the inter-relationship between length-of-stay, readmission and death: impact on hospital outcomes...
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The inter-relationship between length-of-stay, readmission and death: impact on hospital
outcomes
P.J. Marang-van de Mheen, H.F. Lingsma, A. Bottle, S. Middleton,
J. Kievit, E.W. Steyerberg
Disclosures
• No funding for this research
• No pay for talks, advice or conference attendence
Background
• Hospital mortality, readmission & Length-of-Stay (LOS)
commonly used outcomes to measure quality of care
• Problem: interrelation between outcomes affecting
interpretatation
• Deaths included in LOS models
• Deaths not included in readmission models
• Mortality models not adjusted for
readmission and LOS
Purpose of the study
1. Disentangle the relationship between mortality, readmission
and LOS, on patient and hospital level
2. Propose new measure to jointly report these 3 outcome
measures to facilitate insight and evaluation of quality of
care -> less ambiguous interpretation of hospital specific
outcomes
Patients and outcomes
Patients
• Global Comparators Project, 26 hospitals in 6 countries
• Patients discharged between 2007-2012
• All patients, stroke, heart failure and colorectal patients
Outcomes:
Mortality, readmission and prolonged LOS (>75 percentile)
Results: descriptives
All patients Stroke Heart Failure Colorectal
Number 4,327,105 83,163 85,024 35,537
Mortality rate 3.1% 13.6% 6.7% 5.0%
Readmission (survivors)
7.8% 7.3% 16.9% 10.6%
Long LOS 20.8% 20.7% 20.7% 22.6%
Range of standardized outcomes at hospital level:• Mortality: 55-146 • Readmission: 57-124• Long LOS: 51-170
Results: relationships at patient level
Mortality Readmission
All patients
Long LOS 1.45 (1.43-1.47) 1.37 (1.35-1.38)
Stroke patients
Long LOS 0.46 (0.43-0.49) 1.16 (1.08-1.25)
Heart Failure patients
Long LOS 1.38 (1.29-1.47) 1.17 (1.11-1.23)
Colorectal patients
Long LOS 1.31 (1.16-1.47) 1.34 (1.23-1.45)
Odds Ratios adjusted for case-mix & center
Results: correlations at hospital level
• Mortality – readmission:
r= -0.06 p=0.76
• Mortality – long LOS
survivors: r=0.79 p<0.01
• Readmission – long LOS
survivors: r= -0.20 p=0.33
• Long LOS (survivors) – long
LOS (deaths): r=0.77 p<0.01Similar results for upper decile LOS
Composite measure based on 3 outcomes, 5 levels
1. Survivors, no readmission, normal LOS (best)
2. Survivors, no readmission, long LOS
3. Survivors, readmission, normal LOS
4. Survivors, readmission, long LOS
5. Deaths (worst)
• Literature evidence suggests that patients consider
readmission as worse quality of care than long LOS
• Presented at expert meeting (N≈ 100) for agreement
• Analysed using ordinal regression – single standardized rate
to compare hospitals
Variation in composite measure
All patients: 44-172
Stroke: 33-168
Colorectal: 30-246
HF: 30-246
Upper decile LOS: similar, smaller variation
Results: correlation composite with individual outcomes
• Mortality: r=0.78 p<0.01
• Readmission: r= -0.07
p=0.72
• Long LOS: r=0.98 p<0.01
Similar results when constructed with upper decile LOS
Composite measure versus individual outcomes
• Composite measure has
similar or better efficiency to
estimate hospital effect
• Rankability: reliability of
ranking hospitals
• Rankability of composite
measure is similar or better
than individual measures
Conclusions and discussion
• Three outcomes: better total picture of quality of care
• Summary measure:
• Ordering based on content
• Good statistical properties to discriminate between hospitals
• Large influence of LOS? Similar results for upper decile LOS
• No weighting applied, but is possible
• Direction where to improve
Did we improve?
• More patients alive, without
readmission & normal LOS
=> on average better care
• Smaller variance between
hospitals => more uniform
better care
Similar for upper decile LOS