit for discharge but still hospitalised. The characteristics of these patients (n = 510) were compared with all the other patients (n = 5,815) hospitalised in the same operative units during the index period using multilevel logistic regression models. Results The one-day prevalence of DHD was 8.1%. More than half of DHD patients (52.7%) waited to access long-term/rehabilitation units or residential care homes, 16.7% experienced a delay for family-related reasons, and 14.5% were waiting to be admitted to other rehabilitation services. Among DHD patients hospitalised in long-term/rehabilitation units, 45.3% were waiting to be transferred to residential care homes. Patients’ characteristics associated with a higher likelihood of DHD in multilevel logistic regression were older age, provision of intensive care, a diagnosis of dementia, tumours or femoral/shoulder fractures, and a number of comorbidities. Patients hospitalised in long-term/rehabilitation units, as well as in orthopaedics/traumatology units, were significantly more likely to have a DHD compared with patients hospitalised in general surgery units. Moreover, compared with Local Health Authority Hospitals, being hospitalised in Hospital Trusts was associated with a higher likelihood of DHD. Conclusions Although the prevalence of DHD in the present study is markedly lower than that reported in the literature, we submit that the DHD problem should be addressed with major organisational innovations, with a special focus on the ageing of the population and epidemiological trends. Organisational changes imply new ways of managing emerging clusters of patients whose needs are not efficiently or effectively met by traditional organisation models and services.
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