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1.  Variation in length of stay as a measure of efficiency in Manitoba hospitals. 
OBJECTIVE: To examine the efficiency of Manitoba hospitals by analysing variations in length of stay for patients with similar characteristics. DESIGN: Retrospective study. Multiple regression analyses were used to adjust for patient (case-mix) characteristics and to identify differences in length of stay attributable to the hospital of admission for 14 specific, frequently encountered diagnostic categories and for all acute admissions. SETTING: The eight major acute care hospitals in Manitoba. PARTICIPANTS: Manitoba residents admitted to any one of the eight hospitals during the fiscal year 1989-90, 1990-91 or 1991-92. Patients transferred to or from another institution, those with atypically long stays and those who died in hospital were excluded. OUTCOME MEASURE: Length of hospital stay. RESULTS: The length of stay was strongly influenced by hospital of admission, even after adjustment for key patient characteristics. Excluding the most seriously ill patients and those with the longest stays, approximately 186 beds could potentially have been saved if each hospital had discharged its patients as efficiently as the hospital with the shortest overall length of stay. CONCLUSIONS: A substantial proportion of days currently invested in treating acute care patients could be eliminated. At least some bed closures in Manitoba hospitals could be accommodated simply through more efficient treatment of patients in the remaining beds, without decreasing access to hospital care.
PMCID: PMC1337615  PMID: 7882230
2.  Costs of day hospital and community residential chemical dependency treatment 
Background
Evidence suggests that expensive hospital-based inpatient chemical dependency programs do not deliver outcomes that are superior to less costly day hospital programs, but patient placement criteria developed by the Addiction Society of Medicine (ASAM) nonetheless have identified a need for low-intensity residential treatment for patients with higher levels of severity. Community-based residential programs may represent a low-cost inpatient alternative that satisfies the ASAM criteria, but research is lacking in this area. A recent clinical trial has found similar outcomes at social model residential treatment and clinically-oriented day hospital programs, but did not report on the costs associated with treatment in that study.
Aims
This paper addresses whether the similar outcomes in the recent trial were delivered with comparable costs. It also studies costs separately for men and women, and for Whites and non-Whites, subgroups not included or identified in prior cost effectiveness work.
Method
This paper reports on clients who participated in a randomized trial conducted in three metropolitan areas served by a large pre-paid health plan. Clients were eligible if they met the first five dimensions of the ASAM criteria for low-intensity residential treatment and had not been mandated to residential treatment due to dangerous home environment (the sixth ASAM dimension). The five day hospital programs included here are typical of mainstream private chemical dependency programs that were developed as an alternative to inpatient treatment. The seven residential programs are typical of those historically developed by members of alcohol mutual-help programs. Cost data for the study sites were collected using the Drug Abuse Treatment Cost Analysis Program (DATCAP) which produces estimates of average costs per week per client treated at a particular treatment program. Lengths of stay were derived from program records. Costs per episode for each study subject were calculated by multiplying the DATCAP-based program-specific costs (per week) by the number of weeks the subject stayed in the program to which they had been randomly assigned. Differences in length of stay, and in per-episode costs, were compared between residential and day hospital subjects using the Brown-Forsythe robust test of the equality of means.
Results
Lengths of stay at residential treatment were significantly longer than at day hospital, in the sample overall and in the disaggregated analyses for both genders and for both Whites and non-Whites. This difference was especially marked among non-Whites, who had quite short stays in day hospital. The average cost per week was $575 per week at day hospital, versus $370 per week at the residential programs. However, because of the longer stays in residential programs, this lower cost per week did not always translate to lower per-episode costs. Instead, the per-episode costs were significantly higher for those treated in residential programs than in day hospital in the sample overall, and among non-Whites. Costs were comparable for Whites and for women treated in either setting, but were marginally higher for men randomized to residential programs.
Discussion
These cost results must be considered in light of the null findings comparing outcomes between subjects randomized to residential versus day hospital programs in this study, in the overall sample and by gender and race/ethnicity: That is, the longer stays in the sample overall and for non-White clients at residential programs came at higher costs but did not lead to better rates of abstinence. An important component of the cost differential arose from especially short stays in day hospital among non-Whites, calling into question the attractiveness of day hospital for minority clients.
Conclusion
Outcomes and costs at residential versus day hospital programs were similar for women and for Whites in a randomized trial of pre-paid health plan members who met ASAM criteria for low-intensity residential treatment but were not at environmental risk. For non-Whites, and marginally for men, a preference for residential care would appear to come at a higher cost.
Implications for health care provision and use
Lengths of stay in residential treatment are significantly longer than in day hospital, but costs per week are lower. Women and Whites appear to be equally well-served in residential and day hospital programs, with no significant cost differential. Provision of residential treatment for non-Whites may be more costly than day hospital, because their residential stays are likely to be 3 times longer than they would be if treated in day hospital. For men, residential care will be marginally more costly.
Implications for health policy formulation
Residential treatment appears to represent a cost-effective alternative to day hospital for female and White clients with severe alcohol and drug problems who are not at environmental risk, although it will be important that the current study be replicated with different samples and study programs.
Implications for further research
The much shorter stays in day hospital than at residential among non-Whites highlight the need for research to better understand how to best meet the needs and preferences of non-White clients when considering both costs and outcomes.
PMCID: PMC2744443  PMID: 18424874
3.  Patient Referral Patterns and the Spread of Hospital-Acquired Infections through National Health Care Networks 
PLoS Computational Biology  2010;6(3):e1000715.
Rates of hospital-acquired infections, such as methicillin-resistant Staphylococcus aureus (MRSA), are increasingly used as quality indicators for hospital hygiene. Alternatively, these rates may vary between hospitals, because hospitals differ in admission and referral of potentially colonized patients. We assessed if different referral patterns between hospitals in health care networks can influence rates of hospital-acquired infections like MRSA. We used the Dutch medical registration of 2004 to measure the connectedness between hospitals. This allowed us to reconstruct the network of hospitals in the Netherlands. We used mathematical models to assess the effect of different patient referral patterns on the potential spread of hospital-acquired infections between hospitals, and between categories of hospitals (University medical centers, top clinical hospitals and general hospitals). University hospitals have a higher number of shared patients than teaching or general hospitals, and are therefore more likely to be among the first to receive colonized patients. Moreover, as the network is directional towards university hospitals, they have a higher prevalence, even when infection control measures are equally effective in all hospitals. Patient referral patterns have a profound effect on the spread of health care-associated infections like hospital-acquired MRSA. The MRSA prevalence therefore differs between hospitals with the position of each hospital within the health care network. Any comparison of MRSA rates between hospitals, as a benchmark for hospital hygiene, should therefore take the position of a hospital within the network into account.
Author Summary
The prevalence of hospital acquired infections is widely believed to reflect the quality of health care in individual hospitals, and is therefore often used as a benchmark. Intuitively, the idea is that infections spread more easily in hospitals with a poor quality of health care. This assumes that the rate at which admitted patients introduce new infections is the same for all hospitals. In this article, we show that this assumption is unlikely to be correct. Using national data on patient admissions, we are able to reconstruct the entire hospital network consisting of patients referred between hospitals. This network reveals that university hospitals admit more patients that recently stayed in other hospitals. Consequently, they are more likely to admit patients that still carry pathogens acquired during their previous hospital stay. Therefore, the prevalence of infections does not only reflect the quality of health care but also the connectedness to hospitals from which patients are referred. This phenomenon is missed at the single hospital level; our study is the first to address the connectedness between hospitals in explaining the prevalence of hospital acquired infections. Our findings imply that interventions should focus on hospitals that are central in the network of patient referrals.
doi:10.1371/journal.pcbi.1000715
PMCID: PMC2841613  PMID: 20333236
4.  The use of a standardized PCT-algorithm reduces costs in intensive care in septic patients - a DRG-based simulation model 
Introduction
The management of bloodstream infections especially sepsis is a difficult task. An optimal antibiotic therapy (ABX) is paramount for success. Procalcitonin (PCT) is a well investigated biomarker that allows close monitoring of the infection and management of ABX. It has proven to be a cost-efficient diagnostic tool. In Diagnoses Related Groups (DRG) based reimbursement systems, hospitals get only a fixed amount of money for certain treatments. Thus it's very important to obtain an optimal balance of clinical treatment and resource consumption namely the length of stay in hospital and especially in the Intensive Care Unit (ICU). We investigated which economic effects an optimized PCT-based algorithm for antibiotic management could have.
Materials and methods
We collected inpatient episode data from 16 hospitals. These data contain administrative and clinical information such as length of stay, days in the ICU or diagnoses and procedures. From various RCTs and reviews there are different algorithms for the use of PCT to manage ABX published. Moreover RCTs and meta-analyses have proven possible savings in days of ABX (ABD) and length of stay in ICU (ICUD). As the meta-analyses use studies on different patient populations (pneumonia, sepsis, other bacterial infections), we undertook a short meta-analyses of 6 relevant studies investigating in sepsis or ventilator associated pneumonia (VAP). From this analyses we obtained savings in ABD and ICUD by calculating the weighted mean differences. Then we designed a new PCT-based algorithm using results from two very recent reviews. The algorithm contains evidence from several studies. From the patient data we calculated cost estimates using German National standard costing information for the German G-DRG system.
We developed a simulation model where the possible savings and the extra costs for (in average) 8 PCT tests due to our algorithm were brought into equation.
Results
We calculated ABD savings of -4 days and ICUD reductions of -1.8 days. our algorithm contains recommendations for ABX onset (PCT ≥ 0.5 ng/ml), validation whether ABX is appropriate or not (Delta from day 2 to day 3 ≥ 30% indicates inappropriate ABX) and recommendations for discontinuing ABX (PCT ≤ 0.25 ng/ml).
We received 278, 264 episode datasets where we identified by computer-based selection 3, 263 cases with sepsis. After excluding cases with length of stay (LOS) too short to achieve the intended savings, we ended with 1, 312 cases with ICUD and 268 cases without ICUD. Average length of stay of ICU-patients was 27.7 ± 25.7 days and for Non-ICU patients 17.5 ± 14.6 days respectively. ICU patients had an average of 8.8 ± 8.7 ICUD.
After applying the simulation model on this population we calculated possible savings of € -1, 163, 000 for ICU-patients and € -36, 512 for Non-ICU patients.
Discussion
Our findings concerning the savings from the reduction of ABD are consistent with other publications. Savings ICUD had never been economically evaluated so far. our algorithm is able to possibly set a new standard in PCT-based ABX. However the findings are based on data modelling. The algorithm will be implemented in 5-10 hospitals in 2012 and effects in clinical reality measured 6 months after implementation.
Conclusion
Managing sepsis with daily monitoring of PCT using our refined algorithm is suitable to save substantial costs in hospitals. Implementation in clinical routine settings will show how much of the calculated effect will be achieved in reality.
doi:10.1186/2047-783X-16-12-543
PMCID: PMC3351898  PMID: 22112361
5.  Nutritional parameters associated with prolonged hospital stay among ambulatory adult patients 
Background
Comprehensive evaluations of the nutritional parameters associated with length of hospital stay are lacking. We investigated the association between malnutrition and length of hospital stay in a cohort of ambulatory adult patients.
Methods
From September 2006 to June 2009, we systematically evaluated 1274 ambulatory adult patients admitted to hospital for medical or surgical treatment. We evaluated the associations between malnutrition and prolonged hospital stay (> 17 days [> 75th percentile of distribution]) using multivariable log-linear models adjusted for several potential nutritional and clinical confounders recorded at admission and collected during and at the end of the hospital stay.
Results
Nutritional factors associated with a prolonged hospital stay were a Nutritional Risk Index score of less than 97.5 (relative risk [RR] 1.64, 95% confidence interval [CI] 1.31–2.06) and an in-hospital weight loss of 5% or greater (RR 1.60, 95% CI 1.30–1.97). Sensitivity analysis of data for patients discharged alive and who had a length of stay of at least three days (n = 1073) produced similar findings (adjusted RR 1.51, 95% CI 1.20–1.89, for Nutritional Risk Index score < 97.5). A significant association was also found with in-hospital starvation of three or more days (RR 1.14, 95% CI 1.01–1.28).
Interpretation
Nutritional risk at admission was strongly associated with a prolonged hospital stay among ambulatory adult patients. Another factor associated with length of stay was worsening nutritional status during the hospital stay, whose cause–effect relationship with length of stay should be clarified in intervention trials. Clinicians need to be aware of the impact of malnutrition and of the potential role of worsening nutritional status in prolonging hospital stay.
doi:10.1503/cmaj.091977
PMCID: PMC2988532  PMID: 20940233
6.  Event Rates, Hospital Utilization, and Costs Associated with Major Complications of Diabetes: A Multicountry Comparative Analysis 
PLoS Medicine  2010;7(2):e1000236.
Philip Clarke and colleagues examined patient-level data for over 11,000 participants with type 2 diabetes from 20 countries and find that major complications of diabetes significantly increased hospital use and costs across settings.
Background
Diabetes imposes a substantial burden globally in terms of premature mortality, morbidity, and health care costs. Estimates of economic outcomes associated with diabetes are essential inputs to policy analyses aimed at prevention and treatment of diabetes. Our objective was to estimate and compare event rates, hospital utilization, and costs associated with major diabetes-related complications in high-, middle-, and low-income countries.
Methods and Findings
Incidence and history of diabetes-related complications, hospital admissions, and length of stay were recorded in 11,140 patients with type 2 diabetes participating in the Action in Diabetes and Vascular Disease (ADVANCE) study (mean age at entry 66 y). The probability of hospital utilization and number of days in hospital for major events associated with coronary disease, cerebrovascular disease, congestive heart failure, peripheral vascular disease, and nephropathy were estimated for three regions (Asia, Eastern Europe, and Established Market Economies) using multiple regression analysis. The resulting estimates of days spent in hospital were multiplied by regional estimates of the costs per hospital bed-day from the World Health Organization to compute annual acute and long-term costs associated with the different types of complications. To assist, comparability, costs are reported in international dollars (Int$), which represent a hypothetical currency that allows for the same quantities of goods or services to be purchased regardless of country, standardized on purchasing power in the United States. A cost calculator accompanying this paper enables the estimation of costs for individual countries and translation of these costs into local currency units. The probability of attending a hospital following an event was highest for heart failure (93%–96% across regions) and lowest for nephropathy (15%–26%). The average numbers of days in hospital given at least one admission were greatest for stroke (17–32 d across region) and heart failure (16–31 d) and lowest for nephropathy (12–23 d). Considering regional differences, probabilities of hospitalization were lowest in Asia and highest in Established Market Economies; on the other hand, lengths of stay were highest in Asia and lowest in Established Market Economies. Overall estimated annual hospital costs for patients with none of the specified events or event histories ranged from Int$76 in Asia to Int$296 in Established Market Economies. All complications included in this analysis led to significant increases in hospital costs; coronary events, cerebrovascular events, and heart failure were the most costly, at more than Int$1,800, Int$3,000, and Int$4,000 in Asia, Eastern Europe, and Established Market Economies, respectively.
Conclusions
Major complications of diabetes significantly increase hospital use and costs across various settings and are likely to impose a high economic burden on health care systems.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Worldwide, nearly 250 million people have diabetes, and this number is increasing rapidly. Diabetes is characterized by dangerous amounts of sugar (glucose) in the blood. Blood sugar levels are normally controlled by insulin, a hormone produced by the pancreas. Blood sugar control fails in people with diabetes because they make no insulin (type 1 diabetes) or, more commonly, because the fat and muscle cells that usually respond to insulin by removing excess sugar from the blood have become insulin insensitive (type 2 diabetes). Type 2 diabetes can be prevented and controlled by eating a healthy diet and exercising regularly. It can also be treated with drugs that help the pancreas make more insulin or that increase insulin sensitivity. Major long-term complications of diabetes include kidney failure and an increased risk of cardiovascular problems such as heart attacks, heart failure, stroke, and problems with the blood vessels in the arms and legs. Because of these complications, the life expectancy of people with diabetes is about ten years shorter than that of people without diabetes.
Why Was This Study Done?
Diabetes imposes considerable demands on health care systems but little is known about the direct medical costs associated with treating this chronic disease in low- and middle-income countries where more than three-quarters of affected people live. In particular, although estimates have been made of the overall resources devoted to the treatment of diabetes, very little is known about how the different long-term complications of diabetes contribute to health care costs in different countries. Public-health experts and governments need this information to help them design effective and sustainable policies for the prevention and treatment of diabetes. In this study, the researchers estimate the resource use associated with diabetes-related complications in three economic regions using information collected in the Action in Diabetes and Vascular Disease (ADVANCE) study. This multinational clinical trial is investigating how drugs that control blood pressure and blood sugar levels affect the long-term complications of diabetes.
What Did the Researchers Do and Find?
The researchers recorded diabetes-related complications, hospital admissions for these complications, and length of hospital stays in 11,140 patients with severe diabetes from 20 countries who participated in the ADVANCE study. They used “multiple regression analysis” to estimate the number of days spent in hospital for diabetes-related complications in Asia, Eastern Europe, and the Established Market Economies (Canada, Australia, New Zealand, and several Western European countries). Finally, they calculated the economic costs of each complication using regional estimates of the costs per bed-day from the World Health Organization's CHOICE project (CHOosing Interventions that are Cost Effective). Nearly everyone in the study who developed heart failure attended a hospital, but only 15%–26% of people attended a hospital for kidney problems. The chances of hospitalization for any complication were lowest in Asia and highest in the Established Market Economies; conversely, lengths of stay were longest in Asia and shortest in the Established Market Economies. Finally, the estimated annual hospital costs for patients who had a coronary event, stroke, or heart failure were more than Int$1,800, Int$3,000, and Int$4,000 in Asia, Eastern Europe, and the Established Market Economies, respectively (the international dollar, Int$, is a hypothetical currency that has the same purchasing power in all countries), compared to Int$76, Int$156, and Int$296 for patients who experienced none of these events.
What Do These Findings Mean?
Because the ADVANCE trial had strict entry criteria, the findings of this study may not be generalizable to the broader population of people with diabetes. Nevertheless, given the lack of information about the costs associated with diabetes-related complications in low- and middle-income countries, these findings provide important new information about the patterns of hospital resource use and costs in these countries. Specifically, these findings show that the major complications of diabetes greatly increase hospital use and costs in all three economic regions considered and impose a high economic burden on health care systems that is likely to increase as the diabetes epidemic develops. Importantly, these findings should help policy makers anticipate the future health care costs associated with diabetes and should help them evaluate which therapies aimed at preventing diabetes-related complications will reduce these costs most effectively.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000236.
The International Diabetes Federation provides information about all aspects of diabetes
The US National Diabetes Information Clearinghouse provides detailed information about diabetes for patients, health care professionals, and the general public (in English and Spanish)
The UK National Health Service also provides information for patients and caregivers about type 2 diabetes (in several languages)
Information about the ADVANCE study is available
The World Health Organization's CHOICE Web site provides information about the analysis of the cost effectiveness of health care interventions
doi:10.1371/journal.pmed.1000236
PMCID: PMC2826379  PMID: 20186272
7.  Increasing Short-Stay Unplanned Hospital Admissions among Children in England; Time Trends Analysis ’97–‘06 
PLoS ONE  2009;4(10):e7484.
Background
Timely care by general practitioners in the community keeps children out of hospital and provides better continuity of care. Yet in the UK, access to primary care has diminished since 2004 when changes in general practitioners' contracts enabled them to ‘opt out’ of providing out-of-hours care and since then unplanned pediatric hospital admission rates have escalated, particularly through emergency departments. We hypothesised that any increase in isolated short stay admissions for childhood illness might reflect failure to manage these cases in the community over a 10 year period spanning these changes.
Methods and Findings
We conducted a population based time trends study of major causes of hospital admission in children <10 years using the Hospital Episode Statistics database, which records all admissions to all NHS hospitals in England using ICD10 codes. Outcomes measures were total and isolated short stay unplanned hospital admissions (lasting less than 2 days without readmission within 28 days) from 1997 to 2006. Over the period annual unplanned admission rates in children aged <10 years rose by 22% (from 73.6/1000 to 89.5/1000 child years) with larger increases of 41% in isolated short stay admissions (from 42.7/1000 to 60.2/1000 child years). There was a smaller fall of 12% in admissions with length of stay of >2 days. By 2006, 67.3% of all unplanned admissions were isolated short stays <2 days. The increases in admission rates were greater for common non-infectious than infectious causes of admissions.
Conclusions
Short stay unplanned hospital admission rates in young children in England have increased substantially in recent years and are not accounted for by reductions in length of in-hospital stay. The majority are isolated short stay admissions for minor illness episodes that could be better managed by primary care in the community and may be evidence of a failure of primary care services.
doi:10.1371/journal.pone.0007484
PMCID: PMC2758998  PMID: 19829695
8.  Variation in Length of Stay and Outcomes among Hospitalized Patients Attributable to Hospitals and Hospitalists 
ABSTRACT
BACKGROUND
There have been no prior population-based studies of variation in performance of hospitalists.
OBJECTIVE
To measure the variation in performance of hospitalists.
DESIGN
Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models.
SUBJECTS
131,710 hospitalized patients cared for by 1,099 hospitalists in 268 hospitals from 2006–2009.
MAIN MEASURES
We calculated, for each hospitalist, adjusted for patient and disease factors (case mix), their patients' average length of stay, rate of discharge home or to skilled nursing facility (SNF) and rate of 30-day mortality, readmissions and emergency room (ER) visits.
KEY RESULTS
In two-level models (admission and hospitalist), there was significant variation in average length of stay and discharge location among hospitalists, but very little variation in 30-day mortality, readmission or emergency room visit rates. There was stability over time (2008–2009 vs. 2006–2007) in hospitalist performance. In three-level models including admissions, hospitalists and hospitals, the variation among hospitalists was substantially reduced. For example, hospitals, hospitalists and case mix contributed 1.02 %, 0.75 % and 42.15 % of the total variance in 30-day mortality rates, respectively.
CONCLUSIONS
There is significant variation among hospitalists in length of stay and discharge destination of their patients, but much of the variation is attributable to the hospitals where they practice. The very low variation among hospitalists in 30-day readmission rates suggests that hospitalists are not important contributors to variations in those rates among hospitals.
doi:10.1007/s11606-012-2255-6
PMCID: PMC3579964  PMID: 23129162
hospitalist; length of stay; hospitalization; Medicare
9.  Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database 
PLoS Medicine  2014;11(10):e1001745.
Katy Kozhimannil and colleagues use a national database to examine the extent to which variability in cesarean section rates across the US from 2009–2010 was attributable to individual women's clinical diagnoses.
Please see later in the article for the Editors' Summary
Background
Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses.
Methods and Findings
Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status.
The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age.
Conclusions
Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In an ideal world, all babies would be delivered safely and naturally through their mother's vagina. However, increasing numbers of babies are being delivered by cesarean section, a surgical operation in which the baby is delivered through a cut made in the mother's abdomen and womb. In the US, a third of all babies (about 1.3 million babies in 2011) are delivered this way. A cesarean section is usually performed when a vaginal birth would endanger the life of the mother or her unborn child because, for example, the baby is in the wrong position or the labor is not progressing normally. Some cesarean sections are performed as emergency procedures, but others are planned in advance when the need for the operation becomes clear during pregnancy. Although cesarean sections can save lives, women who deliver this way have higher rates of infection, pain, and complications in future pregnancies than women who deliver vaginally, and their babies can have breathing problems.
Why Was This Study Done?
Currently, cesarean section rates vary widely from country to country and from hospital to hospital within countries. Careful assessment of the risks and benefits of cesarean delivery in individual patients can help to ensure that cesarean sections are used only when necessary, but changes to clinical and policy guidelines are also needed to ensure that cesarean delivery is neither overused nor underused. To guide these changes, we need to know whether cesarean section rates vary among hospitals because of case-mix differences (some hospitals may have high rates because they admit many women with complicated pregnancies, for example) or because of differences in modifiable nonclinical factors such as hospital policies and practices. In this retrospective multilevel analysis, the researchers examine whether the current wide variation in cesarean section rates across US hospitals is attributable to differences in maternal clinical diagnoses and patient characteristics or to hospital-level differences in the use of cesarean delivery.
What Did the Researchers Do and Find?
For their study, the researchers used hospital discharge data on nearly 1.5 million births in 1,373 hospitals collected by the 2009 and 2010 US Nationwide Inpatient Sample database, which captures administrative data (for example, length of stay in hospital and clinical complications) from a representative sample of 20% of US hospitals. To assess the chances of cesarean delivery based on hospital and patient characteristics, researchers fitted these data to multilevel logistic regression statistical models. Among women with no prior cesarean deliveries, the (primary) cesarean section rate was 22%, whereas among the whole study population, it was 33% (women who have one cesarean delivery often have a cesarean section for subsequent deliveries). In unadjusted models that compared cesarean section rates between hospitals without considering patient characteristics, the between-hospital variance for primary cesarean section rate was 0.14. Put another way, the likelihood of an individual having a first cesarean delivery varied between 11% and 36% across the hospitals considered. After adjustment for maternal clinical diagnoses, maternal age and other socio-demographic factors, and hospital characteristics such as size, the between-hospital variance for the primary cesarean section rate was 0.16.
What Do These Findings Mean?
The finding that the between-hospital variance for primary cesarean section rate did not decrease after adjusting for maternal characteristics (and other findings presented by the researchers) suggests that differences in case mix or pregnancy complexity may not drive the wide variability in cesarean section rates across US hospitals. However, the lack of information in the US Nationwide Inpatient Sample database on parity (the number of babies a woman has had) or gestational age (the length of time the baby has spent developing inside its mother) limits the strength of this conclusion. Both parity and gestational age strongly predict a woman's risk of a cesarean delivery. Thus, unmeasured differences in the parity of women admitted to different hospitals and/or the gestational age of their babies may be driving some of the variability in cesarean section rates across US hospitals. The lack of hospital-level information on obstetric care policies in the database also means that the many possible administrative explanations for variations across hospitals cannot be assessed. These findings therefore highlight the need for more comprehensive patient data to be collected (including information on parity and gestational age) and on hospital policies, practices, and culture before the variation in cesarean section rate across US hospitals can be fully understood and the use of cesarean delivery can be optimized.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001745.
This study is further discussed in a PLOS Medicine Perspective by Gordon C. S. Smith
The American College of Obstetricians and Gynecologists provides a fact sheet for patients on cesarean birth
The American College of Nurse-Midwives provides a fact sheet for pregnant women on preventing cesarean birth
The US-based Childbirth Connection Project of the non-profit National Partnership for Women and Families has a booklet called “What Every Woman Should Know about Cesarean Section”
The US-based non-profit Nemours Foundation provides detailed information about cesarean sections (in English and Spanish)
The UK National Health Service Choices website provides information for patients about delivery by cesarean section
MedlinePlus provides links to additional resources about cesarean section (in English and Spanish)
The UK non-profit organization Healthtalkonline provides personal stories about women's experiences of cesarean delivery
Information about the US Nationwide Inpatient Sample database is available
doi:10.1371/journal.pmed.1001745
PMCID: PMC4205118  PMID: 25333943
10.  Length of hospitalisation for people with severe mental illness 
Background
In high income countries, over the last three decades, the length of hospital stays for people with serious mental illness has reduced drastically. Some argue that this reduction has led to revolving door admissions and worsening mental health outcomes despite apparent cost savings, whilst others suggest longer stays may be more harmful by institutionalising people to hospital care.
Objectives
To determine the clinical and service outcomes of planned short stay admission policies versus a long or standard stay for people with serious mental illnesses.
Search methods
We searched the Cochrane Schizophrenia Group’s register of trials (July 2007).
Selection criteria
We included all randomised trials comparing planned short with long/standard hospital stays for people with serious mental illnesses.
Data collection and analysis
We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated fixed effects weighted mean differences (WMD).
Main results
We included six relevant trials. We found no significant difference in hospital readmissions between planned short stays and standard care at one year (n=651, 4 RCTs, RR 1.26 CI 1.0 to 1.6). Short hospital stay did not confer any benefit in terms of ’loss to follow up compared with standard care (n=453, 3 RCTs, RR 0.87 CI 0.7 to 1.1). There were no significant differences for the outcome of ’leaving hospital prematurely’ (n=229, 2 RCTs, RR 0.77 CI 0.3 to 1.8). More post-discharge day care was given to participants in the short stay group (n=247, 1 RCT, RR 4.52 CI 2.7 to 7.5, NNH 3 CI 2 to 6) and people from the short stay groups were more likely to be employed at two years (n=330, 2 RCTs, RR 0.61 CI 0.5 to 0.8, NNT 5 CI 4 to 8). Economic data were few but, once discharged, costs may be more for those allocated to an initial short stay.
Authors’ conclusions
The effects of hospital care and the length of stay is important for mental health policy. We found limited data, although outcomes do suggest that a planned short stay policy does not encourage a ’revolving door’ pattern of admission and disjointed care for people with serious mental illness. More large, well-designed and reported trials are justified.
doi:10.1002/14651858.CD000384.pub2
PMCID: PMC4040414  PMID: 18253975
11.  Impact of Hospitalists on Length of Stay in the Medicare Population: Variation by Hospital and Patient Characteristics 
Objectives
To assess how reductions in length of stay associated with hospitalist care vary by patient and hospital characteristics and explore whether these reductions in length of stay changed over time in the Medicare population.
Design
Retrospective cohort study using data from a 5% national sample of Medicare beneficiaries.
Setting
Hospital.
Participants
To examine temporal trends, 1,981,654 Medicare admissions in 2001 to 2006 at 5036 U.S. hospitals were used. To examine the influence of patient and hospital characteristics, 314,590 admissions in 2006 were used.
Measurements
Hospital length of stay.
Results
In multivariable analyses controlling for patient and hospital characteristics, the reductions in length of stay associated with hospitalist care increased from 0.02 days in 2001-02 to 0.22 days in 2003-04, and 0.35 days in 2005-06. For 2006 admissions, reductions in length of stay were greater in older patients and patients with a higher DRG weight. The reductions were three times greater for medical than for surgical DRGs, with greater reductions in length of stay at non-profit vs. for profit hospitals, and at community vs. teaching hospitals.
Conclusion
The reductions in length of stay associated with hospitalist care would appear to be greatest in older, complicated, non-surgical patients cared for at community hospitals.
doi:10.1111/j.1532-5415.2010.03007.x
PMCID: PMC2946246  PMID: 20863324
Hospitalist; Length of Stay; Medicare
12.  Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients with Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx.
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.
Objective
The objective of this analysis was to compare hospital-at-home care with inpatient hospital care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) who present to the emergency department (ED).
Clinical Need: Condition and Target Population
Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. This airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The natural history of COPD involves periods of acute-onset worsening of symptoms, particularly increased breathlessness, cough, and/or sputum, that go beyond normal day-to-day variations; these are known as acute exacerbations.
Two-thirds of COPD exacerbations are caused by an infection of the tracheobronchial tree or by air pollution; the cause in the remaining cases is unknown. On average, patients with moderate to severe COPD experience 2 or 3 exacerbations each year.
Exacerbations have an important impact on patients and on the health care system. For the patient, exacerbations result in decreased quality of life, potentially permanent losses of lung function, and an increased risk of mortality. For the health care system, exacerbations of COPD are a leading cause of ED visits and hospitalizations, particularly in winter.
Technology
Hospital-at-home programs offer an alternative for patients who present to the ED with an exacerbation of COPD and require hospital admission for their treatment. Hospital-at-home programs provide patients with visits in their home by medical professionals (typically specialist nurses) who monitor the patients, alter patients’ treatment plans if needed, and in some programs, provide additional care such as pulmonary rehabilitation, patient and caregiver education, and smoking cessation counselling.
There are 2 types of hospital-at-home programs: admission avoidance and early discharge hospital-at-home. In the former, admission avoidance hospital-at-home, after patients are assessed in the ED, they are prescribed the necessary medications and additional care needed (e.g., oxygen therapy) and then sent home where they receive regular visits from a medical professional. In early discharge hospital-at-home, after being assessed in the ED, patients are admitted to the hospital where they receive the initial phase of their treatment. These patients are discharged into a hospital-at-home program before the exacerbation has resolved. In both cases, once the exacerbation has resolved, the patient is discharged from the hospital-at-home program and no longer receives visits in his/her home.
In the models that exist to date, hospital-at-home programs differ from other home care programs because they deal with higher acuity patients who require higher acuity care, and because hospitals retain the medical and legal responsibility for patients. Furthermore, patients requiring home care services may require such services for long periods of time or indefinitely, whereas patients in hospital-at-home programs require and receive the services for a short period of time only.
Hospital-at-home care is not appropriate for all patients with acute exacerbations of COPD. Ineligible patients include: those with mild exacerbations that can be managed without admission to hospital; those who require admission to hospital; and those who cannot be safely treated in a hospital-at-home program either for medical reasons and/or because of a lack of, or poor, social support at home.
The proposed possible benefits of hospital-at-home for treatment of exacerbations of COPD include: decreased utilization of health care resources by avoiding hospital admission and/or reducing length of stay in hospital; decreased costs; increased health-related quality of life for patients and caregivers when treated at home; and reduced risk of hospital-acquired infections in this susceptible patient population.
Ontario Context
No hospital-at-home programs for the treatment of acute exacerbations of COPD were identified in Ontario. Patients requiring acute care for their exacerbations are treated in hospitals.
Research Question
What is the effectiveness, cost-effectiveness, and safety of hospital-at-home care compared with inpatient hospital care of acute exacerbations of COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on August 5, 2010, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published from January 1, 1990, to August 5, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists and health technology assessment websites were also examined for any additional relevant studies not identified through the systematic search.
Inclusion Criteria
English language full-text reports;
health technology assessments, systematic reviews, meta-analyses, and randomized controlled trials (RCTs);
studies performed exclusively in patients with a diagnosis of COPD or studies including patients with COPD as well as patients with other conditions, if results are reported for COPD patients separately;
studies performed in patients with acute exacerbations of COPD who present to the ED;
studies published between January 1, 1990, and August 5, 2010;
studies comparing hospital-at-home and inpatient hospital care for patients with acute exacerbations of COPD;
studies that include at least 1 of the outcomes of interest (listed below).
Cochrane Collaboration reviews have defined hospital-at-home programs as those that provide patients with active treatment for their acute exacerbation in their home by medical professionals for a limited period of time (in this case, until the resolution of the exacerbation). If a hospital-at-home program had not been available, these patients would have been admitted to hospital for their treatment.
Exclusion Criteria
< 18 years of age
animal studies
duplicate publications
grey literature
Outcomes of Interest
Patient/clinical outcomes
mortality
lung function (forced expiratory volume in 1 second)
health-related quality of life
patient or caregiver preference
patient or caregiver satisfaction with care
complications
Health system outcomes
hospital readmissions
length of stay in hospital and hospital-at-home
ED visits
transfer to long-term care
days to readmission
eligibility for hospital-at-home
Statistical Methods
When possible, results were pooled using Review Manager 5 Version 5.1; otherwise, results were summarized descriptively. Data from RCTs were analyzed using intention-to-treat protocols. In addition, a sensitivity analysis was done assigning all missing data/withdrawals to the event. P values less than 0.05 were considered significant. A priori subgroup analyses were planned for the acuity of hospital-at-home program, type of hospital-at-home program (early discharge or admission avoidance), and severity of the patients’ COPD. Additional subgroup analyses were conducted as needed based on the identified literature. Post hoc sample size calculations were performed using STATA 10.1.
Quality of Evidence
The quality of each included study was assessed, taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Fourteen studies met the inclusion criteria and were included in this review: 1 health technology assessment, 5 systematic reviews, and 7 RCTs.
The following conclusions are based on low to very low quality of evidence. The reviewed evidence was based on RCTs that were inadequately powered to observe differences between hospital-at-home and inpatient hospital care for most outcomes, so there is a strong possibility of type II error. Given the low to very low quality of evidence, these conclusions must be considered with caution.
Approximately 21% to 37% of patients with acute exacerbations of COPD who present to the ED may be eligible for hospital-at-home care.
Of the patients who are eligible for care, some may refuse to participate in hospital-at-home care.
Eligibility for hospital-at-home care may be increased depending on the design of the hospital-at-home program, such as the size of the geographical service area for hospital-at-home and the hours of operation for patient assessment and entry into hospital-at-home.
Hospital-at-home care for acute exacerbations of COPD was associated with a nonsignificant reduction in the risk of mortality and hospital readmissions compared with inpatient hospital care during 2- to 6-month follow-up.
Limited, very low quality evidence suggests that hospital readmissions are delayed in patients who received hospital-at-home care compared with those who received inpatient hospital care (mean additional days before readmission comparing hospital-at-home to inpatient hospital care ranged from 4 to 38 days).
There is insufficient evidence to determine whether hospital-at-home care, compared with inpatient hospital care, is associated with improved lung function.
The majority of studies did not find significant differences between hospital-at-home and inpatient hospital care for a variety of health-related quality of life measures at follow-up. However, follow-up may have been too late to observe an impact of hospital-at-home care on quality of life.
A conclusion about the impact of hospital-at-home care on length of stay for the initial exacerbation (defined as days in hospital or days in hospital plus hospital-at-home care for inpatient hospital and hospital-at-home, respectively) could not be determined because of limited and inconsistent evidence.
Patient and caregiver satisfaction with care is high for both hospital-at-home and inpatient hospital care.
PMCID: PMC3384361  PMID: 23074420
13.  Comparing hospital mortality – how to count does matter for patients hospitalized for acute myocardial infarction (AMI), stroke and hip fracture 
Background
Mortality is a widely used, but often criticised, quality indicator for hospitals. In many countries, mortality is calculated from in-hospital deaths, due to limited access to follow-up data on patients transferred between hospitals and on discharged patients. The objectives were to: i) summarize time, place and cause of death for first time acute myocardial infarction (AMI), stroke and hip fracture, ii) compare case-mix adjusted 30-day mortality measures based on in-hospital deaths and in-and-out-of hospital deaths, with and without patients transferred to other hospitals.
Methods
Norwegian hospital data within a 5-year period were merged with information from official registers. Mortality based on in-and-out-of-hospital deaths, weighted according to length of stay at each hospital for transferred patients (W30D), was compared to a) mortality based on in-and-out-of-hospital deaths excluding patients treated at two or more hospitals (S30D), and b) mortality based on in-hospital deaths (IH30D). Adjusted mortalities were estimated by logistic regression which, in addition to hospital, included age, sex and stage of disease. The hospitals were assigned outlier status according to the Z-values for hospitals in the models; low mortality: Z-values below the 5-percentile, high mortality: Z-values above the 95-percentile, medium mortality: remaining hospitals.
Results
The data included 48 048 AMI patients, 47 854 stroke patients and 40 142 hip fracture patients from 55, 59 and 58 hospitals, respectively. The overall relative frequencies of deaths within 30 days were 19.1% (AMI), 17.6% (stroke) and 7.8% (hip fracture). The cause of death diagnoses included the referral diagnosis for 73.8-89.6% of the deaths within 30 days. When comparing S30D versus W30D outlier status changed for 14.6% (AMI), 15.3% (stroke) and 36.2% (hip fracture) of the hospitals. For IH30D compared to W30D outlier status changed for 18.2% (AMI), 25.4% (stroke) and 27.6% (hip fracture) of the hospitals.
Conclusions
Mortality measures based on in-hospital deaths alone, or measures excluding admissions for transferred patients, can be misleading as indicators of hospital performance. We propose to attribute the outcome to all hospitals by fraction of time spent in each hospital for patients transferred between hospitals to reduce bias due to double counting or exclusion of hospital stays.
doi:10.1186/1472-6963-12-364
PMCID: PMC3526398  PMID: 23088745
Mortality; Quality indicator; Transferred patients; AMI; Stroke; Hip fracture; Cause of death; Hospital comparison; Episode of care
14.  Estimates of the Cost and Length of Stay Changes that can be Attributed to One-Week Increases in Gestational Age for Premature Infants 
Early human development  2006;82(2):85-95.
Objective
To estimate the potential savings, both in terms of costs and lengths of stay, of one-week increases in gestational age for premature infants. The purpose is to provide population-based data that can be used to assess the potential savings of interventions that delay premature delivery.
Data
Cohort data for all births in California in 1998–2000 that linked vital records data with those from hospital discharge abstracts, including those of neonatal transport. All infants with a gestational age between 24 and 37 weeks were included. There were 193,167 infants in the sample after deleting cases with incomplete data or gestational age that was inconsistent with birth weight.
Methods
Hospital costs were estimated by adjusting charges by hospital-specific costs-to-charges ratios. Data were aggregated across transport into episodes of care. Mean and median potential savings were calculated for increasing gestational age, in one-week intervals. The 25th and 75th percentiles were used to estimate ranges.
Results
The results are presented in matrix format, for starting gestational ages of 24–34 weeks, with ending gestational ages of 25 to 37 weeks. Costs and lengths of stay decreased with gestational age from a median of $216,814 (92 days) at 24 weeks to $591 (2 days) at 37 weeks. The potential savings from delaying premature labor are quite large; the median savings for a 2 week increase in gestational age were between $28,870 and $64,021 for gestational ages below 33 weeks, with larger savings for longer delays in delivery. Delaying deliveries <29 weeks to term (37 weeks) resulted in savings of over $122,000 per case, with the savings being over $206,000 for deliveries <26 weeks.
Conclusions
These results provide population-based data that can be applied to clinical trials data to assess the impacts on costs and lengths of stay of interventions that delay premature labor. They show that the potential savings of delaying premature labor are quite large, especially for extremely premature deliveries.
doi:10.1016/j.earlhumdev.2006.01.001
PMCID: PMC1752207  PMID: 16459031
Neonatal care; NICU; health care costs; prematurity; preterm
15.  Accounting for the relationship between per diem cost and LOS when estimating hospitalization costs 
Background
Hospitalization costs in clinical trials are typically derived by multiplying the length of stay (LOS) by an average per-diem (PD) cost from external sources. This assumes that PD costs are independent of LOS. Resource utilization in early days of the stay is usually more intense, however, and thus, the PD cost for a short hospitalization may be higher than for longer stays. The shape of this relationship is unlikely to be linear, as PD costs would be expected to gradually plateau. This paper describes how to model the relationship between PD cost and LOS using flexible statistical modelling techniques.
Methods
An example based on a clinical study of clevidipine for the treatment of peri-operative hypertension during hospitalizations for cardiac surgery is used to illustrate how inferences about cost-savings associated with good blood pressure (BP) control during the stay can be affected by the approach used to derive hospitalization costs.
Data on the cost and LOS of hospitalizations for coronary artery bypass grafting (CABG) from the Massachusetts Acute Hospital Case Mix Database (the MA Case Mix Database) were analyzed to link LOS to PD cost, factoring in complications that may have occurred during the hospitalization or post-discharge. The shape of the relationship between LOS and PD costs in the MA Case Mix was explored graphically in a regression framework. A series of statistical models including those based on simple logarithmic transformation of LOS to more flexible models using LOcally wEighted Scatterplot Smoothing (LOESS) techniques were considered. A final model was selected, using simplicity and parsimony as guiding principles in addition traditional fit statistics (like Akaike’s Information Criterion, or AIC). This mapping was applied in ECLIPSE to predict an LOS-specific PD cost, and then a total cost of hospitalization. These were then compared for patients who had good vs. poor peri-operative blood-pressure control.
Results
The MA Case Mix dataset included data from over 10,000 patients. Visual inspection of PD vs. LOS revealed a non-linear relationship. A logarithmic model and a series of LOESS and piecewise-linear models with varying connection points were tested. The logarithmic model was ultimately favoured for its fit and simplicity. Using this mapping in the ECLIPSE trials, we found that good peri-operative BP control was associated with a cost savings of $5,366 when costs were derived using the mapping, compared with savings of $7,666 obtained using the traditional approach of calculating the cost.
Conclusions
PD costs vary systematically with LOS, with short stays being associated with high PD costs that drop gradually and level off. The shape of the relationship may differ in other settings. It is important to assess this and model the observed pattern, as this may have an impact on conclusions based on derived hospitalization costs.
doi:10.1186/1472-6963-12-439
PMCID: PMC3522016  PMID: 23198908
16.  Automated Detection of Infectious Disease Outbreaks in Hospitals: A Retrospective Cohort Study 
PLoS Medicine  2010;7(2):e1000238.
Susan Huang and colleagues describe an automated statistical software, WHONET-SaTScan, its application in a hospital, and the potential it has to identify hospital infection clusters that had escaped routine detection.
Background
Detection of outbreaks of hospital-acquired infections is often based on simple rules, such as the occurrence of three new cases of a single pathogen in two weeks on the same ward. These rules typically focus on only a few pathogens, and they do not account for the pathogens' underlying prevalence, the normal random variation in rates, and clusters that may occur beyond a single ward, such as those associated with specialty services. Ideally, outbreak detection programs should evaluate many pathogens, using a wide array of data sources.
Methods and Findings
We applied a space-time permutation scan statistic to microbiology data from patients admitted to a 750-bed academic medical center in 2002–2006, using WHONET-SaTScan laboratory information software from the World Health Organization (WHO) Collaborating Centre for Surveillance of Antimicrobial Resistance. We evaluated patients' first isolates for each potential pathogenic species. In order to evaluate hospital-associated infections, only pathogens first isolated >2 d after admission were included. Clusters were sought daily across the entire hospital, as well as in hospital wards, specialty services, and using similar antimicrobial susceptibility profiles. We assessed clusters that had a likelihood of occurring by chance less than once per year. For methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE), WHONET-SaTScan–generated clusters were compared to those previously identified by the Infection Control program, which were based on a rule-based criterion of three occurrences in two weeks in the same ward. Two hospital epidemiologists independently classified each cluster's importance. From 2002 to 2006, WHONET-SaTScan found 59 clusters involving 2–27 patients (median 4). Clusters were identified by antimicrobial resistance profile (41%), wards (29%), service (13%), and hospital-wide assessments (17%). WHONET-SaTScan rapidly detected the two previously known gram-negative pathogen clusters. Compared to rule-based thresholds, WHONET-SaTScan considered only one of 73 previously designated MRSA clusters and 0 of 87 VRE clusters as episodes statistically unlikely to have occurred by chance. WHONET-SaTScan identified six MRSA and four VRE clusters that were previously unknown. Epidemiologists considered more than 95% of the 59 detected clusters to merit consideration, with 27% warranting active investigation or intervention.
Conclusions
Automated statistical software identified hospital clusters that had escaped routine detection. It also classified many previously identified clusters as events likely to occur because of normal random fluctuations. This automated method has the potential to provide valuable real-time guidance both by identifying otherwise unrecognized outbreaks and by preventing the unnecessary implementation of resource-intensive infection control measures that interfere with regular patient care.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Admission to a hospital is often a life-saving necessity—individuals injured in a road accident, for example, may need immediate medical and surgical attention if they are to survive. Unfortunately, many patients acquire infections, some of which are life-threatening, during their stay in a hospital. The World Health Organization has estimated that, globally, 8.7% of hospital patients develop hospital-acquired infections (infections that are identified more than two days after admission to hospital). In the US alone, 2 million people develop a hospital-acquired infection every year, often an infection of a surgical wound, or a urinary tract or lung infection. Infections are common among hospital patients because increasing age or underlying illnesses can reduce immunity to infection and because many medical and surgical procedures bypass the body's natural protective barriers. In addition, poor infection control practices can facilitate the transmission of bacteria—including meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE)—and other infectious agents (pathogens) between patients.
Why Was This Study Done?
Sometimes, the number of cases of hospital-acquired infections increases unexpectedly or a new infection emerges. Such clusters account for relatively few health care–associated infections, but, because they may arise from the transmission of a pathogen within a hospital, they need to be rapidly identified and measures implemented (for example, isolation of affected patients) to stop transmission if an outbreak is confirmed. Currently, the detection of clusters of hospital-acquired infections is based on simple rules, such as the occurrence of three new cases of a single pathogen in two weeks on the same ward. This rule-based approach relies on the human eye to detect infection clusters within microbiology data (information collected on the pathogens isolated from patients), it focuses on a few pathogens, and it does not consider the random variation in infection rates or the possibility that clusters might be associated with shared facilities rather than with individual wards. In this study, the researchers test whether an automated statistical system can detect outbreaks of hospital-acquired infections quickly and accurately.
What Did the Researchers Do and Find?
The researchers combined two software packages used to track diseases in populations to create the WHONET-SaTScan cluster detection tool. They then compared the clusters of hospital-acquired infection identified by the new tool in microbiology data from a 750-bed US academic medical center with those generated by the hospital's infection control program, which was largely based on the simple rule described above. WHONET-SaTScan found 59 clusters of infection that occurred between 2002 and 2006, about three-quarters of which were identified by characteristics other than a ward-based location. Nearly half the cluster alerts were generated on the basis of shared antibiotic susceptibility patterns. Although WHONET-SaTScan identified all the clusters previously identified by the hospital's infection control program, it classified most of these clusters as likely to be the result of normal random variations in infection rates rather than the result of “true” outbreaks. By contrast, the hospital's infection control department only identified three of the 59 statistically significant clusters identified by WHONET-SaTScan. Furthermore, the new tool identified six previously unknown MRSA outbreaks and four previously unknown VRE outbreaks. Finally, two hospital epidemiologists (scientists who study diseases in populations) classified 95% of the clusters detected by WHONET-SaTScan as worthy of consideration by the hospital infection control team and a quarter of the clusters as warranting active investigation or intervention.
What Do These Findings Mean?
These findings suggest that automated statistical software should be able to detect clusters of hospital-acquired infections that would escape detection using routine rule-based systems. Importantly, they also suggest that an automated system would be able to discount a large number of supposed outbreaks identified by rule-based systems. These findings need to be confirmed in other settings and in prospective studies in which the outcomes of clusters detected with WHONET-SaTScan are carefully analyzed. For now, however, these findings suggest that automated statistical tools could provide hospital infection control experts with valuable real-time guidance by identifying outbreaks that would be missed by routine detection methods and by preventing the implementation of intensive and costly infection control measures in situations where they are unnecessary.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000238.
The World Health Organization's Prevention of Hospital-Acquired Infections, A Practical Guide contains detailed information on all aspects of hospital-acquired infections
MedlinePlus provides links to information on infection control in hospitals (in English and Spanish)
The US Centers for Disease Control and Prevention also provides information on infectious diseases in health care settings (in English and Spanish)
The WHONET/Baclink software and the SatScan software, the two components of WHONET-SaTScan are both available on the internet (the WHONET-SaTScan cluster detection tool is freely available as part of the version of WHONET/BacLink released June 2009)
doi:10.1371/journal.pmed.1000238
PMCID: PMC2826381  PMID: 20186274
17.  Direct medical costs of adverse events in Dutch hospitals 
Background
Up to now, costs attributable to adverse events (AEs) and preventable AEs in the Netherlands were unknown. We assessed the total direct medical costs associated with AEs and preventable AEs in Dutch hospitals to gain insight in opportunities for cost savings.
Methods
Trained nurses and physicians retrospectively reviewed 7926 patient records in 21 hospitals. Additional patient information of 7889 patients was received from the Dutch registration of hospital information. Direct medical costs attributable to AEs were assessed by measuring excess length of stay and additional medical procedures after an AE occurred. Costs were valued using Dutch standardized cost prices.
Results
The annual direct medical costs in Dutch hospitals were estimated at a total of euro 355 million for all AEs and euro 161 million for preventable AEs in 2004. The total number of hospital admissions in which a preventable AE occurred was 30,000 (2.3% of all admissions) and more than 300,000 (over 3% of all bed days) bed days were attributable to preventable AEs in 2004. Multilevel analysis showed that variance in direct medical costs was not determined by differences between hospitals or hospital departments.
Conclusion
The estimates of the total preventable direct medical costs of AEs indicate that they form a substantial part (1%) of the expenses of the national health care budget and are of importance to hospital management. The cost driver of the direct medical costs is the excess length of stay (including readmissions) in a hospital. Insight in which determinants are associated with high preventable costs will offer useful information for policymakers and hospital management to determine starting points for interventions to reduce the costs of preventable AEs.
doi:10.1186/1472-6963-9-27
PMCID: PMC2645386  PMID: 19203365
18.  Including post-discharge mortality in calculation of hospital standardised mortality ratios: retrospective analysis of hospital episode statistics 
Objectives To assess the consequences of applying different mortality timeframes on standardised mortality ratios of individual hospitals and, secondarily, to evaluate the association between in-hospital standardised mortality ratios and early post-discharge mortality rate, length of hospital stay, and transfer rate.
Design Retrospective analysis of routinely collected hospital data to compare observed deaths in 50 diagnostic categories with deaths predicted by a case mix adjustment method.
Setting 60 Dutch hospitals.
Participants 1 228 815 patients discharged in the period 2008 to 2010.
Main outcome measures In-hospital standardised mortality ratio, 30 days post-admission standardised mortality ratio, and 30 days post-discharge standardised mortality ratio.
Results Compared with the in-hospital standardised mortality ratio, 33% of the hospitals were categorised differently with the 30 days post-admission standardised mortality ratio and 22% were categorised differently with the 30 days post-discharge standardised mortality ratio. A positive association was found between in-hospital standardised mortality ratio and length of hospital stay (Pearson correlation coefficient 0.33; P=0.01), and an inverse association was found between in-hospital standardised mortality ratio and early post-discharge mortality (Pearson correlation coefficient −0.37; P=0.004).
Conclusions Applying different mortality timeframes resulted in differences in standardised mortality ratios and differences in judgment regarding the performance of individual hospitals. Furthermore, associations between in-hospital standardised mortality rates, length of stay, and early post-discharge mortality rates were found. Combining these findings suggests that standardised mortality ratios based on in-hospital mortality are subject to so-called “discharge bias.” Hence, early post-discharge mortality should be included in the calculation of standardised mortality ratios.
doi:10.1136/bmj.f5913
PMCID: PMC3805490  PMID: 24144869
19.  Can teletechnology improve patient experience and reduce the use of health care resource? 
Introduction
By 2050 it is estimated that there will be 16 million people over the age of 65 years. With the expansion in the older population and improvements in health care the number people living with a chronic health condition (Long Term Condition, LTC) is increasing. Many people will have more than one LTC e.g. diabetes and cardiac disease. With pressure on the health economy and available resources increasing, managing as many people outside of hospital as appropriately possible is essential. The white paper “Our health our care our say” (DH 2006), challenges local health and social care communities to deliver more care closer to the patients own home. The Kent Telehealth pilot study, undertaken in 2005, investigated whether the use of Telehealth in the UK health care setting could replicate the outcomes of the Veterans Administration programme in the US.
Methods
The pilot examined the role of Telehealth in supporting users and their carers, and assessed its impact on hospital admissions, length of stay, GP contact and nursing visits. Patients acted as their own controls. SF12 and QuIL were used for the qualitative evaluation. Health Ethics approval was granted. All participants provided informed consent. Those meeting the eligibility criteria—of at least one LTC (diabetes, COPD, heart failure) were recruited, equipment was provided to record their vital signs. Vital signs parameters were agreed for individual users with their clinician. Data were automatically uploaded to a web based server, accessible to health care staff responsible for the care of the individual. The frequency of data review was dependent on the service delivery model and appropriate communications were undertaken with the user to facilitate any change in their agreed management plan.
Results
Two hundred and fifty users were recruited, data were available for 202 users for the final analysis. There were 88 less A&E visits and 536 bed days were saved. If admitted the length of stay was shorter by up to 4 days. There was a 28% reduction in calls to the GP, a 23% reduction in visits to the surgery, and an 18% reduction in home visits. It has been estimated that over a six-month period, Telehealth intervention saved an average of £1878 per user (£1038 to £2718, p=0.01). Using Hospital Episode Statistics estimates savings that could be generated across Kent (2006–2007 prices) could be £7.56 million (CI £4.18 million to £10.942 million) annually. Users reported an increased peace of mind, increase quality of life with increased empowerment and self management with improvements in SF12 scores improved for General Health +5.7, for Physical health +8.7.
Conclusions
Telehealth is a potentially valuable adjunct in the management of people with LTCs. Patients become more empowered and independent and as a result, reduced their reliance on primary and secondary care. There is the potential for significant financial gains to be realised, through improved working and reduction in attendance at hospital for admission and or outpatient consultations. Patient quality of life also improved which impacts on how and when they interact with services.
PMCID: PMC3571165
telehealth; long-term conditions; patient experience
20.  Effect of Hospital Setting and Volume on Clinical Outcomes in Women with Gestational and Type 2 Diabetes Mellitus 
Journal of Women's Health  2009;18(10):1567-1576.
Abstract
Objective
Efforts to improve health care outcomes in the United States have led some organizations to recommend specific hospital settings or case volumes for complex medical diagnoses and procedures. But there are few studies of the effect of setting and volume on maternal outcomes, particularly in complicated conditions, such as diabetes. Our objective was to estimate the effect of hospital setting and volume on childbirth morbidity and length of stay in pregnancies complicated by type 2 and gestational diabetes.
Methods
We analyzed Maryland hospital discharge data during 1999–2004. The dependent variables were primary cesarean delivery, episiotomy, a composite variable for severe maternal morbidity, and hospital length of stay. The independent variables were hospital setting (community, non-teaching hospitals, community, teaching hospitals, and academic medical centers) and tertiles of annual hospital diabetes delivery volume. Multivariable regression analysis was used to assess the relation of hospital setting with each outcome, adjusting for hospital volume and maternal case mix.
Results
5,507 deliveries with type 2 (15%) and gestational (85%) diabetes were analyzed. Primary cesarean delivery rates among women with any diabetes did not vary across settings. After adjustment for volume and patient case mix, the likelihood of severe maternal morbidity was higher among deliveries at academic centers compared to community, non-teaching hospitals (odds ratio [OR], 2.1; 95% confidence interval: 1.0, 4.2). Academic centers had a protective effect (OR, 0.3; 95% CI: 0.2, 0.7) and community teaching hospitals had a borderline protective effect (OR, 0.8; 95% CI: 0.7, 1.0) on episiotomy, compared to community, non-teaching hospitals. Length of stay was greater at academic centers and community, teaching hospitals compared to community, non-teaching hospitals (5.4 days, 3.5 days vs. 2.8 days, respectively). We did not identify an independent association between hospital diabetes volume and clinical outcomes after adjustment for case mix.
Conclusions
Among women with type 2 and gestational diabetes, hospital setting is associated with a higher likelihood of severe maternal morbidity and length of stay, independent of volume. Patient case mix accounts for some of the variation across settings. The volume-outcome relationship found with other complex medical conditions or procedures was not found among diabetic pregnancies. Further investigations are needed to explain variations in outcomes across hospital settings and volumes.
doi:10.1089/jwh.2008.1114
PMCID: PMC2864466  PMID: 19764843
21.  Energy Delivery Systems for Treatment of Benign Prostatic Hyperplasia 
Executive Summary
Objective
The Ontario Health Technology Advisory Committee asked the Medical Advisory Secretariat (MAS) to conduct a health technology assessment on energy delivery systems for the treatment of benign prostatic hyperplasia (BPH).
Clinical Need: Target Population and Condition
BPH is a noncancerous enlargement of the prostate gland and the most common benign tumour in aging men. (1) It is the most common cause of lower urinary tract symptoms (LUTS) and bladder outlet obstruction (BOO) and is an important cause of diminished quality of life among aging men. (2) The primary goal in the management of BPH for most patients is a subjective improvement in urinary symptoms and quality of life.
Until the 1930s, open prostatectomy, though invasive, was the most effective form of surgical treatment for BPH. Today, the benchmark surgical treatment for BPH is transurethral resection of the prostate (TURP), which produces significant changes of all subjective and objective outcome parameters. Complications after TURP include hemorrhage during or after the procedure, which often necessitates blood transfusion; transurethral resection (TUR) syndrome; urinary incontinence; bladder neck stricture; and sexual dysfunction. A retrospective review of 4,031 TURP procedures performed by one surgeon between 1979 and 2003 showed that the incidence of complications was 2.4% for blood transfusion, 0.3% for TUR syndrome, 1.5% for hemostatic procedures, 2.8% for bladder neck contracture, and 1% for urinary stricture. However, the incidence of blood transfusion and TUR syndrome decreased as the surgeon’s skills improved.
During the 1990s, a variety of endoscopic techniques using a range of energy sources have been developed as alternative treatments for BPH. These techniques include the use of light amplification by stimulated emission of radiation (laser), radiofrequency, microwave, and ultrasound, to heat prostate tissue and cause coagulation or vaporization. In addition, new electrosurgical techniques that use higher amounts of energy to cut, coagulate, and vaporize prostatic tissue have entered the market as competitors to TURP. The driving force behind these new treatment modalities is the potential of producing good hemostasis, thereby reducing catheterization time and length of hospital stay. Some have the potential to be used in an office environment and performed under local anesthesia. Therefore, these new procedures have the potential to rival TURP if their effectiveness is proven over the long term.
The Technology Being Reviewed
The following energy-based techniques were considered for assessment:
transurethral electrovaporization of the prostate (TUVP)
transurethral electrovapor resection of the prostate (TUVRP)
transurethral electrovaporization of the prostate using bipolar energy (plasmakinetic vaporization of the prostate [PKVP])
visual laser ablation of the prostate (VLAP)
transurethral ultrasound guided laser incision prostatectomy (TULIP)
contact laser vaporization of the prostate (CLV)
interstitial laser coagulation (ILC)
holmium laser resection of the prostate (HoLRP)
holmium laser enucleation of the prostate (HoLEP)
holmium laser ablation of the prostate (HoLAP)
potassium titanyl phosphate (KTP) laser
transurethral microwave thermotherapy (TUMT)
transurethral needle ablation (TUNA)
Review Strategy
A search of electronic databases (OVID MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library, and the International Agency for Health Technology Assessment [INAHTA] database) was undertaken to identify evidence published from January 1, 2000 to June 21, 2006. The search was limited to English-language articles and human studies. The literature search identified 284 citations, of which 38 randomized controlled trials (RCTs) met the inclusion criteria.
Since the application of high-power (80 W) KTP laser (photoselective vaporization of the prostate [PVP]) has been supported in the United States and has resulted in a rapid diffusion of this technology in the absence of any RCTs, the MAS decided that any comparative studies on PVP should be identified and evaluated. Hence, the literature was searched and one prospective cohort study (3) was identified but evaluated separately.
Findings of Literature Review and Analysis
Meta-analysis of the results of RCTs shows that monopolar electrovaporization is as clinically effective as TURP for the relief of urinary symptoms caused by BPH (based on 5-year follow-up data).
Meta-analysis of the results of RCTs shows that bipolar electrovaporization (PKVP) is clinically as effective as TURP for the relief of urinary symptoms caused by BPH (based on 1-year follow-up data).
Two of the three RCTs on VLAP have shown that patients undergoing VLAP had a significantly lesser improvement in urinary symptom scores compared with patients undergoing TURP.
RCTs showed that the time to catheter removal was significantly longer in patients undergoing VLAP compared with patients undergoing TURP.
Meta-analysis of the rate of reoperation showed that patients undergoing VLAP had a significantly higher rate of reoperation compared with patients undergoing TURP.
Meta-analysis showed that patients undergoing CLV had a significantly lesser improvement in urinary symptom scores compared with TURP at 2 years and at 3 or more years of follow-up.
Two RCTs with 6-month and 2-year follow-up showed similar improvement in symptom scores for ILC and TURP.
Time to catheter removal was significantly longer in patients undergoing ILC compared with patients undergoing TURP.
The results of RCTs on HoLEP with 1-year follow-up showed excellent clinical outcomes with regard to the urinary symptom score and peak urinary flow.
Meta-analysis showed that at 1-year follow-up, patients undergoing HoLEP had a significantly greater improvement in urinary symptom scores and peak flow rate compared with patients undergoing TURP.
Procedural time is significantly longer in HoLEP compared with TURP.
The results of one RCT with 4-year follow-up showed that HoLRP and TURP provided equivalent improvement in urinary symptom scores.
The results of one RCT with 1-year follow-up showed that patients undergoing KTP had a lesser improvement in urinary symptom scores than did patients undergoing TURP. However, the results were not significant at longer-term follow-up periods.
Two RCTs that provided 3-year follow-up data reported that patients undergoing TUMT had a significantly lesser improvement in symptom score compared with patients undergoing TURP.
RCTs reported a longer duration of catheterization for TUMT compared with TURP (P values are not reported).
The results of a large RCT with 5-year follow-up showed a significantly lesser improvement in symptom scores in patients undergoing TUNA compared with patients undergoing TURP.
Meta-analysis of the rate of reoperation showed that patients undergoing TUNA had a significantly higher rate of reoperation compared with patients undergoing TURP.
Based on the results of RCTs, TURP is associated with a 0.5% risk of TUR syndrome, while no cases of TUR syndrome have been reported in patients undergoing monopolar or bipolar electrovaporization, laser-based procedures, TUMT, or TUNA.
Based on the results of RCTs, the rate of blood transfusion ranges from 0% to 8.3% in patients undergoing TURP. The rate is about 1.7% in monopolar electrovaporization, 1.4% in bipolar electrovaporization, and 0.4% in the VLAP procedure. No patients undergoing CLV, ILC, HoLEP, HoLRP, KTP, TUMT, and TUNA required blood transfusion.
The mean length of hospital stay is between 2 and 5 days for patients undergoing TURP, about 3 days for electrovaporization, about 2 to 4 days for Nd:YAG laser procedures, and about 1 to 2 days for holmium laser procedures. TUMT and TUNA can each be performed as a day procedure in an outpatient setting (0.5 and 1 day respectively).
Based on a prospective cohort study, PVP is clinically as effective as TURP for the relief of urinary symptoms caused by BPH (based on 6-month follow-up data). Time to catheter removal was significantly shorter in patients undergoing PVP than in those undergoing TURP. Operating room time was significantly longer in PVP than in TURP. PVP has the potential to reduce health care expenses due to shorter hospital stays.
Economic Analysis
In the three most recent fiscal years (FY) reported, an average of approximately 5,000 TURP procedures per year were performed in Ontario. From FY 2002 to FY 2004, the total number of surgical interventions decreased by approximately 500 procedures. During this time, the increase in costs of drugs to the government was estimated at approximately $10 million (Cdn); however, there was a concurrent decrease in costs due to a decline in the total number of surgical procedures, estimated at approximately $1.9 million (Cdn). From FY 2002 to FY 2004, the increase in costs associated with the increase in utilization of drugs for the treatment of BPH translates into $353 (Cdn) per patient while the cost savings associated with a decrease in the total number of surgical procedures translates into a savings of $3,906 (Cdn) per patient.
The following table summarizes the change in the current budget, depending on various estimates of the total percentage of the 5,000 TURP procedures that might be replaced by other energy-based interventions for the treatment of BPH in the future.
Budget Impact With Various Estimates of the Percentage of TURP Procedures Captured by Energy-based Interventions for the Treatment of BPH
All costs are in Canadian currency. Parentheses indicative of cost reduction.
PMCID: PMC3379165  PMID: 23074487
22.  Community-based home-care program for the management of pre-eclampsia: an alternative. 
OBJECTIVE: To evaluate the safety, acceptability and cost of a community-based home-care program for the management of mild pre-eclampsia. DESIGN: A descriptive study of outcomes between Apr. 1, 1985, and Dec. 31, 1989. SETTING: St. Boniface General Hospital, Winnipeg. PATIENTS: Urban Winnipeg residents between 27 and 40 weeks' gestation with mild pre-eclampsia who demonstrated acceptance and compliance with home-care management; 321 patients of 1330 were enrolled in the program. INTERVENTIONS: Bed rest at home with daily biochemical and biophysical follow-up protocol and weekly clinic visits; patient education; hospital admission for labour, induction, worsening pre-eclampsia or noncompliance with rest at home. OUTCOME MEASURES: Patterns of referral to the program; clinical, biochemical and biophysical profiles; incidence of severe complications; reduction in total hospital stay and cost analysis. RESULTS: As many women were referred from physicians' offices as were referred from the hospital's antepartum unit, the average gestational age at referral being 36 weeks. Most (205 [64%]) of the women were nulliparous. The average length of stay in the program was 11.5 days. The program's availability resulted in a reduction of 2 days (from 5.7 days to 3.7 days) on average in the length of hospital stay when analysed for all 1330 women with pre-eclampsia. Of the 321 patients in the program 137 (43%) were admitted to hospital for worsening pre-eclampsia; severe pre-eclampsia developed 4 days after admission in 9. No patient suffered eclampsia, disseminated intravascular coagulopathy, abruption or fetal loss related to pre-eclampsia while in the program. The estimated cost saving in the management of pre-eclampsia was over $700,000 over the study period. CONCLUSION: The community-based home-care program is a safe, feasible and less costly alternative to hospital admission in the management of mild pre-eclampsia.
PMCID: PMC1485333  PMID: 8374846
23.  The hospital standardised mortality ratio: a powerful tool for Dutch hospitals to assess their quality of care? 
Aim of the study
To use the hospital standardised mortality ratio (HSMR), as a tool for Dutch hospitals to analyse their death rates by comparing their risk-adjusted mortality with the national average.
Method
The method uses routine administrative databases that are available nationally in The Netherlands—the National Medical Registration dataset for the years 2005–2007. Diagnostic groups that led to 80% of hospital deaths were included in the analysis. The method adjusts for a number of case-mix factors per diagnostic group determined through a logistic regression modelling process.
Results
In The Netherlands, the case-mix factors are primary diagnosis, age, sex, urgency of admission, length of stay, comorbidity (Charlson Index), social deprivation, source of referral and month of admission. The Dutch HSMR model performs well at predicting a patient's risk of death as measured by a c statistic of the receiver operating characteristic curve of 0.91. The ratio of the HSMR of the Dutch hospital with the highest value in 2005–2007 is 2.3 times the HSMR of the hospital with the lowest value.
Discussion
Overall hospital HSMRs and mortality at individual diagnostic group level can be monitored using statistical process control charts to give an early warning of possible problems with quality of care. The use of routine data in a standardised and robust model can be of value as a starting point for improvement of Dutch hospital outcomes. HSMRs have been calculated for several other countries.
doi:10.1136/qshc.2009.032953
PMCID: PMC2921266  PMID: 20172876
Healthcare quality improvement; quality of care; mortality; healthcare quality; control charts
24.  Chronic status patients in a university hospital: bed-day utilization and length of stay. 
OBJECTIVE: To examine the lengths of stay of chronic status patients in an acute care hospital, to identify discharge stages that contribute to excessive stays, to estimate the length of stay at each discharge stage and to link hospital bed-day utilization by the discharge stage to the experience of the patient. DESIGN: Two-year prospective cohort study. The number of hospital days retrospective to the date of the current admission were included in the analysis. SETTING: University hospital. PATIENTS: All 115 inpatients formally declared as achieving chronic status by July 31, 1987. OUTCOME MEASURES: Lengths of stay (total days and days at acute and chronic status) for chronic status patients, including those still in hospital at the end of the study period. Each bed-day was assigned to a discharge stage that corresponded to the patient's status. The disposition of each patient by the end of the study period was reviewed. RESULTS: The study population spent a total of 101 585 days in hospital. The total length of stay per patient was nearly four times that stated in the hospital's annual report, in which the figure was calculated only on the basis of discharge data. On average only 77.2 (8.7%) of the days were spent in acute care. The remaining days were at the chronic level: 24.1% were spent waiting for completion of an application to a long-term care facility, 25.3% for application approval and 41.9% for an available bed in the assigned long-term care institution. For 30 patients no initiation of the discharge process was ever undertaken. As the number of patients in each progressive discharge stage decreased, the wait per patient increased. By the end of the study period only 32 patients had been transferred to a public long-term care facility; 22 were still in hospital, and 35 had died waiting for placement. CONCLUSIONS: Although considered to be a useful measure of hospital efficiency, length of stay determined from discharge data creates an iceberg effect when applied to chronic status patients in acute care hospitals. Lack of access to the assigned resource is the most important reason for a delay in discharge. Interventions, whether undertaken at the patient, hospital or provincial level, must to some degree address this issue. Further study is required to determine which risk factors will predict lags at each discharge stage. Since our discharge staging reflects not only the experience of the patient but also the utilization of hospital bed-days and access to provincial resources, it provides a common language for clinicians, hospital administrators and systems planners.
PMCID: PMC1335939  PMID: 1933708
25.  The Association between Depressive Symptoms and Non-Psychiatric Hospitalisation in Older Adults 
PLoS ONE  2012;7(4):e34821.
Background
It is known that people who suffer from depression are more likely to have other physical illnesses, but the extent of the association between depression and non-psychiatric hospitalisation episodes has never been researched in great depth. We therefore aimed to investigate whether depressed middle-aged and older people were more likely to be hospitalised for causes other than mental illnesses, and whether the outcomes for this group of people were less favourable.
Methods & Findings
Hospital events from 1995 to 2006 were obtained from the Dutch National Medical Register and linked to participants of the Longitudinal Aging Study Amsterdam (LASA). Linkage was accomplished in 97% of the LASA sample by matching gender, year of birth and postal code. Depression was measured at each wave point of the LASA study using the Centre for Epidemiologic Studies Depression (CES-D). Hospital outcomes including admission, length of stay, readmission and death while in hospital were recorded at 6, 12 and 24 months intervals after each LASA interview. Generalised Estimating Equation models were also used to investigate potential confounders. After 12 months, 14% of depressed people were hospitalised compared to 10% of non-depressed individuals. There was a 2-fold increase in deaths while in hospital amongst the depressed (0.8% vs 0.4%), who also had longer total length of stay (2.6 days vs 1.4 days). Chronic illnesses and functional limitations had major attenuating effects, but depression was found to be an independent risk factor for length of stay after full adjustment (OR = 1.33, 95% CI: 1.22–1.46 after 12 months).
Conclusions
Depression in middle and old age is associated with non-psychiatric hospitalisation, longer length of stay and higher mortality in clinical settings. Targeting of this high-risk group could reduce the financial, medical and social burden related to hospital admission.
doi:10.1371/journal.pone.0034821
PMCID: PMC3319609  PMID: 22496867

Results 1-25 (1199900)