Variations in Hospital Length of Stay: Their

Relationship to Health Outcomes

August 1983

NTIS order #PB84-111483
HEALTH TECHNOLOGY CASE STUDY 24:

Variations in

Hospital Length of Stay:

Their Re

Health

ationship to

Outcomes

AUGUST 1983

This case study was performed as a part of OTA’s Assessment of

Medical Technology and

Costs of the Medicare Program

Prepared under contract for OTA by:

Mark R. Chassin, M. D., M. P. P., M.P.H.

OTA Case Studies are documents containing information on a specific medical

technology or area of application that supplements formal OTA assessments. The

material is not normally of as immediate policy interest as that in an OTA Report,

nor does it present options for Congress to consider.

. ~

 :: 

.. CONGRESS OF THE UNITED STATES

 Office of Technology Assessmen t
gy pp

assessment of Medical Technology and Costs of the Medicare Program.

Library of Congress Catalog Card Number 83-600708

For sale by the Superintendent of Documents,

U.S. Government Printing Office, Washington, D.C. 20402
Preface

Variations in Hospital Length of Stay: Their Relationship to Health Outcomes is Case Study 24

in OTA’s Health Technology Case Study Series.

It was prepared in response to a request by the

Senate Finance Committee, Subcommittee on

Health, and is part of OTA’s project on Medical

Technology and Costs of the Medicare Program,

requested by the House Committee on Energy and

Commerce and its Subcommittee on Health and

the Environment and the Senate Finance Committee, Subcommittee on Health. A listing of other

case studies in the series is included at the end of

this preface.

OTA case studies are designed to fulfill two

functions. The primary purpose is to provide

OTA with specific information that can be used

in forming general conclusions regarding broader

policy issues. The first 19 cases in the Health Technology Case Study Series, for example, were conducted in conjunction with OTA’s overall project

on The Implications of Cost-Effectiveness

Analysis of Medical Technology. By examining

the 19 cases as a group and looking for common

problems or strengths in the techniques of costeffectiveness or cost-benefit analysis, OTA was

able to better analyze the potential contribution

that those techniques might make to the management of medical technology and health care costs

and quality.

The second function of the case studies is to

provide useful information on the specific technologies covered. The design and the funding levels of most of the case studies are such that they

should be read primarily in the context of the associated overall OTA projects. Nevertheless, in

many instances, the case studies do represent extensive reviews of the literature on the efficacy,

safety, and costs of the specific technologies and

as such can stand on their own as a useful contribution to the field.

Case studies are prepared in some instances because they have been specifically requested by

congressional committees and in others because

they have been selected through an extensive review process involving OTA staff and consultations with the congressional staffs, advisory panel

to the associated overall project, the Health Program Advisory Committee, and other experts in

various fields. Selection criteria were developed

to ensure that case studies provide the following:

●

●

●

●

●

●

●

●

examples of types of technologies by function (preventive, diagnostic, therapeutic, and

rehabilitative);

examples of types of technologies by physical

nature (drugs, devices, and procedures);

examples of technologies in different stages

of development and diffusion (new, emerging, and established);

examples from different areas of medicine

(e.g., general medical practice, pediatrics,

radiology, and surgery);

examples addressing medical problems that

are important because of their high frequency or significant impacts (e. g., cost);

examples of technologies with associated high

costs either because of high volume (for lowcost technologies) or high individual costs;

examples that could provide information material relating to the broader policy and methodological issues being examined in the particular overall project; and

examples with sufficient scientific literature.

Case studies either are prepared by OTA staff,

are commissioned by OTA and performed under

contract by experts (generally in academia), or are

written by OTA staff on the basis of contractors’

papers.

OTA subjects each case study to an extensive

review process. Initial drafts of cases are reviewed

by OTA staff and by members of the advisory

panel to the associated project. For commissioned

cases, comments are provided to authors, along

with OTA’s suggestions for revisions. Subsequent

drafts are sent by OTA to numerous experts for

review and comment. Each case is seen by at least

30, and sometimes by 80 or more outside reviewers. These reviewers may be from relevant Government agencies, professional societies, consumer

and public interest groups, medical practice, and

academic medicine. Academicians such as economists, sociologists, decision analysts, biologists,

and so forth, as appropriate, also review the cases.

Although cases are not statements of official

OTA position, the review process is designed to

satisfy OTA of each case study’s scientific quality and objectivity. During the various stages of

the review and revision process, therefore, OTA

encourages, and to the extent possible requires,

authors to present balanced information and recognize divergent points of view.

.

111
Health Technology Case Study Seriesa

Case Study Case Study

Series Case study title; author(s); Series Case study title; author(s);

number OTA publication numberb number OTA publication numberb

1

2

3

4

5

6

7

8

9

10

11

12

Formal Analysis, Policy Formulation, and EndStage Renal Disease;

Richard A. Rettig (OTA-BP-H-9 (l))c

The Feasibility of Economic Evaluation of

Diagnostic Procedures: The Case of CT Scanning;

Judith L. Wagner (OTA-BP-H-9(2))

Screening for Colon Cancer: A Technology

Assessment;

David M. Eddy (OTA-BP-H-9(3))

Cost Effectiveness of Automated Multichannel

Chemistry Analyzers;

Milton C. Weinstein and Laurie A. Pearlman

(OTA-BP-H-9(4))

Periodontal Disease: Assessing the Effectiveness and

Costs of the Keyes Technique;

Richard M. Scheffler and Sheldon Rovin

(OTA-BP-H-9(5))

The Cost Effectiveness of Bone Marrow Transplant

Therapy and Its Policy Implications;

Stuart O. Schweitzer and C. C. Scalzi

(OTA-BP-H-9(6))

Allocating Costs and Benefits in Disease Prevention

Programs: An Application to Cervical Cancer

Screening;

Bryan R. Luce (Office of Technology Assessment)

(OTA-BP-H-9(7))

The Cost Effectiveness of Upper Gastrointestinal

Endoscopy;

Jonathan A. Showstack and Steven A. Schroeder

(OTA-BP-H-9(8))

The Artificial Heart: Cost, Risks, and Benefits;

Deborah P. Lubeck and John P. Bunker

(OTA-BP-H-9(9))

The Costs and Effectiveness of Neonatal Intensive

Care;

Peter Budetti, Peggy McManus, Nancy Barrand,

and Lu Ann Heinen (OTA-BP-H-9(10))

Benefit and Cost Analysis of Medical Interventions:

The Case of Cimetidine and Peptic Ulcer Disease;

Harvey V. Fineberg and Laurie A. Pearlman

(OTA-BP-H-9(11))

Assessing Selected Respiratory Therapy Modalities:

Trends and Relative Costs in-the Washington, D.C.

Area;

Richard M. Scheffler and Morgan Delaney

(OTA-BP-H-9(12))

13 Cardiac Radionuclide Imaging and Cost

Effectiveness;

William B. Stason and Eric Fortess

(OTA-BP-H-9(13))

14 Cost Benefit/Cost Effectiveness of Medical

Technologies: A Case Study of Orthopedic Joint

Implants;

Judith D. Bentkover and Philip G. Drew

(OTA-BP-H-9(14))

15 Elective Hysterectomy: Costs, Risks, and Benefits;

Carol Korenbrot, Ann B. Flood, Michael Higgins,

Noralou Roos, and John P. Bunker

(OTA-BP-H-9(15))

16 The Costs and Effectiveness of Nurse Practitioners;

Lauren LeRoy and Sharon Solkowitz

(OTA-BP-H-9(16))

17 Surgery for Breast Cancer;

Karen Schachter Weingrod and Duncan Neuhauser

(OTA-BP-H-9(17))

18 The Efficacy and Cost Effectiveness of

Psychotherapy;

Leonard Saxe (Office of Technology Assessment)

(OTA-Bp-H-9(18)) d

19 Assessment of Four Common X-Ray Procedures;

Judith L. Wagner (OTA-BP-H-9 (19))e

20 Mandatory Passive Restraint Systems in

Automobiles: Issues and Evidence;

Kenneth E. Warner (OTA-BP-H-15 (20))f

21 Selected Telecommunications Devices for HearingImpaired Persons;

Virginia W. Stem and Martha Ross Redden

(OTA-Bp-H-16(21)) g

22 The Effectiveness and Costs of Alcoholism

Treatment;

Leonard Saxe, Denise Dougherty, Katharine Esty,

and Michelle Fine (OTA-HCS-22)

23 The Safety, Efficacy, and Cost Effectiveness of

Therapeutic Apheresis;

John C. Langenbrunner (Office of Technology

Assessment) (OTA-HCS-23)

24 Variation in Length of Hospital Stay: Their

Relationship to Health Outcomes;

Mark R. Chassin (OTA-HCS-24)

aAvai]able for ale by the Suwnntendent of Documents, U.S. Government dBackground papr #3 to The Implications of Cost-Eftkctiveness Analysis of

Printing Office, Washington, D. C., 20402, and by the National Technical Medical Technology.

Information Service, 5285 Port Royal Road, Springfield, Va., 22161. Cal] eBackVound paFr #S to The Implications of Cost-Effectiveness Analysis of

OTA’s Publishing Office (224-8996) for availability and ordering infor- Medical Technology.

mation. fBac~ound Papr #1 to OTAIS May 1982 report Technology and Handibonginal publication numbers appear in parentheses. capped People.

‘The fimt 17 cases in the series were 17 separately issued cases in Background gBackgrouncf Paper M2 to Technology and Handicapped p~p~e.

Paper #z: Case Studies of Medical Technologies, prepared in conjunction

with OTA’s August 1980 report E& hnpkations of Cost-Efktiveness Ana)-

vsis of Medical Tedrtology.
OTA Staff for Case Study 24

H. David Banta, Assistant Director, OTA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Anne Kesselman Burns, Project Director

Cynthia King, Analyst

Pamela Simerly, Research Assistant

Virginia

John

Cwalina, Administrative Assistant

Jennifer Nelson, Secretary

Mary Walls, Secretary

OTA Publishing Staff

C. Holmes, Publishing Officer

John Bergling Kathie S. Boss Debra M. Datcher Joe Henson

Glenda Lawing Linda Leahy Donna Young
Advisory Panel on Medical Technology and

Costs of the Medicare Program

Stuart Altman, Panel Chair

Dean, Florence Heller School, Brandeis University

Frank Baker

Vice President

Washington State Hospital Association

Robert Blendon

Senior Vice President

The Robert Wood Johnson Foundation

Jerry Cromwell

President

Health Economics Research

Chestnut Hill, Mass.

Karen Davis

School of Hygiene and Public Health

Johns Hopkins University

Robert Derzon

Vice President

Lewin & Associates

Washington, D. C.

Howard Frazier

Director

Center for the Analysis of Health Practices

Harvard School of Public Health

Clifton Gaus

Center for Health Policy Studies

Washington, D.C.

Jack Hadley

Urban Institute

Washington, D. C.

Kate Ireland

Chairman, Board of Governors

Frontier Nursing Service

Wendover, Ky.

Judith Lave

Graduate School of Public Health

University of Pittsburgh

Mary Marshall

Delegate

Virginia House of Delegates

Walter McNerney

Northwestern University

Morton Miller

President

National Health Council

New York, N. Y.

James Mongan

Executive Director

Truman Medical Center

Kansas City, Mo.

Seymour Perry

Institute for Health Policy Analysis

Georgetown University Medical Center

Washington, D. C.

Robert Sigmond

Community Programs for Affordable

Health Care

Blue Cross/Blue Shield Associations

Anne Somers

Department of Environmental and

Community Medicine, and

Department of Family Medicine

Rutgers Medical School

Paul Torrens

School of Public Health

University of California, Los Angeles

Keith Weikel

Group Vice President

AMI

McLean, Va.

vi
Contents

Chapter Page

Glossary of Terms... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Glossary of Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

CHAPTER1: INTRODUCTION AND EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . 3

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Organization and Boundaries of the Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

CHAPTER 2: VARIATIONS IN HOSPITAL LENGTH OF STAY . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

CHAPTER 3: LENGTH OF STAY AND OUTCOME: MYOCARDIAL INFARCTION . . . . . . . . . . . 25

CHAPTER 4: LENGTH OF STAY AND OUTCOME: ELECTIVE SURGERY . . . . . . . . . . . . . . . . . . . 31

CHAPTER 5: LENGTH OF STAY AND OUTCOME: OBSTETRICS . . . . . . . . . . . . . . . . . . . . . 37

CHAPTER 6: LENGTH OF STAY AND OUTCOME: PSYCHIATRY . . . . . . . . . . . . . . . . . . . . . . . 43

CHAPTER 7: SUMMARY AND IMPLICATIONS FOR RESEARCH AND POLICY . . . . . . . . . . . . . 49

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Implications for Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Implications for Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Appendix A. Length of Stay and Outcome: Myocardial Infarction . . . . . . . . . . . . . . . . 57

Appendix B. Length of Stay and Outcome: Elective Surgery . . . . . . . . . . . . . . . . . 67

Appendix C. Health Program Advisory Committee and Acknowledgments . . . . . . . . . . . . . . . . . . 75

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Tables

Table No. Page

1,

2,

3,

4,

5.

6,

7,

8,

9.

10.

11.

12.

13.

14.

Admission and Days of Care Per 1,000 Population by Census Region in 1980. . . . . . . . . . . . . . .

Age and Sex Distribution of Hospitalized Patients by Census Region in 1980. . . . . . . . . . . . . . . .

Age and Sex Adjusted Length of Stay by Region in 1980 . . . . . . . . . . . . . . . . . . . . . . . . . .

Diagnosis-Specific Length of Stay by Region: 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Distribution of Cases by Diagnosis by Region: 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Case-mix Adjusted Length of Stay by Region: 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Highest and Lowest DHHS Regions for Medicaid Length of Stay in 1980 by Diagnosis Related Group

1978 Length of Stay Data for Utah and Central Massachusetts PSROs by Source of Payment.

Regional Differences in Length of Stay, Intensity of Service, and Mortality Rates

From the Stanford Institutional Differences Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Populations Studied for Length of Stay Associations . . . . . . . . . . . . . .

Factors Found To Be Associated and Unassociated With Length of Stay . . . . . . . . . . . . .

Regional Trends in Length of Stay for Uncomplicated Delivery, . . . . . . . . . . . . . . . . .

Case Mix Differences Between Baltimore and Portland . . . . . . . . . . . . . . . . . . . . . . . . . .,,

Summary of RCTs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

12

12

13

13

14

14

15

17

19

19

38

49

51

A-1. Uncontrolled Studies of Early Mobilization and Discharge for MI Patients . . . . . . . . . . . . . . . . . 60

A-2. Randomized Clinical Trials of Early Discharge for MI Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

A-3. Power of Randomized Clinical Trials on Early Discharge for MI Patients . . . . . . . . . . . . . . . . . . 65

B-1. Randomized Clinical Trials in Outpatient and Short-Stay Elective Surgery . . . . . . . . . . . . . . . . . 71

Figures

F]gure No. Page

l. Age-Specific Trends in Hospital Length of Stay . . 9

2. Regional Differences in Hospital Length of Stay: Trends Over Time . . . . . . . . . . . . . . . . 10

3. Regional Trends in Length of Stay for Myocardial Infarction. . . . . . . . . . . . . . . . . . . . . . . . 25

A-1. Regional Trends in Length of Stay for Myocardial Infarction . . . . . . . . . . . . . . . . . . . 58

B-1. Regional Trends in Length of Stay for Patients With Inguinal Hernia . . . . . . . . . . . . . . . . 74

vii
Glossary of Terms

Case mix: The relative frequency of various types of

patients, reflecting different needs for hospital

resources. There are many ways of measuring case

mix, some based on patients’ diagnoses or the severity of their illnesses, some on the utilization of services, and some on the characteristics of the hospital

or area in which it is located.

Effectiveness: Same as efficacy (see below) except that

it refers to average or actual conditions of use.

Efficacy: The probability of benefit to individuals in

a defined population from a medical technology applied for a given medical problem under ideal conditions of use.

Length of stay (LOS): The number of days a patient

remains in the hospital from admission to discharge.

Medicaid: A Federal program that is administered and

operated individually by each participating State

government that provides medical benefits to certain low-income persons in need of health and medical care.

Medical technology: The drugs, devices, and medical

and surgical procedures used in medical care, and

the organizational and supportive systems within

which such care is provided.

Medicare: A nationwide, federally administered health

insurance program authorized in 1965 to cover the

cost of hospitalization, medical care, and some related services for eligible persons over age 65, persons receiving Social Security Disability Insurance

payments for 2 years, and persons with end-stage

renal disease. Medicare consists of two separate but

coordinated programs—hospital insurance (part A)

and supplementary medical insurance (part B).

Health insurance protection is available to insured

persons without regard to income.

Morbidity: A measure of illness, injury, or disability

in a defined population. It is usually expressed in

general or specific rates of incidence or prevalence.

Sometimes used to refer to any episode of disease.

See also “mortality (death). ”

Mortality (death): A measure of deaths, used to deP

scribe the relation of deaths to the population in

which they occur. The mortality rate (death rate)

expresses the number of deaths in a unit of population within a prescribed time.

value: In a randomized clinical trial, the probability

of concluding that there is a difference between the

treatment groups when, in fact, there is none. Also

called “Type I error” or “alpha” and commonly

called the “level of statistical significance;” analogous to “false positive. ”

Professional Standards Review Organizations

(PSROs): Community-based, physician-directed,

nonprofit agencies established under the Social

Security Amendments of 1972 to monitor the quality

and appropriateness of institutional health care provided to Medicare and Medicaid beneficiaries.

Randomized clinical trial (RCT): An experimental design by which human or animal subjects are randomly assigned either to an experimental group (in

which subjects receive the treatment being studied)

or to a control group (in which subjects do not receive the treatment being studied). Also referred to

as “randomized controlled clinical trial” or “controlled clinical trial. ”

Reliability: A measure of the consistency of a method

in producing results. A reliable test gives the same

results when applied more than once under the same

conditions. Also called “precision. ”

Risk: A measure of the probability of an adverse or

untoward outcome and the severity of the resultant

harm to health of individuals in a defined population and associated with use of a medical technology applied for a given medical problem under specified conditions of use.

Safety: A judgment of the acceptability of risk (see

above) in a specified situation.

Validity: A measure of the extent to which an observed

situation reflects the “true” situation. lnternal validity is a measure of the extent to which study results

reflect the true relationship of a “risk factor” (e. g.,

treatment or technology) to the outcome of interest

in study subjects. External validity is a measure of

the extent to which study results can be generalized

to the population that is represented by individuals

in the study, assuming that the characteristics of that

population are accurately specified.

Statistical significance: See “p value. ”

Statistical power: In a randomized clinical trial, the

probability of detecting a difference between the

treatment groups when one does exist. Failure to

detect an effect is called “Type II error” or “beta;”

analogous to “false negative, ”

Synthesis: The integration of findings from different

studies and the development of generalizations based

on their results.

Type I error: See “p value. ”

Type II error: See “statistical power. ”

98-8 ? 1 0 - 83 - 2 : CLJ 3

ix
Glossary of Acronyms

CHF — congestive heart failure

DRG — Diagnosis Related Groups

IOM — Institute of Medicine

LOS — length of stay

MI – myocardial infarction

NCHS — National Center for Health Statistics

PAS — Professional Activities Survey

PSRO — Professional Standards Review

Organization

BCPSRO – Baltimore City PSRO

BPSRO – Baltimore area PSRO

CMPSRO – Central Massachusetts PSRO

CM-PSRO – Central Maryland PSRO

MFMC – Multonomah (Portland, Oreg. )

Foundation for Medical Care

UPSRO – Utah PSRO

RCT — randomized clinical trial
Introduction and

Executive Summary
1.

Introduction and Executive Summary — .

Hospital length of stay (LOS) varies markedly

and persistently across geographic areas in the

United States. This phenomenon is the most striking of all the variations in health service use that

have been observed. For example, since 1965 the

Northeast census region has maintained an average LOS that is about 21⁄2 days longer than that

of the West (130). In 1979, Medicare average LOS

varied from a high of 13.1 days in one New Jersey

Professional Standards Review Organization

(PSRO) area to a low of 6.0 in a California PSRO

area (74).

Policymakers have been tempted to conclude

that it is the longer lengths of stay that are inappropriate and should be curtailed. The potential

BACKGROUND

As the search for solutions to rising health care

costs has intensified over the past few years in

both the public and private sectors, the implications of geographic variations in LOS have assumed greater importance. Concern over the costs

of the Medicare program has led policymakers

and researchers to examine the underlying reasons

for the variations with the hope of cost containment. Yet before determining whether variation

in LOS can provide the basis for policies to contain Medicare costs, several key questions must

be addressed. First, are the LOS differences simply

the result of differences in demographic characteristics or severity of illnesses among the different

populations? Second, if the populations are comparable, what do physicians do differently that

leads to different lengths of stay? Finally, and

perhaps most important, do the differences in LOS

lead to differences in patient health outcomes?

As background to its deliberations over Medicare costs, the Senate Finance Committee’s Subcommittee on Health requested that OTA examine

the evidence on variations in lengths of hospital

stay and their relation to health outcomes, This

economic significance of these variations is large,

and this fact has not escaped the attention of those

charged with the administration of public health

care programs such as Medicare and Medicaid.

If all four census regions had experienced the

West’s age-specific lengths of stay in their own

hospitalized populations in 1980, patients in

regions outside the West would have spent some

44.3 million fewer days in the hospital, a saving

of 16 percent (129), Patients 65 years of age and

over would have spent 20.6 million fewer days,

a reduction of 20 percent. Of the remaining three

census regions, the Northeast accounted for 42

percent of the “excess” days, the Northcentral for

36 percent, and the South for 22 percent.

case study presents the results of this examination. It was prepared as part of OTA’s project on

Medical Technology and Costs of the Medicare

Program. The entire project is being conducted

in response to requests by the House Committee

on Energy and Commerce and its Subcommittee

on Health, and the Subcommittee on Health of

the Senate Committee on Finance.

On April 20, 1983, Public Law 98-21 provided

for extensive changes in Medicare reimbursement

policies for hospital-based care. Under the statute,

whose provisions will be phased in over 3 years,

hospitals will receive a flat fee per patient, set prospectively, on the basis of patient diagnosis in one

or more of 467 Diagnosis Related Groups (DRGs). *

Because the payment for any DRG will not increase as an individual patient’s LOS increases,

answers to the questions raised above are even

more critical.

*A recent technical memorandum by OTA entitled Diagnosis Re

lated Groups (DRGs) and the Medicare Program: Implications for

`Mechcal Technology examines the incentives for medical technology adoption and use, for hospital admissions, and for increasing

or decreasing length of hospital stay under the new payment system.

3
4 ● Health Technology Case Study 24: Variations in Hospital Lenght of Stay: Their Relationship to Health Outtcomes

. —

ORGANIZATION AND BOUNDARIES OF THE CASE STUDY

The case study continues in chapter 2 by reviewing and analyzing what is known about geographic variations in hospital LOS in the United

States, including a review of the magnitude of

these differences and their trends over time.

Chapter 2 also discusses how these variations are

affected by population differences and reviews

how various researchers have tried to explain

them. Chapters 3 through 6 and appendixes A and

B take a different approach. Each of these sections

analyzes the medical literature relating to a specific

clinical condition, attempting to ascertain whether

research has established in a scientifically rigorous

fashion that a particular LOS produces the best

health outcome for that condition. Such an optimal LOS could serve as a standard against which

geographic differences could be evaluated. Chapter 7 summarizes the findings across clinical areas

and discusses future research needs and the policy

implications of these geographic LOS variations

for the Medicare and Medicaid programs.

This case study is specifically concerned with

the relationship between hospital LOS and health

outcome. Several important, related areas are not

exhaustively reviewed. A comprehensive study of

the cost implications of LOS variations and different methods of reducing LOS is beyond the

scope of this study. Cost or charge data are

discussed if they are part of studies that assessed

outcome. But no attempt is made to measure directly how much various scenarios of LOS reduction might be worth. This is a complex question.

Some of the problems one encounters in trying

to address it have recently been reviewed (93).

A brief review of the relationship between LOS

and health care costs may illustrate some of these

complexities. Most hospital admissions incur

greater costs at the beginning of a stay than toward the end when patients are nearing discharge

and no longer require the intensity of diagnostic

and therapeutic measures employed at the outset

of their illnesses. If LOS is shortened by decreasing days at the end of a stay, the cost saving may

be small. In fact, it may even be close to zero.

At the end of a stay, most of the services consumed by patients represent fixed costs to the

hospital: housekeeping, dietary, and laundry.

Minimal nursing or ancillary service are provided. If LOS decreases, these fixed costs are still

incurred by the hospital and must simply be distributed over a smaller number of patient days,

thus increasing the average per diem room and

board charge. In addition, if patients leave the

hospital earlier, they may incur outpatient costs

that they would not otherwise have. They may

see their physicians more frequently or obtain

more intensive home care. These factors too

would reduce any savings realized as a result of

early discharge. Further, if patients are discharged

too early from a medical point of view, they may

deteriorate at home and require readmission to

the hospital, thus increasing total costs.

Another set of issues arises when one considers

the likely effects of decreasing LOS for some patients on the rest of the hospital. If LOS were

decreased for some patients, others might fill their

beds, thus negating all or part of any savings that

might be realized by the group that experienced

fewer hospital days. For example, patients leaving early might be replaced by patients awaiting

beds for elective surgery, thus reducing waiting

time for these procedures. Since elective surgery

patients will be likely to use more services per day

on average than those discharged early would

have had they stayed, total health care costs might

easily rise, despite a reduction in LOS,

On the other hand, a decrease in LOS might

lead to decreased occupancy without a rise in

other admissions. Persistently low occupancy

rates might cause some hospitals to close entirely or to convert wings to other, less expensive

uses, such as long-term care, In this latter scenario, considerable cost savings might accrue. It

is thus impossible to predict the effect on society’s health care costs of decreasing LOS. The effect will depend ultimately on precisely how LOS

is reduced, what the other relevant characteristics

of the local health care market are, and whether

any incentives have been established to facilitate

the conversion of acute hospital beds to other

uses,

Another important issue beyond the province

of this case study is a full discussion of the most
Ch. I—Introduction and Executive Summary ● 5

appropriate place for various kinds of medical

treatment. What sorts of procedures should be

done in physicians’ offices? Which kinds of patients must be treated in hospitals, and which

could be managed safely as outpatients? These

questions are important ones, with important economic implications of their own, but equally outside the realm of the present study. This decision

rule also excludes clinical areas such as the treatment of drug addiction. This area has seen many

studies, including some randomized clinical trials

(RCTs), on the most effective LOS (37,97,134,

175). Because treatment of this kind ordinarily

takes place outside the acute care hospital, it is

outside the scope of this case study.

Each of the selected clinical areas was chosen

because of the existence of at least one methEXECUTIVE SUMMARY

Eastern hospitals exhibit lengths of stay that are

about 40 percent higher than western hospitals.

These differences have remained remarkably consistent over the past 15 years. They are unexplained by differences among regions in age, sex,

or race distributions. Current research has also

been unable to demonstrate that differences in

severity of illness across regions explain any of

the variations. This possibility must remain at

least somewhat open, however, since there has

been little research at the most detailed clinical

level to find subtle, but clinically important differences in case mix among regions within specific

disease categories. Available evidence suggests

that physicians in different regions treat patients

with the same illnesses differently with respect to

LOS.

As mentioned earlier, the potential economic

significance of these LOS differences is very large.

If all patients 65 years of age and older had experienced the West’s LOS in 1980, those hospitalized in regions outside the West would have spent

21 million fewer days in the hospital, thus reducing total days in the hospital for this age group

by 20 percent. How much of the potential savings could actually be realized depends entirely

on how LOS is reduced, whether admission rates

rise in compensation, and whether hospitals

odologically sound RCT that attempted to test the

effect of changes in LOS on health outcomes. Each

of these clinical areas is reviewed in depth. Some

studies have assessed the effect of various modifications in medical practice and included measures of LOS in the assessment (38,85,105,146).

Studies of this type have not been systematically

sought. Each of the clinical studies reviewed here

focused on the problem of the effect of changes

in LOS on health. Evaluations of the efficacy of

specific forms of medical technology or treatment

are not within the purview of the present study.

This review does, however, intensively analyze

each clinical area in which researchers have sought

to change LOS and to measure the effects of such

a change on health.

remove acute care beds from service in response

to decreased occupancy. There is almost no research in this area.

Before designing new programs to reduce LOS,

however, one must ask whether these regional differences in LOS are associated with differences in

health outcomes. Are patients in the East harmed

because they stay in the hospital longer than their

western counterparts? Or are patients in the West

suffering because they leave the hospital too early?

Either, both, or neither of these possibilities may

be true.

A great deal of research has addressed the association of LOS with factors such as hospital

ownership, area hospital bed supply, teaching

status, occupancy rate, and other hospital characteristics with varying results. Very little research

has been done on the relationship between regional LOS differences and health outcomes. Very little attention has been devoted to ascertaining precisely how physicians manage the same kinds of

illnesses in different regions of the country, trying to explain regional LOS differences by finding

differences in physician practices.

This case study attempted to find data in the

medical research literature clearly establishing a

particular LOS for specific illnesses that produces
6 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

the best health outcome. Regions above the standard could be judged as having lengths of stay that

were too long. Those below the standard could

be judged too short.

Studies with scientifically sound methods were

found in five clinical areas: acute myocardial infarction, elective surgery, low risk newborn deliveries, low birth weight infants, and psychiatric

hospitalization. Studies in the first four areas

uniformly concluded that shorter lengths of stay

had no different outcomes from the more traditional, longer lengths of stay. None of the studies

was large enough to rule out statistically the

possibility that early discharge causes a small, but

significant negative health impact. Many of the

studies excluded the elderly. In the area of

psychiatric hospitalization, the evidence is

stronger that patients hospitalized initially for

shorter periods do better than patients kept

longer. Even in this area, however, the studies

each assessed different patient groups and employed widely varying definitions of early (11 to

86 days) and late (24 to 179 days) discharge. Thus,

the medical literature failed to establish clear LOS

standards for any clinical condition.

Because the economic benefit of decreasing LOS

to western levels is unclear and because the

possibility of such a program having a negative

health impact has not been excluded, the case for

eastern lengths of stay is not definitive. Further

research will be necessary to establish the relationship between length of hospital stay and

health outcomes. The potential value of such research is very high.
2 ■

Variations in Hospital

Length of Stay
2.

Variations in Hospital Length of Stay

In general, average length of stay (LOS) in

short-term, non-Federal hospitals has been falling since 1968 in the United States, Figure 1 shows

the trends in LOS since 1965, the year in which

the Medicare and Medicaid laws were passed, for

the United States as a whole and for each of four

age groups. The increase in LOS that followed the

enactment of the Federal health insurance legislation and continued through 1968 in both the U.S.

average and the elderly is the only dramatic departure from an otherwise virtually unbroken decreasing trend. The early years of the Medicare

program also witnessed a rapid rise in the proportion of hospitalized patients that were elderly, While this proportion has risen continuously

from 16 percent in 1965 to 26 percent in 1980, fully

40 percent of the increase took place between 1965

and 1968 (130). Since 1968 all age groups have

shown decreasing lengths of stay; the elderly have

decreased by 25 percent, the older adult group by

18 percent, the young adult group by 15 percent,

children by 12 percent, and the combined U.S.

average by 14 percent.

Given this pervasive downward trend in LOS,

the stability of the geographic differences in LOS

over time is remarkable. In 1980, the average LOS

in the Northeast was 39 percent higher than in

Figure 1 .—Age-Specific Trends in Hospital Length of Stay

15 r

10 --. ___=

---- -

9

- -

---------- -

- - -

- - -

● @*** ● , ● ● ** ---- - - - 45-64

‘

O

.. 8 O ● me OOeemgggO@O

---- 

● ● O

—

● 000 ● ,9. ● 0-00.. ● e****@e

7 U.S. average

6

---- 0--- -

15-44 --0.-00--00 -

5 “

under 15

o

I I 1 I I I 1 I I I 1 I 1 I I

1965 1970 1975 1980

Year

SOURCE V//a/ and Health Staf/st/cs series 13, Nos 2, 10, 14, 17, 19, 23, 26, 31, 41, 46, 55, 60, 64 (Washington, D C National Centt r for Health

Statistics 1%782)
10 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

— .

the West, the NorthCentral was 23 percent higher,

and the South 11 percent higher. Figure 2 shows

how consistent these regional differences have

been since 1965. Since the peak year of 1968, both

the Northeast and the West have decreased in LOS

by 14 percent, the Northcentral has fallen by 15

percent and the South by 12 percent.

An analysis of data collected by the Professional Standards Review Organization (PSRO)

program reveals the same concentration of high

LOS areas in the Northeast and low LOS areas

in the West (74). Of the ten PSROs with the

highest overall Medicare LOS in 1979, five were

in New York, three in New Jersey, and one each

in Illinois and Ohio. Of the ten with the lowest

Medicare LOS, six were in California, one each

in Oregon, Idaho, Washington, and Montana.

PSRO Medicaid data from the same year are similar. Of the ten PSROs with the highest Medicaid

LOS, two each were in Pennsylvania and North

Carolina, and one each was in New York, New

Jersey, Maryland, Virginia, Indiana, and Florida.

Of the ten PSROs with the lowest Medicaid LOS,

seven were in California, and one each in Idaho,

Oregon, and Louisiana.

Figure 2.— Regional Differences in Hospital Length of Stay: Trends Over Time

10.0

9.0

 8.0

7.0

6.0

/

---- -

\ \

o -

1 I I I I 1 I 1 I 1 1 I 1 1 I

1965 1970 1975 1980

Year

SOURCE: V/fa/ and Wa/th Sfat/sties, series 13, Nos 2, 10, 14, 17, 19,23, 26,31, 41,46, 55,60,64 (Washington, D. C.’ National Center for Health

Statistics, 1967-82)
Ch. 2— Variations in Hospital Length of Stay ● 11

-- —..—..

Although this case study is concerned solely

with LOS, it is relevant to ask the question: does

this geographic pattern of low lengths of stay in

the West mean that the West uses fewer hospital

services per capita? The most commonly employed measure of hospital service use is total days

of care per 1,000 population. This figure is the

product of the average LOS and the admission

rate per 1,000 in the region.

Table 1 shows data on admission and days of

care rates per 1,000 population by region for 1980.

The data show clearly that the West not only has

the lowest LOS of any region but also the lowest

admission rate. These two factors combine to give

the West the lowest rate of use of total hospital

days of any of the census regions. Some of the

other regions do change their relative positions

in the ranking of admission rates and days of care

from where they stand with respect to LOS. For

example, the Northeast has an admission rate that

is slightly below the U.S. average, whereas the

Northcentral has the highest admission rate. These

factors contribute to the ranking of the Northcentral region as the one with the highest rate of use

of hospital days of care. From another viewpoint,

however, the data on total days of care are similar

to those on LOS. The two regions with below

average LOS (West and South) are the two regions

with below average overall hospital use, as reflected in total days of care per 1,000. The Northeast and Northcentral regions, the areas with

Table 1 .–Admission and Days of Care Per 1,000

Population by Census Region in 1980

Total days of

Admission rate hospital care

(per 1,000 (per 1,000

Regiona

population) population)

Northeast ., . . . . . . . . . . . . 162 1,387

Northcentral. . . . . . . . . . . . 187 1,412

South . . . . . . . . . . . . . . . . . 175 1,191

West . . . . . . . . . . . . . . . . . . 144 873

United States average . . . 170 1,231

a~o~heast . Maine, New Hampshire, Vermont, Massachusetts, Rhode Island.

Connecticut, New York, New Jersey, Pennsylvania

Northcentral = Michigan, Ohio, lllinoIs, Indiana, Wisconsin, Minnesota, Iowa,

Missouri, North Dakota, South D&ota, Nebraska, Kansas

South = Delaware, Maryland, District of Columbia, Virginia, West Virg!nia, North

Caroltna, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama,

Mlsslssippl, Arkansas, Louisiana, Texas, Oklahoma

West = Montana Idaho, Wyoming Colorado, New Mexico, Arizona, Utah,

Nevada, Washington, Oregon, California, Hawall, Alaska

SOURCE !//ta/ and Flea/th StatisfmS series 13, No 64, DHHS publication No

(Pt-iS) 82.1725 (Washington, D C Nattonal Center for Health Statlst!cs,

1982)

above average LOS, are the two regions with

above average overall hospital use.

In attempting to explain regional LOS differences, the first possibility that arises is that the

demographic composition of the populations in

the four census regions may be sufficiently different to account for all or part of the LOS differences. Of all the demographic variables, age

has the strongest relationship to LOS. Figure 1

shows how rapidly LOS rises as a function of age,

with the elderly spending 2.4 times as long in the

hospital per stay in 1980 as those under age 15.

In contrast, the average LOS for men in 1980 was

7.7 days, and for women it was 7’. o days. For

whites the average LOS in 1980 was 7.3 days, the

same as the U.S. average, and for all other races

it was 7..5 days (129). Thus, it is conceivable that

significant differences in age and sex (if not race)

distributions could explain at least some of these

geographic LOS variations.

Table 2 shows the 1980 age and sex distributions of hospitalized patients in each of the four

census regions. On inspection, regional differences

in these distributions appear to be minor. This

observation proves to be correct. Table 3 shows

the results of age and sex adjusting the regional

figures for average LOS, using the direct standardization method. This method uses the entire

U.S. population of hospitalized patients as the

standard. The age- and sex-specific lengths of stay

for each population subgroup of each region are

then multiplied by the proportion that each subgroup represents in the standard population.

These products are summed over all the age and

sex subgroups to arrive at a figure that adjusts

LOS for age and sex differences. Clearly, the effect of the age and sex adjustment is minimal. The

West’s LOS remained the same, the Northcentral

and the South increased by 0.1 days, and the

Northeast decreased by 0.1 days. Thus, while

there are slight differences among the regions in

the demographic characteristics of their hospitalized patients, these differences play a minimal role

in explaining overall LOS variations. Gornick (60,

61,62) came to the same conclusion after a similar

analysis of data pertaining to the Medicare population alone.

The lack of explanatory power of demographic

characteristics has also remained constant over
12 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

Table 2.—Age and Sex Distributions of Hospitalized Patients by

Census Region in 1980

Age group (percent of region’s

Percent hospital patients)

Region male Under 15 15-44 45-64 65 and over

Northeast . . . . . . . . . . . . . . . . . . . . 41.2 8.9 39.5 24.0 27.7

Northcentral. . . . . . . . . . . . . . . . . . 40.0 10.2 41.0 22.9 25.9

South . . . . . . . . . . . . . . . . . . . . . . . 38.9 10.7 41.7 22.2 25.4

West . . . . . . . . . . . . . . . . . . . . . . . . 40.9 7.9 43.4 23.0 25.8

United States average . . . . . . . . . 40.0 9.7 41.3 22.9 26.1

SOURCE Wtal and Health .sfatistcs, series 13, No 64, DHHS publication No (PHS) 82.1725 (Washington, D C National Center

for Haalth Statistics. 1932)

Table 3.–Age and Sex Adjusted Length of Stay by

Region in 1980

Unadjusted LOS Adjusted LOS

Region (days) (days)

Northeast . . . . . . . . . . . . . 8.5 8.4

Northcentral. . . . . . . . . . . 7.5 7.6

South . . . . . . . . . . . . . . . . 6.8 6.9

West . . . . . . . . . . . . . . . . . 6.1 6.1

United States average . . 7.3 —

SOURCE Calculated from data In V/ta/ and Healfh Statistics, series 13, No 64,

DHHS ptillcation No. (PHS) 82.1725 (Washington, DC National Center

for Health Statistics, 1982).

time. If one examines age-specific lengths of stay

for the four age groups displayed in figure 1 for

the 15 years between 1966 and 1980 for each of

the four census regions, one finds that the Northeast had the highest LOS for every age group in

every year save one. * Thus, in 59 of 60 possible

comparisons the Northeast showed the highest

LOS. The same analysis reveals the West to exhibit the lowest LOS in 59 of 60 possible comparisons.

The possibility that case mix** differences

among regions might account for some of the LOS

variations is a much more difficult proposition to

evaluate. Table 4 displays LOS data from the National Center for Health Statistics’ (NCHS) 1980

Hospital Discharge Survey that are diagnosis

specific for the 18 major diagnostic categories of

the International Classification of Diseases: 9th

Edition. Once again the data provide evidence of

● In 1978, the Northcentral region registered a LOS that was 0.1

days higher than the Northeast for patients 15 to 44 years of age.

● ● Case mix has been defined in various ways. In this case study,

it refers to the relative frequency of various types of patients, reflecting different needs for hospital resources. There are many ways of

measuring case mix, some based on patients’ diagnoses or the severity

of their illnesses, some on the utilization of services, and some on

the characteristics of the hospital or area in which it is located.

high LOS in the Northeast and low LOS in the

West. In 13 of 18 categories, the Northeast is

highest in LOS, and in 15 of 18 the West is lowest.

It is also true, however, that the Northeast has

slightly more patients in high LOS diagnostic

categories than the other census regions. Table 5

gives the distribution of cases among the 1 8

diagnostic categories for the United States and the

four census regions. In each of the three diagnostic

categories with the highest average U.S. LOS

(mental disorders, neoplasms, and diseases of the

circulatory system), the Northeast has a greater

proportion of cases than the average U.S. population. What effect do these case mix differences

have on the difference between the Northeast and

the West in LOS? Table 6 presents the results of

a direct standardization of LOS by region using

the U.S. distribution of cases as the reference population. The case mix differences described above

have only a small impact, reducing the average

LOS for the Northeast by 0.2 days.

Other data confirm this finding and extend it

specifically to the Medicare and Medicaid populations. Gornick (61) found that for the Medicare

population LOS for many specific conditions was

highest in the Northeast and lowest in the West.

She also found that adjusting New York’s average

Medicare LOS for California’s case mix resulted

in only a 0.1 day reduction in New York’s LOS.

Table 7 presents data from the PSRO program

on Medicaid LOS for the 15 most common Diagnosis Related Groups in 1980. The same regional

trends appear. In all 15 instances a western region

exhibited the lowest LOS, while in 12 of 15 cases

a northeastern region demonstrated the highest.

Again, it appears that for every population examined, the Northeast has the highest LOS and

the West the lowest for virtually all diagnoses.
Ch. 2– Variations in Hospital Length of Stay ● 1 3

Table 4.— Diagnosis-Specific Length of Stay by Region: 1980

LOS in days

Condition Us.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13,

14.

15.

16.

17.

18.

All

Mental disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.6

Neoplasms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.5

Circulatory disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.0

Endocrine, nutritional, metabolic, and immunity disorders. . . . . . . . . . . . . . . . . . . . 9.6

Perinatal disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.7

Musculoskeletal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3

Skin diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.0

Injury and poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.7

Hematologic disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2

Gastrointestinal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.0

Infectious and parasitic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9

Congenital anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.6

Respiratory diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3

Genitourinary disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6

Diseases of the nervous system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4

Symptoms, signs, and ill-defined conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5

Supplementary classification (850/o newborn deliveries) . . . . . . . . . . . . . . . . . . . . . . 3.7

Complications of pregnancy and childbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5

conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3

NE NC s w

11.6 13.4 9.8 10,7

12.0 10.7 10.1 8.5

12.4 10.2 9.2 8.1

11.8 9.7 8.9 7.7

8.1 9.5 9.0 7.3

9.8 8.9 8.1 6.5

9.5 7.8 7.4 7.8

9.5 7.8 7.3 6.6

8.8 6.9 6.8 6.0

7.9 7,2 6,6 6.2

7.7 7,3 6.6 6.1

6.8 7.5 6.0 5.9

7.6 5.9 6.3 5.4

5.7 5.8 5.6 5.0

6.3 5.5 5.4 4.5

5.0 4.6 4.6 3.7

4.3 4.1 3.4 3.0

2.2 2.6 2.7 2.3

8.5 7.5 6.8 6.1

Key NE = Northeast, NC = NorthcentraL S = South, W = West

SOURCE V/faland Hea/th Sfatisf~cs, series 13, No 64 DHHS publlcatton No (PHS)82-1725 (Washington. DC National Center for Health Statlstlcs 1982)

Table5.— Distribution of Cases by Diagnosis by Region: 1980

Region (percent of cases)

Condition U.S. NE NC s w

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13,

14.

15.

16.

17.

18.

All

Key

Mental disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5

Neoplasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5

Circulatory disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.6

Endocrine, nutritional, metabolic, and immunity disorders . . . . . . . . . . . . . . . . 3.0

Perinatal disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.2

Musculoskeletal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.9

Skin diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6

Injury and poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.5

Hematologic disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.9

Gastrointestinal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3

Infectious and parasitic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7

Congenital anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.9

Respiratory diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1

Genitourinary disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.5

Diseases of the nervous system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.7

Symptoms, signs, and ill-defined conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7

Supplementary classification (850/o newborn deliveries) . . . . . . . . . . . . . . . . . . 11.7

Complications of pregnancy and childbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7

conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0

6.3 4,9 3.3

8.0 6.6 5.5

14.5 13.1 13.6

3.0 3.1 3.1

0.2 0.3 0.2

4.6 6.6 5.7

1.7 1.6 1.6

8.4 9.3 9.3

1.0 0.9 0.9

12.1 12.1 13.4

1.7 1.6 1.9

0.9 1.0 0.8

8.1 9.2 10.1

9.4 9.2 10.4

4,4 5 4 4.0

1.3 1.7 2,0

10.9 11.0 11.8

3.4 2.5 2.4

99.9 100.1 100.0

NE = Northeast, NC = Northcentral, S = South, W = West

3.9

6,7

13,2

2.7

0.3

7.0

1.4

11.8

0.7

10.5

1.6

0.9

8.2

8.3

5.1

1.6

13,5

2.6

100.0

SOURCE V/fa/and *a/th Sfatishcs, sefles 13, No 64, DHHS pubhcatlon No (PHS)82-1725 (Washington, DC” Nat!onal Center for Health Statlstlcs, 1982)

Blumberg (20)recently looked at this question from the NCHS Hospital Discharge Survey. Refrom a different perspective. He studied whether stricted activity days are defined as days during

the low LOS and hospital use rate in the West which activity is decreased from usual because of

might be a reflection of a lower prevalence of mor- an illness or injury that has been present for at

bidity in the population. He compared the NCHS least 3 months. He found that people in the West

Health Interview Survey measure of ’’restricted actually reported the highest rates of restricted acactivity days” with LOS and admission rate data tivity days of any region, 37 percent higher than
14 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcome s

Table 6.—Case-mix Adjusted Length of Stay

by Region: 1980

Unadjusted LOS Adjusted LOS

Region (days) (days)

Northeast . . . . . . . . . . . . . 8.5 8.3

Northcentral. . . . . . . . . . . 7.5 7.5

South . . . . . . . . . . . . . . . . 6.8 6.9

West . . . . . . . . . . . . . . . . . 6.1 6.1

United States average . . 7.3 —

SOURCE Calculated from data In Vita/ and lfealth Sfat/stlcs, series 13, No 64,

DHHS phllcation No (PHS) W-1 725 (Washington, DC. Natlonai Center

for Health Statistics, 1982)

those in the lowest region, the Northcentral. After

standardizing LOS by these morbidity measures,

he found that western lengths of stay were lower

than expected while those in the Northeast and

Northcentral were higher than expected. Thus, adjusting for differences in population morbidity actually widened regional LOS differences. While

one may argue that the measure of morbidity used

was insensitive or subject to biased reporting

because of regional population differences in interpretation, the study does establish that regional

differences in this particular morbidity measure

do not account for regional LOS variations.

Two recent PSRO studies have examined the

relationship between case mix or severity of illness and LOS. In both of them, an eastern PSRO

and a western PSRO paired themselves and carefully scrutinized data from medical records for

two specific kinds of patients in an effort to explain the differences between them in LOS. In one

study, the Utah PSRO (UPSRO) and the Central

Massachusetts PSRO (CMPSRO) analyzed LOS

for their patients with myocardial infarction (MI)

and cholecystectomy. Table 8 presents LOS data

for these two PSROs and these two conditions.

The data demonstrate the typical pattern of lower

western LOS for each diagnosis and each insurance subgroup.

In the MI study (24), patients were included

only if they had had a documented MI and were

Federal beneficiaries (Medicare and Medicaid patients). Patients from small hospitals (less than

1,500 discharges per year) were excluded. All of

the patients were classified into severity of illness

categories to distinguish those with uncomplicated

MIs, those with MIs with congestive heart failure,

and those with cardiogenic shock. There were no

differences between the two patient populations

in proportion of patients in each severity class or

in class-specific mortality rates. However, LOS

for each severity class was longer in the CMPSRO

populations.

This study has some important limitations, including the fact that the UPSRO study population represented patients from 3 months in 1979,

Table 7.–Highest and Lowest DHHS Regions for Medicaid Length of Stay in 1980 by

Diagnosis Related Group (DRG)

Number Highest LOS Lowest LOS

Description and number of DRG of cases region (days) region (days)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Normal Mature Newborn (318) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Normal Delivery (278) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Complicated Delivery (281). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Functional Intestinal Disorder (206) . . . . . . . . . . . . . . . . . . . . . . . . . .

Schizophrenia (89) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Seizures, syncope, chest pain, or epistaxis with secondary

diagnosis (323) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Electrolyte disorder (333) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Urinary symptoms (328) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fracture with major operation, including hip

arthroplasty (348) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes (75) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Congestive heart failure (132) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ischemic heart disease without operation (124) . . . . . . . . . . . . . . . .

Acute Myocardial Infarction (121) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pneumonia over age 30 (167) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Emphysema without operation (176). . . . . . . . . . . . . . . . . . . . . . . . . .

357,633

208,641

159,092

58,990

44,206

30,236

27,016

20,860

16,792

15,276

15,996

12,095

11,578

11,066

10,941

Il

a

v

v

II

II

II

II

II

II

II

II

II

II

II

Ill

5.2

3.3

3.8

5.5

20.5

7.3

9.2

7.2

18.9

12.0

11.6

8.5

14.4

12.0

14.4

lx

lx

lx

x

lx

x

x

x

lx

x

x

x

x

x

x

3.3

2.2

2.8

3.6

11.5

4.0

5.2

4.3

12.0

6.8

6.7

4.8

9.8

7.8

6.9

aReglon II - New York, New Jersey, Region Ill - Pennsylvania, Delaware, West Virglnla, Virglnla, District of Columbla, Maryland; Region V = Illinois, Indiana, Ohio,

Wlsconsln, Michigan, Minnesota; Region IX = California, Nevada, Arizona, Hawall; Region X - Washington, Oregon, Idaho, Alaska,

SOURCE PSRO Oata Report/rig and Ana/ys/s System (Baltimore, Md.: Health Standards and Quallty Bureau, 1982).
Ch. 2– Variations in Hospital Length of Stay ● 1 5

— —

Table 8.—1978 Length of Stay Data for Utah and

Central Massachusetts PSROs by Source of Payment

LOS in days

Condition and payment source UPSRO CMPSRO

Myocardial infarction:

Medicare . . . . . . . . . . . . . . 12.9 15.7

Medicaid . . . . . . . . . . . . . . . . . 11.2 14.7

Cholecystectomy:

Preoperative:

Medicare ... . . . . . . . . . . . . . 2.5 4.2

Medicaid ... . . . . . . . . . . . . . 1.7 3.1

Total stay:

Medicare ... . . . . . . . . . . 10,8 15.2

Medicaid . . . . . . . . . . . . . . . . . 8.0 10.5

SOURCE PHDDS /?eport Ser(es, “1978 Medicare/Medicaid Spilt Report” (Bait!.

more, Md Health Standards and C2uallty Bureau, 1 W30)

whereas the CMPSRO population was a sample

of 1978 patients. In addition, patients were included in the study based in part on electrocardiogram readings performed by different physicians who did not employ uniform criteria. Despite these limitations, however, the study is

significant as one of the very few that have attempted to discover what clinical factors underlie

regional LOS differences.

In the cholecystectomy study (25), data were

collected prospectively in both PSROs from February to June 1980. As in the MI study, patients

were classified into disease stages according to

previously developed severity of illness criteria.

Three categories of patients were identified: those

without gallstones (Stage I), those with stones

(Stage ll), and those with severe conditions such

as cholangitis, perforated gallbladder, or emphysema (Stage III). There were more patients in the

most severe class in the CMPSRO population (22

v. 14 percent), fewer patients in Stage I (6 v. 11

percent), and about the same proportion in Stage

ll (72 v. 75 percent). LOS data were given only

for Stage ll patients, where LOS was 3.1 days

longer for CMPSRO patients.

Four other interesting conclusions emerged

from this study. First, patients initially admitted

to the medical service in central Massachusetts had

a far longer LOS than those admitted first to the

surgical service (18.2 v. 10.4 days). The medical

patients in Utah also had a longer LOS, but the

difference was far less (11.2 v. 8.9 days). In both

cases, 70 percent or more of this difference occurred before the operation. Thus, internists in

central Massachusetts took almost 4 days longer

than their Utah counterparts to make the diagnosis of cholelithiasis and arrange for surgery.

Second, there were no differences in the incidence

of postoperative morbidity, rate of common duct

exploration, or the performance of additional procedures between the two PSROs. All of these factors increased LOS in both populations, but their

relative rate of occurrence was the same.

Third, while there was no difference between

the two groups in the day that patients first resumed oral feeding, there was a significant difference in the day of first ambulation. In Utah,

80 percent of patients were ambulatory the day

after surgery, while only 35 percent of the central Massachusetts patients were so treated. This

difference in medical practice may have contributed to the 1.6 day longer postoperative LOS

in central Massachusetts. Finally, the study analyzed the difference in distribution of its patients

according to the anesthesia risk code assigned by

the individual patients’ anesthesiologists. This

measure may be viewed as an independent severity of illness classification. In this analysis, the

Utah patient population had a slightly greater

anesthesia risk than the CMPSRO population.

This finding indicates that within the Stage 11

severity class, CMPSRO’s greater LOS cannot be

attributed to greater severity of illness. Thus, this

study is consistent with the MI study in suggesting

that severity of illness differences do not explain

higher eastern lengths of stay. It is also significant in that it suggests some differences in medical

and surgical practice that may contribute to these

LOS differences.

A similar set of studies was carried out by two

PSROs in the Baltimore area (BPSRO) and the

Multnomah (Portland, Oreg. ) Foundation for

Medical Care (MFMC). The Baltimore City PSRO

(BCPSRO) and the Central Maryland PSRO (CMPSRO) combined to perform medical audits with

MFMC on cataract and cardiac patients. The first

audit, on cataract patients, was selected because

the BPSROs and MFMC exhibited widely diverging lengths of stay for cataract surgery in 1977,

Medicare patients stayed 3.8 days in the hospital

for cataract surgery in MFMC, 7.1 days in CMPSRO, and 7,2 days in BCPSRO. Analysis of their

combined hospital discharge abstract data for
16 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

1978 revealed that these differences persisted after

controlling for sex, race, discharge status, and

secondary operations. A small part of the variation was found to be due to the fact that some

Baltimore patients had bilateral lens extractions

but no MFMC patients did. Wide variations were

found among physicians and hospitals in both

MFMC and BPSRO in average LOS for cataract

patients.

The medical audit was performed using identical criteria on a sample of BPSRO and MFMC

patients from 1980. The audit found that 20 percent of BPSRO patients had preoperative stays

of more than 1 day and that only 14 percent of

these long stays passed the appropriateness criteria. In addition, 42 percent of BPSRO patients

had lengths of stay greater than 4 days, and only

19 percent of these stays passed the appropriateness criteria for postoperative LOS. A 6-week followup assessment was requested from one-third

of the physicians. Inhospital and 6-week rates of

complications were comparable in the two areas

(7).

Three cardiac diagnoses were studied in the second audit: myocardial infarction, congestive heart

failure, and angina. LOS in MFMC was 4 to 7

days shorter than in the BPSROs for all of these

diagnostic categories after controlling for age, sex,

race, pay source, surgery, and multiple diagnoses.

The audit established criteria for making these

three diagnoses and for determining severity of

illness. The results showed that coding accuracy

was comparable across the two areas. In addition,

Baltimore patients stayed 3 to 11 days longer than

MFMC patients in each severity class of each of

the three diagnostic categories. Once again, large

differences were also found among hospitals

within each PSRO area (7).

These studies are consistent with the two studies

from Utah and Massachusetts in demonstrating

that demographic and case mix differences cannot account for large LOS variations between east

and west. Unlike the previously discussed PSRO

studies, the Baltimore/Portland studies did not

attempt to discover what was different about

physician management in the two areas. One can

also question the reliability of physician selfreports of complication rates. None of the four

PSRO studies adequately assessed the outcome

of the treatment rendered to their study patients.

These investigations do, however, represent the

best attempt to date to study in clinical detail an

eastern and western patient population trying to

find severity of illness differences. All four studies

used carefully designed criteria to define graded

classes of severity within the disease categories

analyzed. All four found that large differences in

LOS remained after controlling for severity of

illness.

Complementing these PSRO studies on specific

clinical conditions is the Stanford Institutional Differences Study, one part of which addressed regional differences in LOS and case mix from a

more global perspective. This study (51) examined

the records of 603,000 patients from 17 hospitals

over the 4 years from 1970 to 1973. The hospitals

were a representative sample from among those

participating in the Professional Activities Survey

(PAS) administered by the Commission on Professional and Hospital Activities. Using PAS

abstract data, the study measured intensity of

service, LOS, and outcomes. Intensity of service

was measured as a composite variable that included measures of numbers of laboratory and Xray procedures, surgical procedures, and transfusions; use of physical therapy or intensive care;

and the number of different types of drugs used.

Each of these components was weighted by the

relative proportion of patient charges each area

consumed in order to construct the single composite score for intensity of service. LOS was

measured simply as the number of days of hospitalization. Outcome was measured as proportion of patients who died prior to discharge. Each

of these measures was standardized for differences

among hospitals in admitting diagnosis, additional

diagnoses, age, sex, number of surgical procedures, and complications. This was done by

pooling all 603,000 records and constructing regression equations for each diagnostic group to

predict the values, in turn, of the composite intensity of service variable, LOS, and proportion

of deaths. Each hospital’s actual experience was

then compared to its “expected” experience.

The results are striking. Hospitals that provided

more services and kept their patients fewer days
Ch. 2— Variations in Hospital Length of Stay ● 1 7

had better than predicted outcomes. Each of these

factors had an independent and statistically

significant effect. The combined effect of the two

factors partitioned the 17 hospitals almost perfectly into performance subgroups. The four hospitals

with the lowest standardized death rates all provided greater than expected intensity of service

and shorter than expected lengths of stay. The five

hospitals with the highest standardized death rates

all provided less than expected intensity of service and longer lengths of stay. The remaining hospitals were intermediate. In a two-way analysis

of variance, intensity of service and LOS explained 77 percent of the variance in mortality

rates with all variables standardized.

Even more significant for the present study was

the finding that virtually all of the variation in

LOS could be explained by regional location of

the hospitals. The usual pattern was found. The

West and South had lower than expected standardized mortality rates while the North’s was

higher than expected. The West also provided a

greater intensity of service than expected, while

the North and South provided fewer than expected services. These results are summarized in

table 9. The study then examined the effects of

LOS and intensity of service within regions. The

study found little variation in LOS within region

but found that the intensity of service variable still

predicted outcome within regions: the greater the

intensity of service, the better the mortality rate.

This study is unique in its attempt to associate

regional LOS differences with outcome differences. Several aspects of the study require further

comment. First, after an extensive standardization process that controlled for demographic and

case mix differences among patients, regional LOS

differences in this sample were not only preserved,

but enhanced. The average LOS difference between North and West before standardization was

2.1 days, while after standardization it was 2.4

days. Thus, this study provides further evidence

that demographic and case mix differences do not

account for regional LOS differences. The study

also suggests one very general way in which eastern, western, and southern physicians may differ in their patient management practices. After

adjusting for differences in patient characteristics,

the study found that western patients received

more services than expected, eastern patients received fewer than expected, and southern patients

received even fewer. Table 9 shows these results.

The study did not present data on the components

of this difference, so it is not possible to analyze

what this difference means for specific kinds of

patients. One cannot determine the clinical meaningfulness of these differences in intensity of service. However, this study does provide convincing evidence of definite, if nonspecific, regional

differences in patient management practices.

The most interesting finding of the study from

the perspective of the present analysis is the

association of lower lengths of stay with better

outcomes. While this finding is suggestive, three

important considerations mitigate its impact. The

first is that the magnitude of the mortality difference is quite small. Table 9 reproduces the

crude and standardized mortality rates for the

hospitals in the sample by region. The data show

that after adjusting for demographic and case mix

differences among patients, regional mortality

rates cluster very closely about their expected

Table 9.— Regional Differences in Length of Stay, Intensity of Service, and Mortality Rates

From the Stanford Institutional Differences Study

Length of stay Intensity of Mortality (percent of

Number of (days) service score deaths at discharge)

Region hospitals Crude Standardizeda Crude Standardized Crude Standardized

North . . . . . . . . . . . . . . . 9 9.3 0.8 46.3 -1.0 4.0 0.3

South ., . . . . . . . . . . . . . . 3 7,1 -0,5 42.0 -3.7 2.9 -0.4

West. . . . . . . . . . . . . ... 5 7,2 — 1,6 52.2 1.6 2,6 -0.3

p value for one-way analysis

of variance . . . . . 0.0007 0.0001 0.095 0.085 0,073 0.012

aNegative sign indicate values less than expected after standardizatio n

SOURCE Adapted frcxn table 5, A B Flood, W Ewy W R Scott, et al , “The Relattonshlp Between lntenslty and Duration of Med!cal Services and Outcomes for Hospltallzed

Pat!ents, ” hled Care 17 10I381 102, 1979
18 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health outcomes

values. The West is only 0.3 percent below expected and the North only 0.3 percent above.

The second consideration is the method chosen

for standardization—using pooled PAS discharge

abstracts. Hospital discharge abstracts, such as

the PAS system, have repeatedly been found to

be unreliable reporters of diagnostic and procedural information. The Institute of Medicine

(IOM) studied private abstracting services (including PAS) in 1974 and found that principal

diagnosis was incorrect 35 percent of the time and

that principal procedure* was incorrect 27 percent of the time (128). Moreover, there is considerable room within these diagnostic categories,

even when accurately reported, for large differences in severity of illness. It is true that

the study did use other measures from the PAS

abstract as proxies for severity of illness, including

number and severity of surgical procedures and

secondary diagnoses. However, these are likely

to be subject to the same reliability problems as

principal diagnosis and procedure. Nor can they

entirely reflect severity of illness differences

among patients in the same general diagnostic categories. For example, the Utah-Central Massachusetts PSRO study showed that MI patients who

showed any degree of congestive heart failure but

no signs of shock on admission (i. e., an intermediate level of severity) experienced more than

twice the mortality of those admitted with no

signs of heart failure (32 v. 14 percent). This kind

of difference in severity of illness could not be discerned from a hospital discharge abstract, and

therefore, could not be controlled for in the Stanford study. Therefore, it is possible that the small

differences in mortality that remained after the

standardization method used in the study was carried out could still be explained by severity of illness differences not measured by PAS abstract

variables.

The third and most important consideration is

that the outcome measure assessed only inhospital

mortality. Since the most important potential

danger of short lengths of stay is the possibility

*Although not reported in the PAS study, IOM found in similar

studies of the Medicare and the National Hospital Discharge Survey

systems that, while patients undergoing no procedures were identified correctly about 80 percent of the time, of those patients undergoing procedures, the principal procedure was incorrectly recorded 36 to 43 percent of the time (126, 127).

that early discharge may lead to clinical deterioration and death after discharge, inhospital mortality is an incomplete outcome measure.

Despite these concerns, one must still emphasize

that this study represents the best effort to control for regional differences in case mix and the

only effort to assess the relationship of regional

LOS variations to any sort of outcome measure.

It is consistent with the date presented earlier that

document large variations in regional LOS unexplained by demographic or case mix differences

among patients. Making the most of its data base,

the study documented small, but statistically significant differences in hospital mortality among

regions, with the better outcome associated with

shorter lengths of stay. Unfortunately, the inadequacy of hospital mortality rate as a measure of

outcome when assessing LOS differences lessens

the significance of this finding.

What then can be concluded concerning the

possibility that differences in severity of illness

might explain regional LOS variations? First, all

of the available studies and data are consistent

in failing to document any significant reduction

in regional LOS differences by case mix adjustment. Second, with the exception of the PSRO

studies discussed previously, there has been no

attempt to scrutinize carefully the different patient

populations for severity of illness differences not

revealed in differences among diagnostic categories. The Stanford study did try to go somewhat

beyond these bounds, and its limitations have

already been addressed. The fact that no comprehensive study has been done that assessed regional severity of illness differences of the kind

reported in the PSRO studies is a major deficiency in the existing literature. Until this deficiency

is remedied, the possibility will remain open that

some of the regional differences in LOS might be

attributable to regional differences in severity of

illness among hospitalized patients. Having admitted this possibility, one must stress that, given

the broad similarity of populations across the four

major census regions, it is unlikely that severity

of illness differences large enough to explain the

considerable regional LOS variations could exist.

If there is little evidence that demographic or

case mix differences explain regional LOS variations, what factors are responsible? While a large
Ch. 2— Variations in Hospital Length of Stay ● 19

number of studies have sought associations between LOS and other variables, few have explicitly addressed regional differences. The studies that

have tried to explain differences in hospital LOS

have examined vastly different samples of patients

and hospitals. Table 10 provides a representative,

but not exhaustive, list of the different kinds of

samples that are reflected in the literature. Table

11 lists the factors that have and have not been

shown to be statistically significantly associated

with LOS differences in these studies.

For the purposes of this review, all of these studies are deficient in three crucial ways. First, none

of them addresses the issue of regional LOS differences. Thus, it is unclear whether any of the

factors identified in these studies is an important

factor in explaining regional variations. Second,

none of these studies attempts to discover differences in physician practices that might account

for LOS differences. These factors have been left

entirely out of account. It is only in the PSRO

and Stanford studies discussed above that this

issue has begun to be addressed. Third, none of

these studies looks carefully at severity of illness

Table 10.—Populations Studied for

Length of Stay Associations

1. Six hospitals in Sweden, pediatric enteritis, 1968 (166)

2. Scottish surgeons, eight procedures, 1974 (31)

3. Cholelithiasis patients, one Australian hospital,

1973-79 (89)

4. Winnipeg General Hospital (155)

5. Long-stay obstetrical and gynecological patients,

Edmonton hospital (144)

6. Medicaid and Blue Cross patients, Maryland,

1967-77 (170)

7. Blue Cross/Blue Shield patients, Michigan, 1976 (94)

8. Patients in matched Veterans Administration and nonFederal hospitals (47)

9. Cesarean section patients, University of Virginia

Hospital, 1978 (44)

10. Toronto West Hospital, 1974 (167)

11. Four Boston area hospitals, 1964 and 1974 (159)

12. Teaching hospital in Pittsburg, 1970-71 (104)

13. Two Baltimore hospitals, 1968-70 (132)

14. A Nottingham hospital, 1970 (181)

15. Two Washington, D. C., hospitals, 1973 (1 56)

16. Cataract patients, Washington, D. C., 1977-79 (185)

17. Patients with diabetic ketoacidosis, University of

Missouri Hospital (67)

18.23 New York hospitals, Medicaid patients, 1972 (139)

19. Two London teaching hospitals, 1972-75 (50)

20.22 Pittsburg hospitals, 1963 (145)

21. Surgical patients, University of Virginia, 1973-74 (63)

NOTE See Reference Ilst for complete citations of stud!es in table

Table 11 .—Factors Found To Be Associated and

Unassociated With Length of Stay

Factors associated with Increased LOS:

Comorbid conditions (50,104,166,185)

Complications (44,50,63,144)

Medicaid insurance (170)

Use of consultations (94)

Federal hospital ownership (47)

Turnaround time for laboratory tests (47)

Adverse drug reactions (167)

Number of surgical procedures (104)

Emergency admissions (104)

Teaching hospital (145)

Factors associated with decreased LOS:

Teaching hospital (31)

Proportion of foreign medical graduates on staff (47)

Occupancy rate (47)

Private room use (104)

Close association with chronic disease hospital (132)

Appropriate drug prescribing (98,99)

Primary physician gatekeeper experiment (120)

Presence of outpatient clinic (145)

Factors not associated with LOS:

Distance patient lives from hospital (166)

Social disadvantages (166)

Occupancy rate (104)

Insurance status (104)

Continuity of care (181)

Teaching hospital (156)

Specialist v. generalist care (67)

Health maintenance organization delivery care (1 10)

NOTE See Reference Ilst for complete citations of studies In table

differences, Where case mix differences are considered, most often only primary diagnosis are

used to adjust for such differences. Some studies

consider the presence or absence of secondary or

multiple diagnoses. But none of them consider the

variation in severity of illness that occurs within

diagnostic groups. Again, the PSRO and Stanford

studies cited previously are unique in their examination of this issue.

While the main body of the literature on hospital LOS and its associations may not be very

useful in this analysis, one study does shed some

additional light on regional LOS variations. The

study by Gornick (61,62) has already been cited

in other contexts in this review. She presents the

results of a multiple regression study that was performed using average LOS for Medicare patients

in 1979 as the dependent variable. The PSRO area

was the unit of analysis. She studied the effect of

region as a dummy variable after differences in

demographic and supply variables had been controlled for. The study found that occupancy rate,
20 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

hospital bed supply, and percent of total population living in Standard Metropolitan Statistical

Areas were all positively and significantly associated with higher LOS. Nursing home bed supply

was negatively correlated with LOS. Age, percent

female, and percent non-white were also positively correlated with LOS, although only the latter

two were statistically significant. Even after

regional differences in these factors were taken

into account, significant regional differences in

LOS persisted. Dummy variables representing the

difference between the West and each of the other

three regions were tested. Those for the Northeast

and Northcentral were highly significant, while

the one for the South was not.

Two aspects of this study deserve further comment. First, no attempt was made to adjust for

case mix differences. Thus, this study cannot further clarify the extent to which these case mix differences explain regional LOS variations. Second,

from the perspective of the current analysis, it is

not clear that one would want to adjust LOS differences for differences in area supply or personnel characteristics. Before assessing the magnitude

of any regional LOS differences, it is appropriate

to remove the effects of differences in variables

that might contribute to LOS differences considered to be medically justifiable. Therefore, adjustments should be made for differences in patient

demographic characteristics and case mix. However, it is not clear that differences in bed supply

or occupancy rate result in medically justifiable

differences in LOS. Indeed, any impact on LOS

they may have is likely to be medically inappropriate. Areas with relatively too many hospital

beds and low occupancy rates may, for example,

be induced to keep patients in the hospital longer

than necessary. If their lengths of stay are higher

for these reasons, then it is not appropriate to adjust for the effects of these variables. The relationships of LOS to supply and personnel variables may be interesting from an econometric

viewpoint, but they have little relevance to the

question of whether Northeast lengths of stay are

“too high” or those in the West “too low. ”

Thus far, it has been demonstrated that regional

differences in hospital LOS cannot be explained

by differences in patients’ demographic characteristics. In addition, there is no evidence that case

mix differences explain these variations. It has

been noted, however, that a comprehensive clinical study of regional case mix differences has not

been done. Therefore, the first key question posed

at the outset of this investigation can probably

be answered in the negative. Regional LOS differences are probably not simple functions of population differences in demographic characteristics

or case mix.

There are only fragmentary data with which

to address the remaining two key questions. The

two sets of PSRO studies discussed above provide some documentation that eastern and western physicians manage similar kinds of patients

differently. One example of this phenomenon is

the difference in cholecystectomy patients’ first

day of ambulation in Utah and central Massachusetts. The Stanford study documented that the

western patients in its sample received more services than the eastern and southern patients. However, it is simply not known in any clinical detail

how eastern and western physicians vary in their

patient management of a variety of similar conditions. There has been no comprehensive study

of differences in eastern and western patient management techniques and how any such differences

might account for regional LOS variations. Because data to answer this important question are

largely absent, the answer to the third key question—how patient management differences affect

outcome—must also remain presently unknown.

No study has even attempted to measure regional

differences in outcomes of hospital care in a way

that would allow an assessment of the medical implications of regional LOS differences.

Does this lack of information mean that no conclusions can be drawn regarding the appropriateness of the large regional differences in LOS?

Are there no other data that might illuminate the

problem? While there have been no adequate

studies of the relationship between regional LOS

differences and health outcomes, a large number

of studies have been done that examine the health

consequences of differing lengths of hospital stay

for the same clinical condition. This body of

literature may be of help, assuming that practice

patterns cause the LOS variations.

Since it has been demonstrated that differences

in population demographics and case mix are
Ch. 2— Variations in Hospital Length of Stay ● 21

unlikely to be important factors in explaining

regional LOS differences, it thus appears that

physicians treat similar kinds of patients differently in different regions of the country. If the medical literature clearly establishes that for a particular condition a 10-day LOS has the best health

outcome, regions with lengths of stay for this condition of more than 10 days could be judged as

keeping their patients too long while those under

10 days would be providing too little hospital

care. In performing this analysis, one must be prepared for the possibility that all regions may exhibit current lengths of stay that are either above

or below an optimal LOS determined from the

literature. One must also be prepared for the more

likely possibility that an optimal LOS cannot be

inferred from the literature. However, because it

may shed some additional light on the problem

of regional LOS differences, this kind of analysis

may assist health policy decisions in this area.

The remainder of this case study reviews the

medical literature that describes the relationship

between LOS and health outcomes. A review of

this literature disclosed five clinical areas in which

methodologically sound studies have been performed: acute myocardial infarction, certain elective surgical procedures, low risk newborn deliveries, low birth weight infants, and psychiatric

hospitalization. The studies in each of these areas

are carefully examined to discover what is known

in each clinical condition about the health consequences of differing lengths of stay.

Before proceeding to examine each of these clinical conditions independently, it is important to

consider conceptually the ways in which LOS and

health outcomes might be related. One must first

recognize that the duration of a hospital stay is

not a directly manipulable factor in patient management. If LOS is shortened, then treatment

schedules must be altered in very specific ways.

Some treatments must be foregone, others

changed, and others shortened in duration. For

example, if a patient with pneumonia is sent home

early, one might have to decrease the number of

days during which intravenous antibiotics are

given. The MI patient may be required to get out

of bed and walk sooner. The surgical patient

might have to begin a normal diet sooner and

perhaps leave the hospital with his or her sutures

still in place.

Each of these changes from preexisting practice

may have negative health consequences. The

pneumonia patient might experience a relapse

because potent intravenous therapy was discontinued too soon. The MI patient might suffer an

extension of the infarct, because too much work

was required of the recuperating myocardium.

The surgical patient might experience a wound infection or dehiscence if the wound is not watched

closely and cared for antiseptically. In general,

the potential negative health impact of decreasing LOS would flow from the failure to provide

some aspect of treatment that is effective in improving the health outcome of a particular condition.

Hospital stays may also be beneficial in protecting patients from the adverse health effect of

factors present in their home environments during especially vulnerable periods in their convalescence. Family conflicts may adversely affect

recuperating MI patients. While compliance with

therapeutic regimens can be assured to a great

degree in hospital inpatients, the same is not true

for those discharged. Lack of compliance may

have particularly significant adverse effects early

in convalescence. Early discharge of tuberculosis

patients has been criticized as a possible danger

to public health (133).

On the other hand, hospitals can be hazardous

to one’s health. Complications of hospital treatment are many, including nosocomial infections,

adverse drug reactions (which may also occur

with outpatient treatment, but those that occur

in association with inpatient intravenous drug use

are more frequently very serious), complications

related to procedures, and others. Clearly, one’s

probability of experiencing one of these adverse

effects of hospital care increases directly with one’s

exposure; the greater the LOS, the greater the

chance.

It should be clear, therefore, that the health effect of decreasing LOS cannot be determined a

priori; it is an empirical question that can be addressed only by careful research. The kind of

study best able to illuminate this issue is one in

which the patient population is carefully described

and in which a clearly defined set of treatments

is modified in order to effect a shortened LOS.

Such a study must also measure a set of outcomes
22 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

—

plausibly related to the treatments that have been

altered. From a methodological viewpoint, the

randomized clinical trial (RCT) offers the best

chance at measuring the effects of such an experiment in an unbiased fashion. This case study,

therefore, pays special attention to RCTs.

This case study also excludes studies if changes

in clinical practice render them obsolete. One example is an RCT done in the late 1950’s on early

ambulation of patients with upper gastrointestinal

tract bleeding that was done prior to the advent

of flexible fiberoptic endoscopy and cimetidine

(138). Another example is the question of the

value of bed rest in the treatment of hepatitis. A

series of studies, including some RCTs on military

populations, has failed to demonstrate any benefit

of bed rest in the treatment of this condition

(32,91,142,176). But treatment for hepatitis now

ordinarily takes place on an outpatient basis.

Because hospital treatment is usually reserved

only for patients who experience serious complications of their disease, this subject was considered

outside the scope of this study.

One final point should be borne in mind. Because the effect of changes in treatments on health

outcomes is so dependent on precisely which treatments are altered, in precisely what manner, in

which kinds of patients, one cannot generalize the

results of one study in a particular clinical area

to another. Indeed, because of the many ways in

which study populations can be defined even for

a single condition, one may not be able to compare studies of the same condition very well. The

general proposition of the relationship of LOS to

health outcomes must be investigated by studying each medical condition of interest by itself.
3 .

Length of Stay and Outcome:

Myocardial Infarction
3.

Length of Stay and Outcome:

Myocardial Infarction

Myocardial infarction (MI) is the clinical con- Beginning in the 1960’s and accelerating into the

dition most often studied in the attempt to find 1970’s, increasing numbers of research studies of

a relationship between length of stay (LOS) and early ambulation for MI patients were published.

health outcome. These studies are reviewed in Associated with the appearance of these studies

depth in appendix A and are summarized here. has been a rapid decline in the United States LOS

Virtually all physicians prescribed prolonged bed for MI patients. Figure 3 describes the extent of

rest (usually 6 to 8 weeks) for patients with MIs this decrease by region since 1968. Over the 12

through the 1940’s (109,1 12,123,179). By the early years prior to 1980, LOS for MI patients in the

19.50’s, a few centers were trying earlier ambula- United States fell by 33 percent, compared with

tion and discharge (8,10,27,43,70,90,107,108). 14 percent for LOS for all patients.

Figure 3.— Regional Trends in Length of Stay for Myocardial Infarction

21,0

20.0

19,0

18,0

17.0

 6.0

15.0

 14.0 —

 13.0

< 12. 0

11.0

10.0

r

Northeast

\

\

Northcentral

\

---- -\ U.S. average

West

9.0

o

I 1 1 1 I I 1 1 1 1 I I

1968 1971 1975 1980

Year

SOURCE V/ta/ and Health Stat/st/cs series 13, Nos 2, 10, 14, 17, 19, 23, 26, 31, 41, 46, 55, 60, 64 (Washington,

D G Nafional Center for Health Stat! stlcs, 1967-82)

25
26 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

—

The literature contains three different kinds of

studies. The first group comprises studies that

analyzed clinical data retrospectively trying to explain variations in treatment practices or to identify characteristics of low-risk MI patients who

might be candidates for early discharge. Studies

in the second group reported the effects of early

ambulation and discharge programs for MI patients without providing any control data. Studies

in the third group provided control data, including

some that were randomized clinical trials (RCTs).

The data provided by each of these groups of

studies are summarized in turn, focusing on the

third group. They are reviewed in detail in appendix A.

Several studies have attempted to examine variations in individual physician practices with

respect to LOS for MI patients (46,76,137,147,177)

with no conclusive results aside from demonstrating large variations in LOS among physicians.

Another series of studies has attempted to define

criteria that would identify low-risk MI patients

(111,117,158,163,165,182,183). Of all these sets

of criteria, the one most often studied is the one

developed by McNeer and colleagues at Duke

University. They first observed in 1975 (117) in

an analysis of 522 consecutive patients with documented MIs, that patients who had suffered a serious complication after the first 4 hospital days

also had had one during the first 4 days. The complications identified as serious were: death, ventricular fibrillation or tachycardia, second or third

degree AV block, pulmonary edema, cardiogenic

shock, persistent sinus tachycardia or hypotension, atrial flutter or fibrillation, and extension

of infarct. They also found that of the patients

without complications in the first 4 days, there

was no inhospital mortality during an average

LOS of 17 days. The 6-month mortality was 8 percent. This compared with an inhospital mortality of 14 percent and a cumulative 6-month mortality of 19 percent in the complication group. In

their original series, patients with uncomplicated

MIs made up 51 percent of the total MI population.

The Duke criteria have been replicated in three

retrospective studies with similar results (158,165,

183). However, one cannot conclude from these

studies that patients without complications in the

first 4 hospital days following an MI can be safely discharged after that time. All of the studies

thus far mentioned were retrospective; no attempt

was made to actually discharge the low-risk patients earlier than their physicians at the time

thought appropriate. It is entirely possible, then,

that earlier ambulation in preparation for earlier

discharge would have proved harmful. The fact

that all of these studies used almost identical criteria and found similar results lends added weight

to the potential reliability and validity of these

criteria as predictors of good prognosis and, therefore, of candidates for early discharge. Better data

are needed, however, in order to establish this

proposition conclusively.

Eight studies report results from uncontrolled

attempts to mobilize and discharge uncomplicated

MI patients early (2,22,26,27,35,53,173,174). It

is difficult to draw definitive conclusions from

these studies. First, none of them was performed

in the United States. Second, the studies excluded

significant, but varying portions of the population. Four excluded women, and two excluded the

elderly. Third, the definitions of early ambulation and discharge varied among the different

studies. But the most serious difficulty with these

studies is the absence of any comparison data.

Without carefully selected control groups, one

does not know whether the patients who ambulated and left the hospital early would have done

better or worse if treated for a longer time in the

hospital.

Of those studies that have provided data from

control groups, five reported results for controls

selected in ways other than by random assignment

(21,66,69,102,116). All of these studies developed

protocols for identifying and discharging early

low-risk patients with uncomplicated MIs. Their

methods of selecting controls, however, prevents

one from concluding that the differences they

report between study and control patients are due

solely to the early discharge program. One (66)

allocated patients to study and control groups

based on which of two physicians cared for the

patients. One (69) allocated patients according to

which of two hospitals was the site of treatment.

A third (21) compared patients who left within
Ch. 3—Length of Stay and Outcome: Myocardial Infarction ● 2 7

10 days to those who remained after that time.

The fourth study (102) is unclear about how its

controls were selected.

The fifth study (116) in this group is a prospective study conducted by McNeer and colleagues

to test the Duke criteria. Using these criteria, the

authors identified 67 of 158 consecutive patients

with MIs as candidates for early discharge. Only

33 were actually discharged early (at 1 week),

because most of the remaining patients did not

have a home environment suitable for the planned

intensive followup care. There were no deaths in

either subgroup of patients at 6 months following discharge. There were five nonfatal complications at 6 months in the early subgroup and nine

in the late.

This study and its accompanying editorial generated some lively correspondence (125,149).

Many writers were concerned that the lack of randomly chosen control patients may have resulted

in a control group that was different in subtle

ways from the study group. Perhaps the less optimal home environments of the patients discharged late somehow contributed to their somewhat higher rate of nonfatal complications. Only

a true RCT is capable of laying this kind of argument to rest.

Five RCTs have been reported that attempt to

assess the health consequences of discharging lowrisk MI patients early (5,17,71,86, 118). Two are

so methodologically flawed that their results cannot be interpreted with a satisfactory degree of

reliability (5,71). The three remaining studies

merit close scrutiny. In the earliest one, Hutter

and his colleagues (86) compared 2 weeks of hospital care with 3 weeks in the treatment of patients

with uncomplicated MIs. Their criteria for an uncomplicated MI were quite strict, and only 17 percent of patients assessed for possible inclusion in

the study were actually included. At 6 months

following discharge, 4 percent of the patients discharged at 2 weeks were dead compared with 7

percent of those discharged at 3 weeks.

The other two RCTs, one from Scotland (118)

and one from Switzerland (17), used similar protocols and studied the difference between 3- and

4-week hospitalizations for patients with uncomplicated MIs. They excluded patients over 70 in

addition to those with complicated MIs, but 6 9

and 80 percent of patients assessed were actual] y

included in the study. In the Scottish study, II

percent of patients discharged at 3 weeks had died

by the end of the 12-month followup period as

opposed to 15 percent of the 4-week group. In the

Swiss study, 6 percent of the early group had died

by the end of an Ii-month followup period compared with 10 percent of the late group. None of

the differences between the early and late patient

groups in any of these three RCTs was statistically

significant at the 5-percent level.

Constructing 95-percent confidence intervals for

the difference in mortality between the early and

late groups in each of these three studies is very

informative. In the first study, the findings are

compatible with differences ranging from 11 percent in favor of the early group to 5 percent in

favor of the late group. In the second study, the

data vary from 9 percent in favor of the early

group to 2 percent in favor of the late group. And

the third study varies from 13 percent in favor

of the early group to 5 percent in favor of the late

group. Because zero is included in all of these confidence intervals, the findings of these studies—

that slightly fewer patients in the early group

died—does not attain statistical significance.

The principal conclusion that one may draw

from these studies is that early discharge of patients with uncomplicated MIs, as defined in the

studies, is unlikely to pose a major health hazard.

It may carry with it a significant benefit, about

a lo-percent decrease in mortality. But it may also

carry with it a small adverse outcome, about a

5-percent increase in mortality. The studies do not

rule out the possibility of a negative impact on

health. Studies of much larger sample size would

be required in order to settle the question definitively. Finally, with respect to the Medicare program, it is important to recall that since two of

the three rigorous RCTs excluded patients over

70, there is a special dearth of data from which

to draw any informed conclusions concerning the

elderly and early discharge for MI patients.
4 ■

Length of Stay and Outcome:

Elective Surgery
Length of Stay and Outcome:

Surgeons now commonly encourage their patients to get out of bed and walk within the first

day or two following many different surgical procedures. The history of attempts to achieve early

postoperative ambulation is long and colorful, beginning in Chicago with Emil Ries in 1899 (143)

and culminating with the widespread acceptance

of the practice in the 1950’s (8,18,19,23,28,36,59,

103,106,131,136,141). Once the principle of early

ambulation was accepted, the next step was to experiment with shorter and shorter lengths of stay

(LOS).

As in the myocardial infarction literature, three

different kinds of studies have been performed

evaluating the relationship between health outcome and LOS for elective surgery. The first

group includes studies that have analyzed existing

data on LOS, trying to explain differences. The

second group comprises the large number of uncontrolled trials of early discharge following certain kinds of elective surgery. The third group includes a number of randomized clinical trials

(RCTs) that have been carried out. Each of these

groups of studies is reviewed in detail in appendix B. They are summarized here, focusing on

RCTs.

The studies in the first group reported and analyzed LOS differences (64,65,75,92,119,157,168,

178). Some looked at differences between the

United States and Great Britain, finding British

lengths of stay longer, but not discovering why.

The rest of the studies in this group reported large

differences in lengths of stay across regions,

among individual hospitals in the same region,

and among individual surgeons. None found any

relationship between LOS and outcome or quality of care, though these were usually crudely

measured. None succeeded in explaining the LOS

differences they observed.

The second group of studies represents the most

common type of report found in this literature:

the uncontrolled trial of early discharge (6,11,12,

Elective Surgery

30,33,34,41,45,49,55,84,87,122, 150,152,153,169,

171,180). This usually takes the form of a single

surgeon reporting his hospital’s experience with

a particular scheme of early ambulation and discharge. The specific surgical procedures most

commonly studied are repair of inguinal hernia,

varicose vein ligation, and hemorrhoid removal.

The studies are almost exclusively British. Some

report experience with same-day surgery, where

the patient is treated in the same hospital by the

same staff that might otherwise have used inpatient postoperative care. But in these studies patients are observed for a variable period following the procedure and then discharged home within 8 hours, without an overnight stay in hospital.

Some of the studies report trials of short-stay

surgery, where patients are simply discharged

from the postoperative inpatient ward 1 to 3 days

after surgery, Studies involving treatment provided at freestanding surgicenters have not been

reviewed, because the scope of this case study is

limited to LOS in the acute hospital.

The results of these studies are fairly consistent.

Mortality is extremely small, less than 0.1 percent. Thus, it is difficult to evaluate these studies

with respect to operative mortality. While a study

would have to include over 1,000 patients before

even one postoperative death could be expected

to occur, each of these studies comprise at most

a few hundred patients, frequently representing

patients undergoing several different procedures.

Yet, other outcome measures have been reported.

Recurrence of inguinal hernia is perhaps the most

important for evaluation of herniorrhaphy. The

rate of recurrence is also usually low, often under

1 percent. It is also often difficult to determine

the rate precisely from published reports, since

patients have been followed over different postoperative periods, and total patient-years at risk

for recurrence are usually not reported. In addition, postoperative complications have been reported as an outcome measure. These complications may range from small wound hematomas

98-821 0 - 83 - 6 : Q L 3

31
32 ● Health Technology Case Study 24: variations in Hospital Length of Stay: Their Relationship to Health Outcomes

.

to serious infections. Their incidence is often not

small, 10 percent in some of these studies. But it

is usually difficult to interpret these figures, because different authors use different definitions

of complications, and many authors do not state

what these definitions are.

The most crucial defect in all of these studies,

however, is the lack of control data. Without

knowing precisely how a comparable group of patients fared when treated in the more traditional

manner, one cannot evaluate these programs of

early ambulation and discharge. Since the only

outcome measure these studies are large enough

to address is postoperative complications, the

most important question that they leave unanswered is: Would the rate of complications have

been even lower in a group of patients treated with

longer periods of inpatient postoperative care?

The seven RCTs that have been performed in

this area are potentially able to answer this question (3,4,48,54,121,151,154,161). Two of these

studies are so methodologically poor that their

results are impossible to interpret (48,54). One of

them concerns LOS for gallbladder and ulcer surgery (161). This last study was very well done and

demonstrated that LOS could be shortened by 2

days for these patients without any demonstrable

harm. The remaining four RCTs tested the effects

of early discharge, from 3 hours to 2 days following surgery, for patients undergoing inguinal herniorrhaphy, varicose vein ligation, and hemorrhoidectomy. The early discharge schemes were

compared usually to traditional inpatient postoperative stays of 5 to 6 days. All of the studies

were performed in Great Britain, and all excluded

the elderly and patients with chronic disease. One

excluded women.

The results of these four RCTs are remarkably

consistent. There were no significant differences

in any of them between the early and late discharge groups in operative mortality or hernia

recurrence. No operative deaths were reported in

any of the studies. This should not be surprising,

however, since only 880 patients were involved

in all four studies combined. All of the studies also

reported higher postoperative complication rates

for the groups of patients discharged early, from

8 to 15 percent higher than the patients with traditional lengths of stay. In two studies, the differences did not attain statistical significance; in

one, the difference was of borderline significance

(significant only at the lo-percent level); and in

one, the difference was statistically significant at

the 5-percent level. Finally, all four studies reported that their early discharge patients used

significantly more outpatient services following

their surgery than the patients discharged later.

One of the studies tried to measure the extent of

the savings realized by the early discharge (3,4).

These authors reported a definite savings in hospital costs, but this was almost entirely offset by

an increased cost in the early discharge group due

principally to longer time off from work.

Interpreting the results of these studies raises

some difficult questions. None of the studies was

large enough to address the effects of early discharge for the two most clinically important outcomes of herniorrhaphy-operative mortality and

hernia recurrence. This is particularly distressful,

since herniorrhaphy is the prototype early discharge procedure. One is thus left in a situation

similar to that found when examining the myocardial infarction literature. Very large and expensive studies would have to be done to answer the

question of whether early discharge has a small,

but clinically significant effect on these outcome

measures.

Should such studies be done? Or should the risk

be taken that operative mortality and recurrence

rates may be somewhat higher in early discharge

or outpatient surgery programs in order to reap

their monetary benefits? And what are those benefits? The only RCT to address this issue explicitly

found that men who had their hernias repaired

on a short-stay basis were out of work somewhat

longer than those patients who stayed longer in

the hospital. Short-stay patients also consume

somewhat more outpatient services than their

longer staying counterparts. These findings suggest that any immediate savings realized from

shorter hospital stays may be offset in part or in

full by other costs. How the results of this RCT,

which was performed in Great Britain, might have

differed if done in the United States is difficult to

assess.

Finally, these studies raise the difficult issue of

how to balance the cost of a slightly higher postoperative complication rate against the benefit of
any monetary savings. All of the authors describe

the complications they report as minor, but they

do not provide any information on how long these

complications persisted or how much disability

they caused. Perhaps the higher rate of minor

complications in the short-stay group accounted

for their somewhat longer absence from work.

Ch. 4—Length of Stay and Outcome: Elective Surgery ● 3 3

Comparing these complications against the

monetary savings is made all the more difficult,

because so little is reported concerning them, and

because the level of monetary savings is unknown.

The studies reviewed here do not provide definitive answers to any of these difficult questions but

have provided the data necessary to frame them.
Length of Stay and Outcome:

Obstetrics
5 ■

Length of Stay and Outcome: Obstetrics

Discussions of length of stay (LOS) in the obstetrical literature have centered around two different patient groups: patients with normal deliveries and patients with low birth weight infants.

The discussion here will focus on U.S. studies of

these problems. Although there has been some

work done in Great Britain on normal deliveries

(1,160,172), the long tradition of home births

makes their experience very different from that

of the United States and of only slight relevance.

Some work has also been reported from developing countries (162, 164), including a randomized

clinical trial (RCT) from India (16). Major differences in maternal risk factors, prevalence of infectious diseases, and infant mortality rates between

the United States and these areas make it impossible to generalize from this work to U.S. populations. As already discussed in other chapters, this

case study does not deal with places of care outside the acute care hospital. Thus, a discussion

of birth settings outside the hospital is beyond the

scope of the present analysis. A review of the literature on the safety of different birth locations has

recently been published (88).

Following World War II, rising birth rates rapidly led to shortages of maternity beds in U.S.

hospitals, where the vast majority of birth takes

place. This situation forced obstetrical departments to reduce lengths of stay for postpartum

patients. One study appeared in 1962 that described this phenomenon. Hellman and Kohl (77)

describe a study that compared outcomes among

all patients discharged within 72 hours of a normal delivery with a random sample of all other

maternity patients. They found no difference in

the incidence of complications among either mothers or infants discharged early, as measured by

subsequent development of illness in the infants

when seen as outpatients, by readmission rates,

and by mortality rates. More of the short-stay

mothers were dissatisfied (7. 7 percent) with their

LOS than were those mothers who stayed longer

(1.8 percent). The authors concluded that while

they did not document any risks to early discharge, the risk of neonatal jaundice developing

at home within the first week of life was significant and warranted home visits by a nurse during that time. The operation of such a program

has also been reported (40).

This study has all of the problems of studies

failing to employ random allocation procedures

to select control groups. There is a clear potential bias in this study for the control group to be

significantly sicker than the experimental group.

The finding that on some measures the experimental group did slightly better than the control group

is therefore not surprising. One does not know

whether they did better simply because they were

healthier or because they were discharged earlier.

In fact, one may wonder about the possibility of

early discharge having actually harmed the experimental group, since none of the differences

in outcome was statistically significant. If there

was a significant bias and the study group was

healthier, perhaps early discharge canceled this

advantage.

There is a single RCT involving early discharge

of patients following normal deliveries. Yanover

and colleagues (184) reported it in 1976 from San

Francisco. This study compared discharge planned

for 12 to 24 hours following delivery with discharge at 48 to 72 hours in a highly selected group

of patients. Eligible patients were required to have

had at most one other child; the mother was required to be between 19 to 35 years of age and

of low medical risk; and the father was required

to attend prenatal classes and to be living with

the mother within 20 miles of the hospital. These

criteria resulted in the elimination of 76 percent

of the 362 mothers initially screened for participation in the study. The remaining 88 patients were

randomly assigned to study and control groups.

Study patients were discharged at 12 or 24 hours,

providing the mother and infant met certain criteria designed to identify fitness for early discharge. These included the absence of fever, the

presence of normal blood pressure, and the absence of excessive vaginal bleeding in the mother.

The criteria also included a birth weight between

6 and 9 pounds, normal vital signs, absence of

37
38 ● Health Technology Case Study 24: variations in Hospital Length of Stay: Their Relationship to Health Outcomes

feeding difficulty, and an Apgar score of eight or

greater at 1 minute for the baby, Following discharge, the study group received home visits from

a specially trained perinatal nurse practitioner.

Failure to meet discharge criteria prevented 23 of

44 study patients from going home within the targeted period of 24 hours after delivery. The average LOS was considerably lower in the study

group (1.8 v. 3.4 days), and none of the control

patients went home within the first 24 hours.

The patients were followed for 6 weeks after

discharge. No statistically significant differences

were measured in rates of complications among

infants or mothers, although the rate of morbidity

among infants in the study group was less than

among those in the control group (9 v. 20 percent). None of the mothers was readmitted during the 6-week followup period. The authors concluded that their program was safe and stated that

they hoped that it would promote better bonding

between mother and infant, although they did not

attempt to measure this phenomenon. They also

estimated that the costs of the program were about

the same as the savings that resulted from early

discharge.

This study documented that, for a highly selected group of patients, the combination of early

discharge, prenatal education, and a program of

home care produced results comparable to more

traditional care. Once again, small sample sizes

prevent one from drawing any solid conclusions

about the effect of the program on infrequently

occurring events such as neonatal mortality. The

study almost demonstrated a statistically significant benefit of the program in reducing neonatal

morbidity. The 95-percent confidence interval for

the difference in morbidity rates for the infants

in the study and control groups ranges from 26

percent in favor of the study group to 3 percent

in favor of the control group. From a clinical

viewpoint, one must believe that the program of

home followup care included in this study was

heavily responsible for this result, with some contribution from the decreased exposure of the infant to the hospital environment by early discharge. It is not at all clear that the same results

could be achieved by a program that involved

only early discharge and did not also provide

home care. From an economic viewpoint, therefore, this study does not offer great hope of saving large amounts of resources by drastically reducing LOS for the millions of patients discharged

annually with normal deliveries. Moreover, this

study does not provide evidence that such a policy

would be safe.

LOS for uncomplicated deliveries in the United

States has fallen steadily since 1968, even in the

absence of pressure from the postwar baby boom.

Table 12 shows how each region has declined in

this measure. All but the South experienced declines greater than the decline in average LOS for

all patients in their regions. Based on 1978 regional

LOS patterns, if all regions were able to achieve

the same 1.8 day average LOS for 24 percent of

their patients with uncomplicated deliveries as this

study did, then a total of about 848,000 postpartum hospital days could have been saved: 11 percent of the total spent. While this calculation

clearly shows the great potential saving in this

area, one must hesitate from generalizing too

widely from a single study. One must be even

more careful to avoid generalizing beyond the

limits imposed by the study itself. This was a

study of early discharge, education, and home

followup care, where the costs of the second entirely canceled the savings from the first. Additional research is required before it can be conTable 12.—Regional Trends in Length of Stay for Uncomplicated Delivery

Length of stay (days) Percent change

Region 1968 1978 1968-78

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.7 3.9 - 1 7

Northcentral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 3.7 - 1 6

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5 3.1 -11

West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 2.5 - 2 6

United States average. . . . . . . . . . . . . . . . . . . . . . 4.1 3.3 -20

SOURCE Vita/ and F/ea/th Statisfic$ series 13, No 84, DHHS publication No (PHS) 82.1725 (Washington, D C. National Center

for Health Statistics, 1982)
Ch. 5—Length of Stay and Outcome: Obstetrics ● 3 9

eluded that early discharge alone is safe and

economical.

Low birth weight infants are generally defined

as those born weighing 5 pounds or less at birth.

Traditionally, in the United States, they have been

kept in the hospital until they have attained a

weight of 5 to 511⁄2 pounds, This procedure was

questioned in the late 1960’s and early 1970’s by

three studies that allowed these infants to go home

prior to the attainment of fixed target weights.

Instead, they used criteria designed to assess the

infant’s ability to function satisfactorily at home.

The first study (14) examined a group of 68 babies

who went home with a mean discharge weight of

41⁄2 pounds after an average LOS of 11 days. This

group was compared to a sample of other low

birth weight infants cared for at other hospitals

in the same State. These infants were discharged

at an average weight of 51

/3 pounds after an average LOS of 22 days. No significant illness occurred

in the study group. The two other early studies

(9,13) were uncontrolled. Both found a low incidence of problems following early discharge for

a group of low birth weight babies. Bauer and

Tinklepaugh (9) reported that 2 of 57 such infants

did poorly after discharge, one recovering after

a period of slow growth, the other succumbing

to sepsis that apparently began 5 days after discharge. Berg and Salisbury (13) extended their previous series and reported no fatalities at 2 months

after discharge in a group of 170 early discharges.

However, they found that one infant developed

pneumonia and one pair of twins experienced

poor weight gain. Without randomly selected com

parison groups, these data are difficult to

interpret.

One RCT has been done in a U.S. population

in this area, Dillard and Korones (42) reported

a study in which low birth weight infants in Memphis were randomly assigned to study and control groups. In the study group, infants were required to attain a weight of 2,000 gm (4 pounds

6 ounces) prior to discharge; control infants were

required to weigh the usual 2,268 gm (5 pounds).

Other criteria were included to ensure that the

babies were healthy and gaining weight consistently before discharge. Of 548 infants randomly

assigned, 51 died prior to discharge, and another

87 were excluded because their discharge weights

were more than 100 gm over the target for their

group. Average LOS was 19 days for the study

group and 25 days for the controls. There was

no difference in average daily weight gain as outpatients. At four weeks, 4 percent of the study

group and 5 percent of the controls had been rehospitalized, while 0.5 percent of each group had

died. A similar study from England (39) showed

no readmission in three months for 20 early

discharge low birth weight infants and 20 controls.

The study reported by Dillard and Korones (42)

was a well-executed RCT. The principal problem

in interpreting the results of the study is the

familiar one of statistical power. The study had

a very small chance of detecting any clinically important differences in mortality rate. Assuming

the mortality rate in the control group to be 0.5

percent, as measured, the study had only a 14-percent chance of rejecting the null hypothesis of no

difference even if the study group’s mortality rate

had actually been twice that. As with elective surgery, the sample size in this RCT was inadequate

to measure important differences in mortality.

On the other hand, the study was not so bad

with respect to readmission rates. The 95-percent

confidence interval for the true difference between

the study and control groups in hospital readmission rates ranged from 4.9 percent in favor of the

study group to 3.6 percent in favor of the control group. If the true readmission rate for the

study group had been twice that actually measured for the control, the sample sizes in this study

would have given it a 58-percent chance of detecting this difference at the 5-percent level of significance. The study did show that this particular

early discharge program did not result in large differences in either positive or negative events for

the study group. Whether patients discharged

early were exposed to a somewhat greater risk of

dying or a slightly increased risk of readmission

to hospital has not been proven.
6

Length of Stay and Outcome;

Psychiatry
6

Length of Stay and Outcome: Psychiatry

The trend toward less inpatient hospital treatment for psychiatric patients has been established

for well over a decade. A series of randomized

clinical trials (RCTs) appeared in the 1970’s that

compared various regimens of brief hospital treatment with more traditional, longer periods of inpatient care for serious psychiatric disorders.

Herz and colleagues (80) reported the first large

RCT studying the appropriate length of stay

(LOS) for psychiatric patients, 49 percent of

whom were schizophrenic. All patients newly admitted to the psychiatric unit of Columbia Presbyterian Medical Center in New York were evaluated for possible inclusion in the study. Seventynine percent of all patients screened were rejected—patients who were too ill or too healthy,

those with uncooperative families, and those with

concomitant physical illness. The remaining 90

patients were randomly assigned either to a control group receiving usual 24-hour per day inpatient treatment or to a study group that was

treated with day care in the same ward, 8 hours

per day, 5 days per week. LOS for the initial hospitalization was drastically reduced—48 days for

the study group as opposed to 139 days for the

control. During the followup period, the control

group was rehospitalized more often and demonstrated more psychopathology than their counterparts in the study group.

Caffey (29) reported a trial that included two

study groups in addition to a control group

treated with the usual inpatient care. One study

group received a maximum of 21 days hospitalization followed by intensive outpatient treatment.

The second study group received the usual hospital care followed by the same outpatient treatment. The study accepted 201 schizophrenic men

after a larger, but unreported, number were

screened at the 14 participating Veterans Administration hospitals using criteria similar to the

first study. The study was successful in discharging the short hospitalization group, as 81 percent

were released within a month. In contrast, only

33 percent of the control group and 24 percent

of the second study group were discharged during the first month. Readmission rates during the

year after discharge were equal in the first study

and control groups (34 percent) and somewhat

lower in the second study group (24 percent). The

average length of time spent out of the hospital

prior to readmission was 20 days longer in both

of the study groups compared to the controls.

There was no difference among the groups in

measured levels of psychopathology or functioning abilities.

Glick and his coworkers (56) randomly assigned

consecutively admitted patients to short- or longstay groups. They analyzed their results separately

for their nonschizophrenic and their schizophrenic

populations. The 74 nonschizophrenics were evenly divided among study and control groups. The

study patients averaged only 26 days during their

initial hospitalization compared with the control

group’s 100 days. At 1 year following discharge

(58), the long-stay patients had experienced twice

as many readmission (0.4 readmission per patient for the long-stay group v. 0.2 per patient for

the short-stay group) and almost twice as long a

LOS per readmission (35 v. 19 days). In addition,

fewer patients avoided rehospitalization in the

long-stay group (76 v. 84 percent). None of these

differences is statistically significant at the

5-percent level. Functional evaluation showed that

on the vast majority of measures, no differences

could be found between the two groups; on 2 of

27 measures the long-stay group showed a slight

advantage, These differences were considered

clinically insignificant as the authors concluded

that their study did not provide “strong support

for the use of the more expensive longer hospitalization for nonschizophrenic patients. ”

The results for schizophrenic patients showed

similar evidence of increased use of psychiatric

services for the long-stay group (57,68). At 2 years

following discharge, the long-stay group had spent

almost twice as many days in the hospital as the

short-sta y group (17 days per patient v. 9 days).

They also averaged 46 percent more psychotherapy visits per month. In addition, fewer patients

43
44 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

in the short-stay group were taking phenothiazines, and those who were taking the drugs were

receiving a lower dose than their counterparts in

the long-stay group. While the hospitalization results were not statistically significant, the drug

results were. Functional testing showed that at 1

year after discharge, the long-stay group scored

slightly better on global measures of severity of

illness than the short-stay patients. These differences, which were statistically significant, had decreased by the 2-year followup assessment. The

authors noted that the better results might have

been caused not by the longer initial hospital stay

directly, but rather by the greater exposure of

long-stay patients to psychiatric care during the

followup period. In addition to this possibility,

this study has been criticized for inadequate comparability of study and control groups despite random assignment, It has also been criticized for inappropriate treatment of the short-stay group, in

particular the failure to provide post-discharge

treatment (81).

Herz, et al. (78,79), have also reported a study

in which newly admitted patients, selected because

they had cooperative families, were randomly assigned either to one study group in which a brief

planned hospitalization was followed by day care,

to a second study group in which brief hospitalization was followed by discharge to the community, or to a control group treated with the more

lengthy, traditional period of hospitalization. A

total of 175 patients were randomly allocated to

these three treatments. Of the total, 63 percent

of the patients were schizophrenic. It is not clear

how many were rejected by failing to meet the

selection criteria. LOS for both study groups

averaged 11 days; the control patients stayed an

average of 60 days. All groups improved in their

measured levels of psychopathology; there were

no statistically significant differences in improvement among groups. Furthermore, there were no

differences among groups in readmission rates.

However, both study groups spent far fewer total

days in the hospital during the 2-year followup

period than the control patients. The study group

with home care spent an average of 27 days per

patient in the hospital during the followup period,

the study group without home care experienced

47 days per patient, and the controls experienced

115 days.

A similar study was performed by Hirsch and

colleagues (83, 100) in London. Selection criteria

similar to those noted above were used to identify 224 candidates for this RCT, in which the

study patients were treated with a brief period of

hospitalization and the controls with the usual,

longer period. The study patients spent an average

of 22 days in the hospital, exactly twice as long

as the study patients in the previous study, and

the controls averaged 28 days. No differences in

readmission rates or days hospitalized during the

followup period were found. Nor were any differences measured between the two groups in improvements in psychopathology; 81 percent of the

study group improved as did 79 percent of the

controls.

Kennedy and Hird (95) reported a study in

which 76 percent of newly admitted patients were

randomly assigned either to one brief treatment

ward or to two traditional treatment wards all at

the Royal Edinburgh Hospital. The only reported

criterion for rejection from the study was continuity of care—i. e., if a physician felt that particular

patients would be best served by remaining with

staff who had treated them previously, they were

withdrawn from the study, This criterion applied

to 27 percent of patients randomly assigned to the

experimental ward and to 22 percent of those assigned to the control wards. There were 86 study

patients and 161 controls. Significant differences

were recorded between study and control patients

in average LOS for the initial hospitalization (11

v. 24 days) and in average hospital days during

the entire study period (17 v. 31 days). It should

be noted that, as with the previous study, there

was no difference between the groups in followup

hospital days. Thus the difference in total days

was entirely accounted for by differences in the

initial LOS. No differences in outcome measures

assessing the patients’ psychopathology by interviews with patients and families were found. Nor

were there any differences in the degree to which

patients burdened their families. Control patients

were seen more often by their general practitioners; they averaged one contact per patient in

the 3 weeks after discharge while controls averaged 0.5,

Rosen and colleagues (114,115,148) have published a series of papers describing a study that
Ch. 6—Length of Stay and Outcome: Psychiatry ● 4 5

. .

was not strictly a RCT. The study is reviewed here

briefly, because it is cited prominently in the field

as an influential work. Patients were allocated to

two experimental wards and three control wards

on the basis of bed availability. No clinical or

sociodemographic characteristics were used to

assign patients. For reasons not explained, control beds were filled first, then study beds. The

study evaluated results only for the patients officially discharged; patients leaving against medical advice were excluded. The proportion of patients in the study and control groups who chose

this option was similar (28 v. 27 percent). Shortstay patients stayed an average of 86 days; they

had a target stay of less than 90 days. Long-stay

patients experienced an average LOS of 179 days;

they were discharged when their attending physicians felt that maximum benefit had been

achieved. The fact that the study was conducted

from 1970-71 may explain why the short-stay

group’s LOS was so much longer than that employed in later studies. Despite lack of random

assignment, study and control groups were similar

in most demographic and clinical measurements.

The short-stay group did exhibit more cognitive

disturbance than the long-stay group; this was the

only significant initial difference.

The study also found that the short-stay patients had improved slightly more than the longstay patients at the time of their respective

discharges. At the end of the 3-year followup

period, 24 percent of the 58 control patients had

been readmitted compared to 22 percent of the

study patients. The control patients were readmitted almost twice as frequently (2.1 v. 1.1 readmission per patient) and for longer periods each

time (4.6 v. 2.9 months) than the study patients.

Followup at 3 and 4 years showed that the two

groups were similar in exhibiting mild to moderate

psychopathology, but the long-stay group did

score slightly better where the differences were

statistically significant. None of these differences,

which were few in number, was felt to be clinically

significant. The results of this study, while consistent with those of the main body of RCTs discussed above, can be criticized, because a true random allocation procedure was not used. While it

is difficult to determine precisely how the assignment scheme actually used might have biased the

experiment without a great deal more information, there is no question that the risk of bias was

greater in this study than in a true RCT.

The information generated by these studies is

largely internally consistent. In four of seven

studies, the long-stay groups experienced more

days in the hospital during the followup period

than did the short-stay groups, In five of seven

studies, no clinically significant functional differences could be found between the two groups.

One study found slight differences in favor of the

short-stay group, and one study found similar differences in favor of the long-stay group. While

the authors of these studies discussed Type 11 errors no more frequently than the authors of the

other studies reviewed here, it is evident that the

power of these studies was greater than those

previously discussed. Because data on standard

deviations of functional assessment measures were

not given, one cannot calculate precise estimates

of power from the data reported in these studies.

However, several of them noted statistically significant improvements over time in their patient

populations, frequently about 20 percent (95).

One infers that similar differences could have been

detected had they been present between study and

control groups.

The general conclusion that emerges from this

review of the psychiatric literature is that prolonged initial hospitalization for acutely ill

psychiatric patients is associated with greater

levels of treatment following the initial period and

shows no better results than a period of briefer

initial hospital treatment, There is thus good

evidence that short stays are not harmful and

should be employed where possible. This same

conclusion was reached by a prominent psychiatrist in a recent review (96). At the same time, it

is also clear from the widely divergent treatment

patterns and heterogeneous patient populations

employed in this group of RCTs that the optimal

LOS for specific subgroups of psychiatric patients

has yet to be established.
7 .

Summary and Implications for

Research and Policy
SUMMARY

This case study has

7

Summary and Implications for

Research and Policy

demonstrated that large dif -

ferences exist in hospital length of stay (LOS)

among geographic regions in the United States.

The Northeast region has consistently exhibited

the longest lengths of stay in the Nation and the

West the shortest. Since 1968, despite a trend

toward shorter LOS across all regions, the differences between East and West have persisted at

about the same level. Although no attempt was

made here to place a dollar value on these differences, there can be no doubt that the magnitude

of the variation in LOS is potentially of considerable economic significance. The evidence is persuasive that these differences are not a function

of differences in population characteristics such

as age, sex, or race.

The extent to which case mix or severity of illness differences can account for LOS variations

is more controversial. Adjusting regional LOS for

differences in the distribution of diagnostic groups

at a general level of aggregation reveals little effect on regional differences in LOS. However, severity of illness could explain some of the observed variation in regional LOS. This could occur if physicians in the Northeast systematically

admit to the hospital only the sickest patients in

each diagnostic category while those in the West

admit the least sick patients.

Case mix differences among regions have rarely

been studied at this level of clinical detail. In the

Professional Standards Review Organization

(PSRO) studies discussed in chapter 2, five conditions were studied in such a way as to be able to

draw inferences concerning differences in severity

of illness. In the Utah/Central Massachusetts

studies there was a small, but statistically significant difference in seventy of illness of cholecystectomy patients, with the eastern PSRO experiencing the more severe case mix. There was no difference in case mix for myocardial infarction (MI)

patients. In the Baltimore/Portland studies, there

were significant differences in case mix for MI and

congestive heart failure (CHF) patients but not for

angina patients. In both cases where the distribution of cases was different, the eastern PSRO experienced the more complex case mix.

In two of the three examples of differing case

mix, it was possible to adjust average LOS for

these differences. Table 13 presents these results.

Table 13.—Case Mix Differences Between Baltimore and Portland

Bait i more Portland

Number LOS Number LOS

Condition and severity class of cases (days) of cases (days)

1. Uncomplicated Ml . . . . . . . ... 21 13.6 11 ‘-

8.0

2. Moderately complicated Ml . . . . . . . 88 16,9 63 11.4

3. Severely complicated Ml ., . . ... 26 20.5 4 9.3

Total . . . . . . . . . . . 135 17.1 78 10,8

Adjusted Ml LOS . . . . . . . . (16.9) (10.6)

1. Uncomplicated-CHF ., 15 9.1 13 4 7

2. Moderately complicated CHF . 27 11,3 34 8.3

3. Severely complicated CHF . 71 14.0 19 7.0

Total . . . . . . ... . ... . 113 12.7 66 7,2

Adjusted CHF LOS ... . . . . . — (12.3) ( 7,1)

Calculated from data in A Ankrum Baltlmore City Profe~slonal Standards Review Organ !zatlon, personal communtcat!on

November 1982
50 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

The adjustments were performed by using the entire study population of both PSROs as the reference population and then by applying each

PSROs severity-class-specific LOS to the

reference population. Thus, adjusting for case mix

differences failed to affect the difference between

PSROs in average LOS for MI patients and reduced the difference for CHF patients by only 5

percent. This might be explained by the fact that

while LOS was related directly to severity of illness in the Baltimore patient population, the Portland patients did not show the same simple relationship. In Portland, the most severe patient

group in both cases had a shorter LOS than the

group with moderate severity. This, in turn, may

have occurred because there were more early inhospital deaths in the Portland group of most

severely ill patients. These data are not contained

in the reports from which this information is

drawn. This apparent discrepancy may also be

due to a failure to adequately define severity of

illness.

Whatever the reason for the short LOS in the

Portland patient populations, it is apparent that

adjusting for case mix differences in these two instances does not diminish differences in average

LOS. On the other hand, it is also true that for

these two conditions and for each of the other

three studied, LOS was shorter in the western

PSRO in each severity class. In reviewing all of

the evidence, therefore, while allowing the possibility that some case mix differences between East

and West may exist, one must conclude that such

differences are most unlikely to account for a large

part of observed regional LOS variations.

If substantial differences in LOS remain after

controlling for case mix, one is forced to conclude

that physicians must employ different treatments

for the same conditions in the East and West.

Research in this crucial area simply does not exist. The Utah/Central Massachusetts PSRO study

provided some intriguing data on differing practices with respect to ambulation and feeding of

postoperative cholecystectomy patients. Except

for this example, there has been no attempt to

gather this kind of information at a detailed clinical level. Furthermore, no studies have adequately addressed the question of whether these different lengths of stay have any impact on health status. There is simply no evidence as to whether

western patients fare better or worse with their

short lengths of stay compared to eastern patients.

In order to address the critical question of how

hospital LOS is related to health outcome, the

medical literature has been reviewed to discover

the extent to which good quality research had

established what LOS produces the best health

outcome in specific clinical conditions. The goal

of this analysis was to ascertain whether LOS

standards could be inferred from these research

studies and used to assess the appropriateness of

regional LOS differences. If a medically optimal

LOS could be determined from analyzing the medical literature, then regional LOS patterns could

be compared to this standard, evaluating which

region’s LOS is too high and which is too low.

The medical literature has been examined, focusing on studies in which researchers attempted

to change LOS for specific medical conditions in

order to improve health outcomes. Randomized

clinical trials (RCTs) have been given special attention in this review of the medical literature,

because their design is most likely to produce valid

results. Study and control groups are as comparable as possible in order to be as certain as possible that observed differences in outcomes are attributable to the experimental treatment. The RCT

is certainly not a guarantee of such results and

generalizability may be limited. Nor is the RCT

the only informative design for medical research.

Nevertheless, it is the most effective approach to

the complex questions addressed here.

At least one methodologically sound RCT was

found in five different clinical areas: MI, elective

surgery (primarily inguinal herniorrhaphy), lowrisk obstetrics, low birth weight infants, and

psychiatry. All of these RCTs experimented with

shorter lengths of stay than had been traditionally

used, none with longer. All of the studies concluded that the shorter LOS was not harmful.

Table 14 summarizes the overall characteristics

and results of these 17 RCTs. In reviewing these

studies, it is noteworthy that all but one study

in each of the MI and surgery categories excluded

the elderly from participation. Therefore, even the

limited conclusions one can draw from these

studies do not apply to the elderly. In addition,
Ch. 7—Summary and Implications for Research and Policy ● 5 1

virtually all of these studies excluded a significant

proportion of patients screened for potential participation, the single exception being the study on

low birth weight infants from Memphis. In all

cases, patients were excluded because they were

felt to be too sick to be candidates for early

discharge.

Only two studies discussed mortality as an outcome: MI and low birth weight infants. The trend

in the MI studies was for the groups with the

shorter LOS to have slightly lower mortality, but

these differences did not achieve statistical significance at the 5-percent level. There were no differences between groups in the low birth weight infant studies; the two studies combined reported

only a single death in each patient group.

In table 14, morbidity is defined as follows: for

MI patients, the rate of nonfatal cardiovascular

complications during the followup period; for

elective surgery, the rate of postoperative complications; for low-risk obstetrics, the rate of neonatal complications; and for low birth weight infants

and psychiatry, the rate of readmission during the

followup period, Only one surgery study and

three psychiatry studies reported that their differences in morbidity were significant at the 5-percent level. However, the authors of the surgical

studies stated uniformly that the complications

observed were of little clinical significance and

should not be considered reason enough to discontinue the practice of early ambulation and discharge. It should also be noted that some of these

studies presented data on morbidity other than

those summarized in table 14. These morbidity

data were discussed in relation to each study and

have been omitted for simplicity. They do not

alter the general conclusions of this discussion.

The authors of all of these studies concluded

that the experimental short LOS could be employed with safety, because there was no statistically significant increase in morbidity or mortality. As previously discussed, only in the case of

psychiatry does this conclusion seem justified by

the data. For the other areas, the most distressing problem is the lack of statistical power to detect clinically significant increases in morbidity

or mortality. None of these studies had less than

a 25-percent chance of making a Type II error in

accepting the null hypothesis of no difference if

in fact a clinically significant difference existed.

Thus, the statistical power in these studies was

always less than 75 percent. Increasing sample

sizes would increase the power (and decrease the

chance of a Type 11 error), but in clinical trials,

sample size is often kept small in case of harmful

effects to patients.

The problem in interpreting negative clinical

trials has been reviewed by Freiman and colleagues (52). They were concerned about the possibility that a new treatment might be abandoned

Table 14.—Summary of RCTs

Elective Low-risk Low birth

Ml surgery obstetrics weight infants psychiatry

1. Number of methodologically sound RCTs . . . . . . . . . . . . . . . . . . . . . 3

2. Number of studies excluding the elderly. . . . . . . . . . . . . . . . . . . . . 2

3. Average percent of screened patients accepted into study . . . . . . 55

4. Mortality: number of studies where

a. E > Lb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

b. L > E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

c. L = E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

5. Power: number of studies with power > 0.75 to detect 50°/0

increase in mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

6. Morbidity : number of studies where

a.. E > L . . . . . . . . . . . . . . . . . . . . . . . . 1

b. L > E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

c. L = E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

7. Power: number of studies with power > 0.75 to detect 50°/0

increase in morbidity . . . . . . . . . . . . . . 0

5

4

68

n d

c

nd

nd

o

4

1

0

0

1

N A

a

24

nd

nd

nd

o

0

1

0

0

2

N A

a

100

0

0

2

0

0

1

1

0

6

0

68

nd

nd

nd

nd

o

5

1

nd

aNA . not applicable

bE . early discharge group, L = late discharge

C

nd = data not reported or cannot be derived
5Z ● Hea]th Techno]ogv, case Studp, z4: \’ariations ]n Ho.spltal lxngth of St~>: Their Relatlonsh]p to Health Outcome s

after a negative clinical trial in which no difference

was observed between study and control groups.

In that circumstance, a Type II error might lead

to a failure to appreciate a beneficial effect of a

new treatment simply because the sample size was

too small to demonstrate a statistically significant

difference.

The problem in the present analysis is just the

reverse—a concern with missing a harmful effect

of early discharge. A negative RCT in this situation might mistakenly conclude that early discharge was safe, when in fact, the study could not

detect a clinically significant harmful effect due

to small sample size. All of the RCTS except the

psychiatric studies have some, degree of this problem in evaluating differences m mortality. In elective herniorrhaphy, low-risk obstetrics, and even

low birth weight infants, the rates of reported

mortality are so low that very large sample sizes

would be required in order to have any reasonable

chance of observing even large differences among

different treatments, The sample sizes required for

MI studies are somewhat less, but still greater than

those employed in the reported RCTS. The same

arguments apply to the morbidity measures reported.

In conclusion then, one cannot exclude the possibility that patients with uncomplicated MIs, elective surgery, uncomplicated deliveries, or low

birth weight infants may experience a clinically

significant increased risk of mortality or morbidity

when discharged earlier than more conventional

treatment practices. The RCTS reviewed do establish persuasively the lack of extremely large negative or positive effects on health outcomes of early

discharge in these clinical areas. Studies with

larger sample sizes will be required to evaluate

the possibility of small to moderate effects.

In addition to failing to establish unequivocally the safety of early discharge, the medical literature also fails to shed additional light on the meaning of regional LOS variations. It cannot be inferred that western lengths of stay are as safe as

eastern, because a clinically significant adverse effect of early discharge cannot be ruled out in those

clinical areas studied. Further, the precise ways

in which eastern and western physician practices

differ are unknown. Since these practices have not

been explicitly compared in any of the reviewed

RCTS, it is also unknown whether the results of

the RCTS would differ between regions. How long

are MI patients kept at bed rest in the East and

the West? What kind of anesthesia is used in herniorraphy patients in the East and the West, and

when are they first ambulated? When are low

birth weight infants sent home in the East and the

West and are the discharge criteria (implicit or explicit) at all similar to those used in the RCTS summarized here?

Moreover, only a limited number of clinical

areas have been studied. The LOS differences between the East and the West are pervasive-found

in virtually every diagnostic group. As demonstrated, the medical issues involved in the relative

safety of early discharge vary enormously from

one clinical condition to another: from whether

a 4% pound neonate is feeding adequately to

whether a &l-year-old man with an uncomplicated

MI should be allowed out of bed on the sixth or

seventh day of his hospital stay. This heterogeneity precludes generalizing the results of a few RCTS

in a few clinical areas to other patients with other

conditions. No information exists at all that would

allow conclusions to be drawn concerning the relative safety of various lengths of stay in these unstudied clinical areas, which comprise the vast majority of hospital patients.

A recent review by Berk and Chalmers (15)

evaluated data in the literature for evidence that

outpatient care could be safely and economically substituted for inpatient care. They reviewed

some of the same RCTS on early discharge that

were reviewed in this case study. They concluded

that many of the studies were methodologically

flawed and that little support was available for

the proposition they set out to investigate. Although the analysis in this case study did not address the issue of savings attributable to short

LOS, a similar conclusion has been reached with

respect to the safety of short lengths of stay.
Ch. 7–Summaxy and Implications for Research and Policy ● 5 3

—

IMPLICATIONS FOR RESEARCH

Two overall suggestions for future research

emerge from this study. The potential economic

significance of regional LOS variations combined

with a general lack of understanding of their

health implications make a large-scale study of

current medical practice very important. A diverse

sample of clinical conditions should be selected

for which large differences in regional LOS exist

and for which a significant proportion of the inpatient population is affected. A protocol should

be designed to sample patients in several eastern

and western localities .Thus, severity of illness can

be precisely measured, regional differences in physician practices can be recorded within severity

classes, and regional differences in outcomes can

be assessed. Only a study of this nature can

remove the mystery concerning the meaning of

regional LOS variations.

The second research suggestion concerns future

RCTS designed to test the efficacy of early disIMPLICATIONS FOR POLICY

What are the policy implications of this review?

Should western lengths of stay serve as standards

and somehow be enforced on the rest of the country? As noted in this case study, with the exception of psychiatric hospitalization, medical research has thus far failed to exclude the possibility that early discharge is harmful. Only a handful of clinical conditions have been studied, frequently excluding substantial segments of the population. The most common finding of these studies

is that for the outcome measures employed, there

is no statistical difference between early and late

discharge groups. Faced with this lack of definitive

data, what conclusions may be drawn? The answer depends somewhat on where one considers

the burden of proof to lie. Must proponents of

early discharge prove that it is beneficial, or at

least harmless? Or must proponents of longer hospital stays prove that early discharge is harmful?

Physicians are likely to adopt the first position,

while policy makers may prefer the second.

charge. The central problem is that very large

RCTS will be required to address definitively

many of the remaining questions concerning the

safety of early discharge, At the same time, some

of the risks that such studies would be designed

to assess are quite small. The more infrequent the

event, the larger the sample size, and the more

expensive the study needed to detect changes in

its incidence. A study is needed to set research

priorities in this area. In which clinical areas are

additional data on the safety of early discharge

most critically needed? This question should be

evaluated both from the perspective of the magnitude of the risk involved and the potential size

of the economic benefit to be obtained from shortening LOS. Such a study should survey all clinical

conditions for which substantial regional differences in LOS exist and should not be limited to

a consideration of those areas in which studies

have already been done.

This question is made all the more difficult to

answer, because the economic benefit of early discharge programs is difficult to specify. If the economic benefit of shortening LOS were indisputably large, then the case for early discharge would

be much stronger. As already discussed, however,

it is far from clear how reducing LOS produces

monetary savings, either to society or to government health care programs. At one extreme, LOS

may be shortened by uniformly eliminating days

at the end of hospital stays through early discharges. If, however, these patients are replaced

by patients who require more services per day,

the net effect of such a program of LOS reduction would be to increase total costs.

On the other hand, if LOS is reduced to the

point where an individual hospital experiences a

large decrease in its occupancy rate and if this deficit is not replaced, the hospital may close entirely

or convert some portion of its beds to another,
S4 . ffea]th Technology Case study 24: Variations in Hospital Length of Stay: Their Relationship to Health ~tcomes

less costly use. In this circumstance, reducing LOS

could result in a net reduction in total costs. Thus,

whether LOS reductions actually save money will

depend heavily on precisely how they are brought

about.

How to reduce LOS so that such savings occur

is an area totally unapproached by current health

services research. No U.S. study has even attempted to address this question. The one British

study that did address the issue (3,4) looked only

at the effect of early discharge on the costs of care

for the patients in the study. No attempt was made

to assess the effect of early discharge on total

health care costs to the community. Therefore,

in the face of limited data, uncertain benefits, and

possible harm, the case for early discharge seems

unconvincing at best.

Does this conclusion change if one considers the

perspective of the Medicare and Medicaid programs? Many of the most rigorously designed

studies in the medical literature that tested the effects of early discharge programs excluded the elderly from their study populations. No study has

been performed that specifically and rigorously

examined the effect of early discharge on a Medicare or Medicaid population, These populations

are sufficiently different from the general populations ordinarily represented in the medical literature that one must be hesitant before extrapolating

results from the one to the other. Thus, the data

available to judge the effects on health outcomes

of early discharge for the poor and the elderly are

even more scarce than for the rest of society. It

is therefore even more difficult to make a strong

argument in favor of early discharge in the context of the Federal health programs.

Hospital LOS varies greatly from place to place

across the United States. This review has demonstrated that very little is known concerning the

health consequences of these variations. Only

future research along the lines described earlier

in this chapter can provide the basis for rational

judgments about whether hospital stays are too

long in the East, too short in the West, both, or

neither. Existing data cannot exclude any of these

possible interpretations.

Appendix A.— Length of Stay and Outcome:

Myocardial infarction (MI) is the clinical condition

that has received the most attention from researchers

with respect to how much hospital care is required for

treatment. Prolonged bed rest was the hallmark of the

treatment of acute MI patients until the 1960’s. Lewis

(109), for example, recommended 8 weeks of bed rest

in 1937. White (179) recommended 1 month of bed rest

in 1945. These recommendations were based in part

on fears that inadequate bed rest would lead to cardiac rupture or ventricular aneurysm formation

(112,123). A few dissenting voices were heard (70,43).

In 1947, Asher (8) wrote colorfully of the dangers of

too much time spent in bed:

Look at a patient lying long in bed. What a pathetic

picture he makes! The blood clotting in his veins, the

lime draining from his bones, the scybala stacking up

in his colon, the flesh rotting from his seat, the urine

leaking from his distended bladder, and the spirit evaporating from his soul.

He thought the traditional 6 weeks of bed rest following a MI was unsupported by good evidence of efficacy. Levine and others (10,107,108) recommended

that MI patients be placed in a sitting position as soon

as possible, believing that greater rest was afforded to

the heart in this position.

In 1950, Irvin and Burgess (90) discussed the disadvantages of bed rest, including poor circulation to the

basilar part of the lungs, worsened congestive failure,

increased thrombophlebitis and pulmonary embolism,

negative nitrogen balance, and negative psychologic

sequellae. They recommended a period of 2 weeks bed

rest and 4 weeks hospitalization for MI patients. Brummer and his colleagues (27) reported on 258 consecutive MI patients whom they treated with an average

of 16 days bed rest and 23 days hospitalization. They

reported two cases of sudden death during the ambulation period in the hospital, both occurring in patients

who had been kept in bed longer than usual, presumably to treat complications. They also noted one patient with sudden death and 21 with recurrent MI during the first month after discharge. Although this incidence of recurrent infarction seemed to the authors

to be higher than they expected, they concluded that

on the whole early ambulation should be prescribed

for MI patients.

Beginning in the 1960’s and accelerating into the

1970’s, increasing numbers of research studies of early

ambulation for MI patients were published. Associated

with the appearance of these studies has been a rapid

decrease in the U.S. length of stay (LOS) for MI patients. Figure A-1 describes the extent of this decline

Myocardial Infarction

by region since 1968. From 1968 to 1980, LOS for MI

patients in the United States has declined 33 percent,

as opposed to 14 percent for all patients. The decreases

for each region have been striking, with the West declining the most (38 percent), followed by the Northcentral (35 percent), the Northeast (32 percent), and

the South (26 percent).

Three fundamentally different types of studies have

been reported in the literature. The first group comprises studies that analyzed clinical data trying to explain variations in treatment practices or to identify

characteristics of low-risk MI patients who might be

candidates for early discharge. Studies in the second

group reported on the effects of early ambulation and

discharge programs for MI patients without providing

any control data. Studies in the third group also

reported on early ambulation and discharge but included control data for comparison, in some instances

from randomized clinical trials (RCTs). The studies in

each of these groups are reviewed in turn.

Two retrospective studies documented large variations among individual physicians in the care of MI

patients. Heasman and Carstairs (76) found that in

1967 among Scottish physicians who each cared for

at least 20 MI patients, the average LOS per physician

ranged from 10 to 36 days, with physicians at teaching

hospitals experiencing a lower median LOS (20 days)

than physicians at nonteaching hospitals (25 days). No

attempt to adjust case mix was made. Duke (46) examined 313 MI patients at a single hospital in Connecticut, all under 65 years of age from 1965 to 1968. He

found that physicians differed in how much bed rest

they prescribed (the average physician varying from

7 to 15 days), in how long their patients stayed in the

hospital (from 21 to 29 days), and in how much bed

rest they prescribed as a proportion of the total

hospital stay (from 30 to 65 percent). Moreover, there

was no relationship between those physicians who prescribed the longest period of bed rest and those who

prescribed the longest total hospital stay. Finally, an

assessment of the frequency of complications in these

physicians’ MI patients failed to document significant

case mix differences to account for these varying

practices.

Phineas and Lovell (137) reviewed the decreasing

LOS for MI patients at the Royal Melbourne Hospital

in the early 1960’s. Without adjusting for severity of

illness, they reported no difference in 3-month mortality among groups of patients with differing lengths

of stay.

5 7
58 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcome s

Figure A-1 .—Regional Trends in Length of Stay for Myocardial Infarction

21.0 

20.0

19.0

18.0

17.0

16.0

15.0

14.0

13.0

12.0

11.0

10.0

Northeast

\ \ Northcentral

9.0

0

I 1 1 1 1 1 1 I 1 1 1 J

1968 1971 1975 1980

Year

SOURCE V/fa/ and Hea/th Sfafi.st/cs, series 13, Nos 2 10 14, 17, 19 23 26, 31 41 46, 55 60 64 (Washlnaton D C

National Center for Health Statlsttcs, 1967.82)

Rose (147) reviewed the evidence available in 1972,

before any of the RCTs were published, and concluded

that a week of bed rest was all that was necessary and

that hospital discharge could take place a “few days”

after being allowed to walk on the eighth day. Figure

A-1 shows that U.S. physicians were a good deal more

conservative in their practice; the average LOS in the

United States for MI patients was 15.6 days in 1972.

Wenger and colleagues (177) surveyed U.S. general

practitioners, internists, and cardiologists in 1970 and

reported on the treatment pattern that “most physicians” reported. Their treatment of choice was strict

bed rest for 3 days, a total intensive care unit stay of

4.5 days, up in a chair by the eighth day, walking by

the 12th day and discharged by the 21st day. This

report is a good deal more conservative than the actual practice reflected in figure A-1. However, no

distribution of physicians is given, so one does not

know how much variation in physician reports there

was.

The lack of solid data establishing the optimal LOS

for MI patients prompted some researchers to analyze

clinical data, either retrospectively or prospectively,

in an attempt to identify characteristics of a low-risk

group that might be able to be discharged earlier than

the practice of the time. Wilson and Pantridge (182)

evaluated 466 MI patients in Belfast that had survived

3 days hospitalization and found that of those without

certain risk factors (shock, serious arrhythmias, and

high enzyme levels), lack of persistent ST segment displacement on the electrocardiogram was a good predictor of the absence of late occurring serious ventricular arrhythmias. They suggested that patients in

this category, which constituted 26 percent of the total

population of MI patients, might be candidates for discharge after only 48 hours, since only a single patient
App. A— Length of Stay and Outcome: Myocardial Infarction ● 5 0

—

in that subgroup experienced a late ventricular arrhythmia.

The most often studied criteria for early discharge

are those developed by McNeer and his colleagues

(11 7) at Duke University. They first observed in 1975

in an analysis of 522 consecutive patients with documented MIs that patients who had suffered a serious

complication after the first 4 hospital days also had

one during the first 4 days. The complications identified as serious were: death, ventricular fibrillation or

tachycardia second or third degree AV block, pulmonary edema, cardiogenic shock, persistent sinus tachy -

cardia or hypotension, atria] flutter or fibrillation,

and extension of infarct. They also found that of

the patients without complications in the first 4 days,

there was no inhospital mortality during an average

LOS of 17 days and a 6-month mortality of 8 percent.

This compared with an inhospital mortality of 14 percent in the complication group and a cumulative 6-

month mortality of 19 percent. In their original series,

patients with uncomplicated MIs made up 51 percent

of the total MI population.

The Duke criteria have been replicated in three

retrospective studies. Worth and colleagues (183)

studied 455 definite MIs in four Honolulu community

hospitals. They found four patients in whom serious

complications first presented themselves between the

sixth and eighth days. Three of these patients died in

the hospital. All of these patients had been admitted

for recurrent MIs. Of the 182 first MIs without complications through day 4, there were no inhospital

deaths. Actual LOS at the four hospitals varied in this

study from 12 to 18 days for patients with uncomplicated MIs and from 15 to 20 days for those with complicated MIs. Patients with uncomplicated MIs comprised 51 percent of the total population of patients

with MIs.

The same criteria were used to evaluate a patient

population in a community hospital in North Carolina.

Severance and colleagues (158) reported that 81 of 400

MI patients (20 percent) had no serious complications

during the first 4 days of hospitalization. Only one of

these patients later had a serious complication; this patient survived an extension of his infarct. LOS was 17

days in the uncomplicated group and 18 days for the

remainder. There were no deaths in this group during

a I-month followup period. Finally, Skoulas and colleagues (165), applied the McNeer criteria retrospectively to 210 consecutive MI patients in a Kaiser hospital in northern California. Like McNeer, they found

that all patients with serious complications had had

one during the first 4 days of hospitalization. There

were no hospital deaths among the group without

complications during the first 4 days and only one

death during a 6-month followup period. The

87 patients with uncomplicated MIs comprised 41 percent of the total. They spent the least amount of time

in the hospital of any group studied thus far, an average of 7.9 days. The complicated patients stayed only

an average of 11.2 days. These patients were treated

during 1978-79, and figure A-1 shows that these LOS

figures were consistent with the West’s average LOS

for MI patients of 9.7 days in 1979. Other studies

(11 1,163) have attempted to find criteria for early discharge (or safe transfer from intensive care) but none

of them has been as successful as the Duke criteria.

Other investigators (124,140) have analyzed patients

admitted with suspected MIs retrospectively in order

to determine criteria for safe early discharge or transfer

from intensive care, but these studies have not been

replicated, nor their criteria applied prospectively.

One cannot conclude from these studies that patients

without complications in the first 4 hospital days following a MI can safely be discharged after that time.

None of these studies was a prospective trial of early

discharge. In three of the four, LOS for the uncomplicated MIs was 2 weeks or longer, and no attempt

had been made actively to discharge these patients

earlier than their physicians thought appropriate. It

is thus not at all clear that earlier ambulation in preparation for earlier discharge would not have proved

disadvantageous. The fact that all of these studies used

almost identical criteria and found similar results lends

added weight to the potential reliability and validity

of these criteria as predictors of good prognosis and,

therefore, of candidates for early discharge. Better data

are needed, however, in order to establish this proposition conclusively.

Eight studies (2,22,26,27,35,53,173,174 ) report the

results of early ambulation and discharge programs

without providing control data. Table A-1 summarizes

the most important findings from these studies. It is

very difficult to draw any definitive conclusions from

these studies. First of all, none of them was performed

in the United States. Second, the study populations

varied considerably. Four included only men, and two

excluded the elderly. Third, the protocols used by the

individual studies also varied. Even if attention is confined to those studies published in the 1970’s, the period of bed rest varied from 1 to 3 days. Ambulation

began on day 4 to 6, and discharge was planned from

day 7 to 14. Fourth, results are reported inconsistently.

Some studies report results for high- and low-risk

groups, usually those patients able to be discharged

according to the protocol are separated from those

with complications to whom the protocol for early

discharge could not be applied. Other studies report

results for the entire MI patient population. Some
60 ● Health Techno]ogy Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcome

—————— 

Table A-1 .—Uncontrolled Studies of Early Mobilization and Discharge for Ml Patients

Results (o/o of those ambulated)

Study a

1 Brummer, 1956

Deaths before

Patient population ambulation (O/. )

332- consecutive Mls 22

2 Brummer, 1966 . . . 775 consecutive Mls 28

Protocol

Bed rest 2 wks – -

(mean . 16 days)

Walk day 15

Discharge day 21

(mean . 23 days)

Bed rest 10 days (mean)

Discharge day 19 (mean)

3 Adgey, 1969 102 consecutive Mls, —

under 70, survived

admission, discharged

 18 days

4 Royston, 1972, 200 consecutive 11

males with Ml

5. Tucker, 1973

6. Chaturvedi, 1974

7. Gelson, 1976 ..,

342 consecutive 1 5

b

males with Ml

275 consecutive Mls —

surviving 6 days

in hospital

405 consecutive 15C

males with Mls

8. Thornley, 1977 142 consecutive 11

males under 65

with Mls

Discharged 18 days

Bed rest 3 days

(60$%<5 days)

Walk day 4

Discharge 11-14 days

(97% < 14 days) —

Bed rest 24 hr.

Walk day 6

Discharge 7-10 days

(mean = 8 days)

Low risk (680/0

discharged by day 7)

High risk (64°/0

discharged by day 11)

Bed rest 24 hr.

Walk day 6

Discharge 7-8 days

(76% by day 8)

Bed rest 2 days

(mean . 5 days)

Walk day 4

Discharge 10-14 days

(mean . 15 days)

In hospital Followup (cumulative)

Nonfatal . . .

Death reinfarct

(“/0) (%) Time

1 04 6 mo

Nonfata l

Death reinfarct

(%) (“/0 )

8 9

2

—

A

1 1 mo. 3 4

— 2 wks. o 0

? 6 mo. 11 ?

? 2 6 wks.

7 ? 3 mo.

1 yr.

7 ? 3 mo.

1 yr.

7 6 wks.d

6 wks.e

2 ? 24 wks

22

0

2

6

11

7

8

6

4

10

~ee Reference Ilst for complete c!tations of studies in table

‘No data on deaths before ambulation F}gure g!ven IS all Inhospltal deaths Followup data are given as percent of total Dat!ent DoDulatlon

C No data on deaths before ambufat!on F!gure given IS all Inhospital deaths

dof 27 I patients discharged by day 8

eof 87 patients discharged after day 8

report results in terms of only those patients that could

be ambulated, others for the entire group. All of these

difficulties combined make it extremely difficult to interpret the data provided by these studies. For example, all of the studies that report death during inpatient ambulation found that some patients died during this process (1 to 4 percent). Would these patients

have benefited from a longer period of bed rest? Or

would more have died as the result of complications

of bed rest? Without control groups carefully selected

so as to be comparable to the study groups, these questions cannot be answered. Similar questions can be

raised concerning the data reported on outpatient mortality, which ranged from a low of zero in 2 weeks,

to a high of 7 percent in 6 weeks. Why did the 7 percent result occur in studies which employed only 24

hours of bed rest when another study with 10 days bed

rest found a 1 percent outpatient mortality? Again,

answers to these questions cannot be derived in the

absence of control populations.

Five studies (21, 66, 69, 102, 116) reported the results

of early discharge programs for MI patients and also

reported results for control groups that were selected in a nonrandom manner. In the first such trial,

Groden (66) reported on 105 men with MIs. Patients

were allocated to the early or late discharge groups

based on which of two consultants cared for them.

Early discharge consisted of bed rest for 2 weeks, mobilization on day 15 and discharge on day 22. Late

discharge consisted of bed rest for 3 weeks, mobilization on day 25, and discharge on day 36. Survival data

were presented only for the period of hospitalization:

18 percent of the early discharge and 22 percent of the

late discharge group died prior to discharge. Clearly,
App. A—Length of Stay and Outcome: Myocardial Infarction . 61

these two groups may have differed in more ways than

the treatment they received. Selection of a control

group from among patients of a different physician

than that of the study group is a less than adequate

research design. Moreover, the lack of provision of

outpatient mortality data is another serious defect.

Harpur and colleagues (69) reported a study in

which patients admitted to one hospital were mobilized

after 7 days of bed rest and discharged on day 15 and

those admitted to a second hospital were mobilized

after 3 weeks of bed rest and discharged on day 28.

The two hospitals received admissions on alternate

weekdays and weekends. In addition, the hospitals

changed roles in the study at 4-month intervals for a

2-year period in order to ensure that both early and

late discharge programs were carried out by both institutions. This study found that mortality at 8 months

was 5 percent in the early group and 8 percent in the

late group. Nonfatal complications were equally distributed. The two groups returned to work at about

the same rates (about 75 percent of those eligible), but

the early group returned about 2 weeks sooner than

the late group.

Boyle and colleague (21) reported on a group of

Ml patients who were discharged from their hospital

within 10 days. They compared the experience of this

group with that of patients remaining in the hospital

more than 10 days. They found that after adjusting

for severity of illness, there was no difference in 3-

month mortality for the intermediate severity group

for those patients discharged in less than 10 days compared with those who stayed longer than 10 days.

They also found nonsignificant differences for the

other severity groups and concluded that their program was not harmful.

Some of the problems associated with choosing a

control group in a nonrandom fashion have already

been discussed. In the Boyle study a new problem

arises. The data presented are quite consistent with the

hypothesis that early discharge is harmful. The argument is as follows: One would expect that of a total

population of MI patients those who would be discharged early would be the ones with less severe infarcts. Thus, one would expect those discharged early

to experience a lower mortality rate than those more

complicated patients who were unable to be discharged

early. Therefore, a study that found, as this one did,

that its early discharge patients had the same mortality experience as their late discharges might be appropriately subject to the criticism that its early discharge

program had in fact been harmful to those low-risk

patients who participated in it. The only way to produce data not subject to arguments of this kind is by

the employment of a random allocation strategy of

study and control subjects.

Lamers and associates (102) described a unique

study in 1973. They tested the difference between mobilizing MI patients on the 10th hospital day as

opposed to the 20th day, while holding total LOS constant at 30 days. This study is included in the present

discussion, because its report does not explicitly state

that subjects were randomly assigned. They may have

been, but no statement to this effect appears in the published report. In this study, patients were evaluated

for possible inclusion on the ninth hospital day. This

procedure eliminated 119 of the 555 patients admitted

with definite MIs who had died before day 9. An additional 148 were eliminated because of the presence

of complications, and 86 were eliminated because of

“statistical problems. ” Thus, 202 patients (36 percent)

were assigned to early and late mobilization groups.

The study protocol involved a graded schedule of

mobilization beginning with dangling the legs over the

side of the bed, then sitting in a chair, and finally beginning to walk only 4 days into the schedule. Thus,

the early group was not actually ambulatory until day

14, the late group not until day 24. Compared with

the programs summarized in table A-1, this is a very

conservative early mobilization scheme. There were

no inhospital deaths in either study or control groups.

At an average followup period of 18 months, the early

mobilization group had experienced a mortality rate

of 17 percent, while 15 percent of the late group had

died. The question that this study tried to test is an

interesting one: What is the effect of early ambulation

on MI patients, independent of total hospital LOS?

Unfortunately, several study design and reporting

flaws make the results of the Lamers study difficult

to interpret, even leaving aside the question of whether

or not the subjects were randomly assigned. First, the

study did not really test “early” ambulation as that

term has now come to be understood. The previously

described programs aimed for ambulation between

days 4 to 6. Thus, the study was testing treatments

that, even in the late 1960’s, were not considered by

most U.S. physicians to be innovative. Second, the

study failed to report its followup data in adequate

form. Life table analysis must be used if participants

have not all been followed for the same time period.

The reported data do not allow one to determine how

many person-years of risk were contributed by each

group. Thus, the outcome data are somewhat difficult

to interpret.

Finally in this group of nonrandomly controlled

studies, McNeer and his colleagues ( 116) have described an early discharge program in which they applied their own criteria in a prospective fashion. Of

158 consecutive MI patients, 67 had none of the complications previously described by the fifth hospital

day. All 67 of these patients (42 percent of all patients
with MIs) were candidates for early discharge according to the criteria, but only 33 were actually discharged

at 1 week. In 33 of the remaining 34 cases, the reason

for the lack of an early discharge was either a home

too distant for the followup nurse visits planned by

the study or a home environment not conducive to MI

convalescence. The patients who were discharged at

1 week were visited by a specially trained nurse practitioner equipped with a transmitter for cardiac rhythm

monitoring every other day for the first week and

every third day for the second week following

discharge. The study reported no deaths in either

subgroup of the 67 patients with uncomplicated MIs

either at 3 weeks or at 6 months of followup. There

were five nonfatal complications at 6 months in the

early group and nine in the late group.

This study and its accompanying editorial generated

some lively correspondence. The editorial commenting on the study (149) concluded that: “It is now clear

that certain patients designated as ‘low risk’ can be

discharged from the hospital at the end of one week. ”

The correspondence that followed (125) both criticized

and praised the study’s design and findings. There is

first of all the issue of the selection of the control

group. Once again the lack of a random assignment

subjects the study to several lines of criticism, each

concluding that the study and control groups might

have differed in ways other than their LOS. Even

though the groups appeared well-matched when the

usual demographic and clinical variables were assessed, the late subgroup did experience more late nonfatal complications (26 v. 15 percent). This could indicate that they were somewhat sicker than the early

group at the outset, or that their less optimal home

environment predisposed them to poorer outcomes,

or that their longer hospital stay somehow made their

outcome somewhat worse. There is no way to answer

these questions in the absence of a random assignment

design.

A much more serious question is raised by the small

sample sizes in the early and late groups in this study.

In part, the question is what can be concluded by a

demonstration of no statistical difference between two

experimental groups or, more precisely, by a failure

to reject the null hypothesis. In this study, for example, if it is assumed that the zero percent mortality rate

at 6 months in the late discharge group is correct, then

if the true 6-month mortality rate in the early group

is in fact 5 percent, this study stood a 63-percent

chance of being unable to recognize it at the 5-percent

significance level. The “power” of the study in this circumstance was, therefore, only 0.37. * If the true mor-

‘ All power calculations performed here are done u~lng the blnomlal approxlmat](ln tor proportions, a method wh]ch t]verest Lmates power slightly

tor very small pr(lportlon~

tality rates were 1 percent in the late group and 6 percent in the early group, the power of this study to reject the null hypothesis of no difference between the

two rates would be only 0.30. The small sample size

also prevented the difference in the rate of nonfatal

complications noted above from attaining statistical

significance at the 5-percent level. The problem of

small sample sizes will be discussed later in greater

depth.

These technical issues aside, the fact remains that

neither the early nor the late subgroup experienced any

deaths at 6 months of followup. This fact certainly

means that McNeer and his colleagues have been successful in identifying a low-risk subgroup of patients

who came for care to the Duke Coronary Care Unit.

It is also true that this study produced the lowest mortality rate reported for any study reviewed in this analysis. No other group has reported a 6-month mortality rate for its low-risk MI patients that is this low. This

observation raises the question of whether the Duke

population of MI patients is somehow different from

others or whether their combination of treatments is

somehow peculiarly successful. Unfortunately, these

questions cannot be resolved until further prospective

studies, hopefully RCTs, have been done.

The last group of studies to be reviewed includes

5 RCTs that have evaluated early discharge for MI patients. Their results are summarized in table A-2. The

first (86) and most well known, was conducted in

Boston and randomly assigned patients with uncomplicated MIs to 2- and 3-week LOS subgroups. The

early discharge group was ambulated on day 12, the

late group on day 17. It is noteworthy that only 17

percent of MI patients who survived to the day of assessment for participation in the study (day 5) were

selected for randomization. Of those survivors rejected, 90 percent were excluded due to complications

of infarction, due to a MI within 6 months of the current admission, or due to other medical illnesses. The

early and late groups were fairly well matched, except

that significantly more of the late patients had experienced previous angina than the early patients (23

v. 7 percent) (p < 0.05, chi square). Postrandomization complications prolonged the hospital courses of

seven early patients and three late patients, but actual

LOS figures were not reported for the two groups.

There were no inpatient deaths. None of the outcome

differences listed in table A-2 was statistically significant at the 5-percent level using the chi-square test.

The second reported trial (118) was carried out in

Scotland and excluded patients over 70 years of age

and patients with complications as assessed on the

seventh hospital day. A far greater proportion of patients was included in this study (69 percent) than in

the previous one (17 percent). This study also differed
App. A— Length of Stay and Outcome Myocardial lnfarction ● 6 3

m l=

c 

o’

I

I

o

I
64 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

from the previous one in that those patients randomly assigned to the early discharge group were permitted

to walk at an earlier time (day 7 v. day 12) but were

kept in the hospital for a longer total time (21 v. 14

days). Those allocated to the late group were both ambulated later and discharged later than their counterparts in the previous study. Once again the two groups

were well matched with one slight exception—the early

group contained slightly more males than the late

group (83 v. 74 percent; chi square, p < 0.05). As with

the previous study, however, actual LOS figures were

not reported. Unlike the previous study, however, this

study showed significant inhospital mortality, 5 percent in the early group and 4 percent in the late group.

The remainder of the cumulative l-year mortality displayed in table A-2 occurred after discharge. None of

the differences in outcomes was statistically significant

at the 5-percent level.

Hayes and colleagues (71) reported a study from

England that assessed MI patients on the third hospital

day and excluded 29 percent of those patients surviving to be assessed as too ill to participate in the trial.

In this study, patients were randomly allocated to early

and late mobilization groups but were then sent to different hospital wards, based on a monthly schedule.

Each hospital ward alternated on a monthly basis treating first early, then late patients, or vice versa. This

design feature was employed in order to avoid having both early and late discharge patients on the same

ward at the same time, apparently in order to avoid

nursing confusion. Unfortunately, this scheme broke

down during the trial when some wards became too

full to accept patients. As a result, some patients were

unable to go to the ward to which they had been

randomly assigned. More unfortunately, when this occurred, the patients were sent to the ward with the

most empty beds. Since this ward was most often a

ward practicing early discharge, more patients were

allocated to the early discharge group than to the late

discharge group (107 v. 82). It is thus clear that the

random assignment procedure in this study was seriously flawed. The early mobilization and discharge

group in this study was treated with the earliest ambulation of any study in this group (day 4). The late

group was treated with the earliest ambulation of any

late study group (day 9). The two groups were fairly

well matched on the following variables: age, sex,

duration of pain, average blood pressure, site of infarct, and average enzyme levels. The 6-week mortality rate given in table A-2 conceals the fact that in this

study all of the mortality in the late group occurred

during the hospital stay, while four of the seven deaths

in the early group occurred prior to discharge. There

were no statistically significant differences between the

two groups in the overall outcome measures.

The fourth RCT was performed in Switzerland and

reported by Bloch and colleagues (17). Patients with

documented MIs were assessed on the third hospital

day and those with uncomplicated MIs who were also

under age 70 were randomly assigned to early and late

mobilization groups. Only 20 percent were excluded,

the lowest figure of all the RCTs. The protocols for

treatment in this study were very comparable to those

used in the Glasgow study, with ambulation on day 8

and 22 for the early and late groups respectively and

discharge on day 21 and 28. The actual lengths of stay

for the early and late groups were 21 and 33 days.

Again the groups were well matched. There was significant inpatient mortality in this study, with the rates

being 5 percent and 6 percent in the early and late

groups respectively. As with prior studies, no statistically significant differences were observed in the outcome variables listed in table A-2.

The fifth RCT is from Sweden, reported by Ahlmark

and colleagues (s), They assessed patients on the fourth

hospital day and excluded those over age 70 and those

with complicated MIs. They randomly assigned 75 percent of the patients surviving to day 4 to early and

late discharge groups. The essentials of the protocol

are given in table A-2 and are similar to those of

Hayes. Unfortunately, the researchers in this study

compromised the random assignment process in a serious way. They excluded from the study all patients

who had complications during hospitalization that precluded the possibility of discharging them at the appropriate time, day 8 or day 15. It is reported that 24

patients in the late group and 21 patients in the early

group were so excluded. Even worse, followup data

are not provided for these patients, making it impossible for the reader to add them back into the analysis

retrospectively. The number of inhospital deaths is not

reported for this group of excluded patients, although

it is reported that one patient in the early group died

in bed 4 days after admission while undergoing the

early phases of the early mobilization protocol. This

is the reason that the outcome measures reported for

this study in table A-2 are given in terms of percent

of patients discharged, instead of patients randomly

allocated as is the case with the other studies. As with

the other studies, no significant differences in the outcome measures were noted.

Before analyzing these studies further, a word is necessary about two other RCTs that compared home and

hospital care for a selected sample of MIs initially

determined to be uncomplicated (82,113). These

studies have not been included in the present analysis
App. A— Length of Stay and Outcome: Myocardial Infarction . 65

—

for two reasons. First, they are not directly concerned

with the issue of hospital LOS and health outcome.

The question of the most appropriate institutional setting in which to care for particular kinds of patients

is a question separate from the one presently under

consideration. Secondly, both these studies were done

in England. The present social and medical-legal pressures that exist in the United States make it practically impossible either to perform such a study in this

country or to care for any significant number of MI

patients at home. Thus, this medical option is not viable in the United States at the present time.

From both clinical and health policy perspectives,

the most important question that these RCTs can answer is: Does early discharge carry with it a negative

health impact? A well-designed and well-executed RCT

should be able, within certain limits, to provide the

answer to this question. It is evident from the previous

description that the third and fifth studies in table A-2

had their random assignment procedures sufficiently

compromised that they cannot be considered true

RCTs. They will be discussed later. The remaining

three studies all showed similar results. The early discharge group fared slightly better than the late group

in each of the three studies with respect to mortality

(17, 86, 118) The studies also have in common the fact

that none of the differences was statistically significant.

There are also important differences among the studies. Two of the three excluded elderly patients, and

one included only 17 percent of those patients who

were evaluated for possible participation. Each of the

studies assessed their patients for possible inclusion on

different days, and each used somewhat different exclusion criteria and mobilization protocols.

What, then, can be concluded regarding the health

impact of early mobilization and discharge for MI patients? After sifting through all of the studies that have

been reported and narrowing the field down to these

remaining three RCTs, the most rigorously designed

and executed of all the studies that have been done,

what conclusions can be drawn? The most important

conclusion that can safely be drawn is that early

mobilization and discharge, when applied under the

terms stated in these studies, clearly does not pose a

major health hazard to patients with uncomplicated

MIs, as defined in these studies.

The issue of statistical power must still be discussed.

Even the study with the smallest sample size (i. e., the

first study in table A-2 with samples of 69 in each

group) has an excellent chance of finding a large difference in mortality between the early and late groups.

For example, assuming the control or late group had

the same mortality as it actually had (7 percent), if the

study or early group had a true mortality rate of

30 percent, the study design actually employed would

have had only a 3-percent chance of making a Type

II error at the 5-percent level of significance and falsely accepting the null hypothesis of no difference. The

power of the design under these circumstances would

be 0.97. However, the smaller the difference that is

of interest, the greater the chance of making a Type

II error. For example, most physicians would certainly agree that if the true mortality rate for uncomplicated MI patients discharged early were 10 percentage

points greater than for those discharged late, none

should be discharged early, This same study, again

assuming a 7-percent mortality rate for the late group,

has a power of only 0.57 if the true mortality rate of

the early group is 17 percent. Thus, one could expect

to make a Type II error barely less than half the time

in trying to observe a difference in mortality rates of

this magnitude with this study design.

Table A-3 displays some similar power calculations

for the three true RCTs just identified. It is clear that

while all of these study designs are sufficiently robust

to detect large differences, none is especially powerful in trying to detect a difference of 5 percent. From

a clinical perspective, it is certainly prudent to perform

an experiment with small sample sizes first to rule out

the possibility of a large negative effect before proceeding to a large trial to evaluate the possibility of much

smaller negative or positive effects. However, such an

initial experiment may not provide sufficient evidence

by itself to justify adoption of the experimental

treatment.

Another way to analyze the data is to take a closer

look at the actual study results instead of hypothesizing about possible results. For example, one can construct 95-percent confidence intervals for the difference

between the mortality rates in the early and late groups

in each of these RCTs. In doing this, one finds that

the data in the first study are compatible with differences ranging from 11 percent in favor of the early

Table A-3.—Power of Randomized Clinical Trials on

Early Discharge for Ml Patients

Statistical power under three

alternative hypotheses

Study a

5 %

b

1 0 %

c

2 0 %

d

1. Hutter, 1977 . . . . . . . . . . 0.26 0.57 0.94

2. Glasgow, 1973 ... , . . . . 0,45 0.90 0,9999

3. Bloch, 1974 . . . . . . . . . . . 0.25 0.53 0.94

aSee Reference list for complete cltatlons of studies in table

%hance of appropdately rejecting the null hypothesis of no difference at the

5.percent slgnlflcance level If the true mortality rate for the early group was 5

percentage points greater than the actual rate experienced by the late group

cchance of appropriately rejecting the null hypothesis of no difference at the

5.percent slgnlflcance level if the true mortallty rate for the early group was 10

percentage points greater than the actual rate experienced by the late group

dchance of appropriately rejecting the null hypothesis of no difference at the

5-percent significance level If the true mortallty rate for the early group was 20

percentage points greater than the actual rate experienced by the late group
66 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

group to 5 percent in favor of the late group. The second study varies from 9 percent in favor of the early

group to 2 percent in favor of the late group. And the

third study varies from 13 percent in favor of the early

group to 5 percent in favor of the late group.

The best data available to answer the question of

the effect of early discharge on the health status of uncomplicated MI patients suggests that it is most unlikely that a large negative health impact will ensue. The

data do not, however, exclude a small negative impact, on the order of a mortality rate at 6 months to

1 year that is 5 percentage points greater in the early

than in the late group. Many clinicians would undoubtedly feel that this is a clinically significant risk.

The data are also consistent with the possibility that

early discharge is associated with a modest (about 10

percent) decrease in mortality. A much larger study

than any of these RCTs would have to be designed in

order to settle the issue definitively. One additional

point should be raised in the context of the Medicare

program. Since two of the three RCTs excluded patients over age 70, as did a number of the other less

sophisticated studies, one must admit that there is a

special dearth of data from which to draw any informed conclusions with respect to the elderly and

early MI discharge.

Is there any additional information to be gleaned

by adding the data from the studies previously reviewed? While accepting the fact that they are less

rigorous than the RCTs, one can look generally at the

results obtained by the five nonrandom controlled

studies and the two flawed RCTs (5, 21, 66, 69, 71,

102, 116), Across all of these studies the mortality rate

for the early group varied from O to 18 percent and

that for the late group from O to 22 percent, with a

followup period that varied from O to 18 months. In

two of the studies (5,102), the early group experienced

a greater mortality at followup than the late group;

in three (21, 71, 116), the mortality rates were equal;

and in the remaining two (66,69), the late group

experienced a greater mortality rate than the early

group. This group of studies appears to come down

squarely on the middle of the fence between early and

late discharge.

Going back to the studies summarized in table A-1

is equally fruitless. One can conclude that some of

these research groups do indeed appear to have identified groups of MI patients at low-risk for early discharge, with mortality rates comparable to those seen

in the RCTs. But these data shed no further light on

the question of whether these low-risk patients would

have done even better with longer periods of bed rest

and hospitalization. In addition, as in the RCTs many

of the earlier studies excluded the elderly, and some

excluded females. These studies do not therefore help

to bridge the information gap for these population

subgroups.

One final comment is in order. It has been concluded

from this review that the best data on early discharge

for uncomplicated MI patients demonstrate that 3

weeks hospitalization is not a lot worse than 4 weeks

(17,118). There is also some evidence, albeit somewhat

less sturdy, that 2 weeks is not a lot worse than 3

weeks (86). Figure A-1 demonstrates, however, that

the U.S. average LOS for all MI patients was down

to 12.6 days in 1980 and down to a mere 9.6 days in

the West. Unless there are massive problems with diagnosis coding, the LOS for patients with uncomplicated

MIs must be even briefer. U.S. physicians may have

adopted an early discharge policy for MI patients that

is more aggressive than a conservative assessment of

the available data would justify. Does this imply that

medical practice today is reaching the opposite extreme

to that of medical practice 40 years ago? Can a series

of editorials be expected soon decrying the abuse of

early ambulation and discharge for MI patients? Additional research is required before an optimal LOS

for MI patients can be defined.
Appendix B.— Length of Stay and Outcome:

Of late I have allowed my patients to get up within

twenty-four to forty-eight hours and to leave the

hospital four to six days after their vaginal celiotomy.

I could not fail to notice that these same patients did

not present the picture of listlessness and muscular

weakness which the same category of patients present

after the performance of the same operations by the abdomen with the usual after-treatment ( 143).

Emil Ries began the movement toward encouraging

postoperative patients to walk within the first day or

two after surgery with this statement at a meeting of

the American Medical Association in 1899. In the same

paper, Ries also advocated early postoperative feeding

as another means to speed recovery. Although he practiced these principles throughout his career and although this paper received a positive reception, Ries

did not influence the majority of surgical practice,

which continued to employ long periods of bed rest

following surgery.

Although a few other voices were heard in support

of “early rising” and even outpatient surgery (131), it

was not until the 1930’s that this practice was revived

in the United States. Leithauser (106) summarized the

experience of others, largely European and Russian,

and tallied 15,000 reported cases of early postoperative

ambulation with only four “fatal emboli. ” He showed

that the well-documented postoperative decrease in

vital capacity (36) improved with early ambulation.

He also presented a personal series of 900 patients

whom he treated with an average of 1.3 days of bed

rest and 4.0 days of total hospital stay. He claimed

that his patients did not show a greater than usual incidence of wound dehiscence or infection.

In the 1940’s and 1950’s, a series of nonrandom controlled studies appeared (18,19,28,59,136,141). Each

of them compared a group of surgical patients who

had been encouraged to ambulate within a few days

of surgery to those who had remained in bed for longer

periods of time, frequently over a week. One study

(28) analyzed patients from two hospitals, one of

which practiced early ambulation. Only patients who

had undergone abdominal surgery were examined. The

patients at the hospital practicing early ambulation experienced a rate of wound disruption of 0.05 percent

while the patients treated more traditionally had a rate

of 1.05 percent. The other studies were similar in their

use of control populations other than those created by

a random allocation procedure. All of the studies

found fewer complications in the group that ambulated

early, including no increase in recurrences after herniorrhaphy (19).

Elective Surgery —

Even though these studies are subject to the usual

criticisms of studies employing nonrandom controls,

they were apparently very influential. By the 1950’s,

early ambulation for surgical patients was a well-established principle of surgical management. Editorial

writers (8,23, 103) routinely warned of the dangers of

too much bed rest. As they often took pains to point

out, however, early ambulation did not mean early

discharge (23,103).

As in the myocardial infarction (MI) literature, since

the 1950’s three different kinds of studies have been

performed. The first group comprises data analyses,

studies which have examined length of stay (LOS) differences and tried to explain them. Second, there have

been a large volume of uncontrolled trials of early ambulation and discharge. And third, a number of randomized clinical trials (RCTs) have been carried out.

Each of these groups of studies are reviewed and summarized, with particular attention to RCTs.

Early in the 1960’s, many researchers in Great Britain noted that LOS there was much higher than in the

United States and Western Europe. Stallworthy (168)

criticized a lack of efficiency in British hospitals and

called for a decrease in LOS generally accompanied

by experiments to document the increased efficiency

which he believed would be obtained in the presence

of shorter lengths of stay. He wrote (168):

Any major reform is certain to challenge many traditional concepts and may arouse powerful opposition.

Experiments with pilot schemes can be valuable; for

once facts prove a contention it is difficult for opposition to survive.

Jones (92) commented that although British LOS had

fallen during the 1950’s, there was room for further

declines. Heasman (75) noted regional differences in

British LOS for tonsillectomy (2 to 6 days) and herniorrhaphy (8 to 12 days). She also saw a need for better data on the relationship between LOS and outcome

(75):

Statistically controlled studies are needed to show objectively the effect of different lengths of stay in hospital

for uncomplicated cases.

Analyses of LOS differences for surgical patients

continued into the 1970’s (64,65,119, 157, 178). These

studies continued to show large differences in LOS

among surgeons and hospitals, but none of them were

successful in building models to explain these variations. One study (119) assessed LOS by surgeon for

uncomplicated cholecystectomy at the Marshfield

Clinic. This study found that postoperative stay varied

among the five surgeons from 5.3 days to 7.3 days.

67
68 ● Health Technology Case Study 24: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

— —

No statistically significant differences were found

among surgeons with respect to patient outcome or

quality of care, although the surgeon with the longest

LOS did have the best outcomes. Seventy-six percent

of his patients were asymptomatic and had returned

to normal activities, compared with 61 percent of the

patients of the surgeon with the shortest postoperative

LOS.

The most common type of study in this literature

is the uncontrolled trial of early ambulation or early

discharge. This usually takes the form of a single

surgeon reporting his or his hospital’s experience with

a particular scheme of this kind of postoperative management. No less than 14 such studies have appeared

since Farquharson (49) reported the first large series

of herniorrhaphies performed on outpatients in 1955.

Before reviewing the data from these analyses, a discussion of the limits of the present analysis with respect

to surgery is appropriate. The logical extension of early

discharge for surgical patients is outpatient surgery.

This subject will be included in the analysis to follow.

However, there are many ways in which to do outpatient surgery. The model that will be discussed here

is one in which the only difference in the treatment

received by inpatients and outpatients is that the outpatients are discharged without spending a night in the

hospital and receive much of their postoperative care

on an ambulatory basis after discharge. The same staff

and facilities that provide surgical services to inpatients

also provide the same services to outpatients. Excluded

from this analysis are studies in which both type and

place of treatment were varied—e.g., the RCT comparing inpatient surgery and outpatient injection

therapy for varicose veins (34,12).

This analysis will also not evaluate the establishment

of a separate facility designed solely for the provision

of outpatient surgery (e. g., a surgicenter). Just as it

was beyond the scope of the present analysis to consider the appropriate place of service for provision of

services to MI patients (home V . hospital), so is it

beyond its scope to consider the most appropriate

place of service for surgical patients. This is a very

complex question, involving questions of physician

training, ancillary staffing levels, nature of anesthesia

used, equipment availability, resuscitation capabilities,

and other factors. This discussion will be limited to

an evaluation of data pertinent to the question of how

a hospital can best provide surgical services to its

patients.

Equally beyond the scope of the present discussion

is the question of the appropriateness of the surgery

itself. This is not an analysis of the necessity of surgery

as opposed to other treatment modalities. The rest of

this chapter will try to answer the following question:

Once the decision that a patient should undergo surgery in a hospital has been made, what is the relationship between LOS and health outcome?

Farquharson (49) recalled Ries’ work and described

a series of 485 patients on whom he had performed

inguinal herniorrhaphies under local anesthesia and

then discharged. His description of this outpatient

surgical procedure merits repeating:

As a rule the patient is little disturbed by the operation. He climbs down from the operating table, walks

out of the theatre, dresses in his lounge suit, and then

walks out to the ambulance in which he is taken home.

Our aim is to get him back to his own bed while the

local anesthetic is still effective.

The usual procedure for inguinal herniorrhaphy patients at that time was 5 to 6 days bed rest (down from

21 days in the early 1940’s) and 10 days hospitalization. Farquharson selected patients with home environments conducive to home convalescence, though

he gave no objective criteria. He noted a decreasing

complication rate, 10 readmission to the hospital for

complications in the first 285 patients, but only 1 in

the last 200 patients. He reported “some” recurrences

without giving actual numbers but asserted that his

experience was “at least as good” as that claimed by

supporters of more traditional approaches. He also

wrote that patients were satisfied with the novel procedure and that one of the most important benefits of

the outpatient strategy, aside from monetary saving,

was the dramatic reduction in waiting time that was

possible. At that time, considerable waiting lists had

built up in Great Britain for elective surgical procedures. Sicker patients were admitted to scarce hospital

beds ahead of candidates for elective surgery, who

were called in for their procedures when inpatient beds

and operating time were available. Eliminating the

need for a 10-day hospitalization enabled surgeons to

operate on more patients during a given time period.

This study establishes the parameters by which all

succeeding work may be judged. First, one must recognize that the scope of this study is narrower than

those cited previously. Previous studies discussed the

early ambulation of essentially all surgical patients.

This study and succeeding studies are concerned with

even earlier ambulation and discharge of a selected

subgroup of elective surgery patients, typically patients

with inguinal hernias, varicose veins, and hemorrhoids. Second, outcome measures are difficult to define and measure. Mortality is vanishingly small (122)

so other measures must be sought. For hernia patients,

the one most clinically important is the recurrence rate.

This too is often quite low (under 1 percent) (122). It

may also be difficult to compare figures from one study

to another. In order to evaluate these figures, it is necessary to know precisely how many patients were fol-
App. B— Length of Stay and Outcome: Elective Surgery ● 6 9

lowed over what time period; one must be able to determine the population at risk for recurrence. Postoperative complications are another possible outcome

measure. To be useful, however, careful definitions

must be constructed and followed. Patient satisfaction

may also serve as an outcome measure, but again careful attention to reliable and valid measurement is important to the production of accurate data. Finally,

one may wish to assess the monetary impact of early

discharge programs. Since all of the studies that attempt to do this were performed outside the United

States, these exercises will have only slight relevance

to U. S, health policy. They will serve to illustrate,

nevertheless, how, difficult such analyses are to

perform.

Farquharson (49) discussed all of these issues but

provided data on only one, complications requiring

admission to hospital. Without having a control group

with which to make comparisons, these results cannot be judged good or bad. Stephens and Dudley (169)

reported data similar to the previous study in 1961.

Of 212 patients on their waiting list for hernia or

varicose vein surgery, they selected 164 (77 percent)

as candidates for outpatient surgery, excluding those

over age 70, with complicating medical problems, or

with homes too distant or incompatible with immediate postoperative convalescence. No specific criteria

were given regarding the medical exclusions or what

constituted an unsuitable home environment. These

patients were operated under general anesthesia and

discharged 5 to 8 hours later. The initial recovery from

anesthesia took place in a general ward bed. These

authors reported no serious postoperative complications, though there was a high incidence (27 percent)

of nausea and vomiting until the premeditation schedule was altered (171). Recurrence data were not reported. Patients reported a high degree of satisfaction

(96 percent) with outpatient treatment. No financial

data were presented, but a significant impact was

claimed in reducing the size of the waiting list.

Williams (180) described similar results with a small

series of patients and raised an additional issue. He

noted that the general practitioners in Great Britain

were being asked to increase their workload as a result

of outpatient surgery programs. Dean and Wilkinson

(41) confirmed Williams’ opinion that most general

practitioners were in favor of selective outpatient surgery despite the increased visits required by it, chiefly

because of its salutary effect on elective surgery waiting

lists. Ruckley reported two series of patients, primarily

those with hernias and varicose veins, who had outpatient surgery ( 152, 153). Both groups of patients experienced a complication rate of 10 percent in the postoperative period, and 6 percent of the second group

of patients could not be discharged as planned because

of complications. An additional 2 percent of patients

had to be readmitted after discharge because of complications. There were no fatalities, and the complications were not considered serious enough to entertain

thoughts of discontinuing the program. No data on

patient selection were given except that no patients

over 68 years were included. The remaining uncontrolled study (11) of outpatient surgery added no new

data.

The principal conclusion that may be drawn from

this body of data on ambulatory surgery is that these

authors have succeeded in identifying a subgroup of

patients with inguinal hernias and varicose veins in

Great Britain who can have surgery performed on an

ambulatory basis with a very low rate of serious complications and an even lower mortality rate. However,

in the absence of adequate control data, one cannot

be sure that this same subgroup would not have done

even better as inpatients.

The group of studies on early discharge for elective

surgery follows a pattern quite similar to the group

just reviewed on ambulatory surgery. Aldridge (6) reported a l-percent complication rate with a discharge

program at 48 hours postoperatively for herniorrhaphy patients. No selection or recurrence data are given,

and high rates of satisfaction among patients, staff,

and general practitioners were claimed. Hockey (84)

reported the results of a program in which a nurse provided home followup care in order to permit early discharge for patients undergoing herniorrhaphy, appendectomy, and other surgical procedures. The author

estimated, using usual LOS figures for her patient population, that 4.7 days per patient were saved as a result

of the program. No complications could be identified

that could clearly be related to the early discharge program, though 6 of 126 patients were readmitted in the

postoperative period for unrelated problems. Again,

high rates of satisfaction were claimed. No selection

criteria were given.

One of Ruckley’s reports (153) on outpatient surgery

also contained a series of patients discharged early. He

estimated a saving of 3 to 6 days per patient depending on the procedure using the same method as

Hockey, No other data were given. Doran (45) reported on 705 patients discharged within 48 hours following herniorrhaphy and varicose vein surgery.

These patients represented 77 percent of all patients

evaluated, again with no criteria for acceptance specified beforehand. Only 5.4 percent could not be sent

home earl y because of immediate postoperative complications, and an additional 9 percent developed late

postoperative complications at home. None of these

proved serious but 0.9 percent did require readmission.
70 . Health Technology Case Study 2 4 :: Variations in Hospital Length of Stay : Their Relationship to Health Outcome s

Doran also reported high rates of satisfaction among

patients and referring general practitioners, in large

part due to reductions in waiting time for surgery.

Chant and colleagues (33) reported a similar study of

105 herniorrhaphy patients with a complication rate

of 10 percent. Cannon and colleagues (30) reported an

early discharge study in unselected hernia patients and

found that they were able to plan early discharge for

54 of 104 patients (52 percent) but only able to

discharge 24 within that targeted period.

Finally, two reports from the Shouldice Clinic in

Toronto (87,55) suggest that attainable rates of mortality and recurrence for elective herniorrhaphy are

small indeed. The first report from 1965 (87) documented an operative mortality rate of 0.05 percent

among 30,946 patients between 1945 and 1960. This

Clinic treats only hernia patients and reported a recurrence rate of 0.6 percent. Although precise data on

years of followup were not provided, many patients

were followed for 10 years or more. The Clinic uses

local anesthesia on adults and ambulates patients on

the day of surgery with discharge 72 hours following

the operation. In the first series, a wound infection rate

of 1.8 percent was reported, but no complication data

except that for recurrence were reported in the second.

The most serious deficiency of this group of uncontrolled studies on outpatient surgery and early discharge is the lack of an appropriate comparison group.

The implications of this failing have already been discussed. In addition, without a strictly defined set of

selection criteria, it is difficult to know precisely to

which kinds of patients the results might apply. Similarly, without preset, uniform criteria for what constitutes complications, it is difficult to compare one series

to another or even patients within a single series if

more than one physician determines the presence or

absence of complications. In this group of studies,

complication rates ranged from O to 10 percent. How

much of this variation is attributable to differences in

implicit criteria among individual physicians? Finally, none of these studies reported hernia recurrence

rates precisely in terms of person-years of followup.

Before discussing the true RCTs, two studies should

be mentioned. Palumbo and Sharpe (135) describe a

trial of early ambulation of herniorrhaphy patients in

which patients were ambulated at different times postoperatively: at O to 1 days, 3 to 10 days, or after

10 days postoperatively. The study found lower rates

of complications and recurrences in the earliest ambulated group. Unfortunately, this study is described

briefly as part of a larger review and its methods are

so inadequately delineated that it is impossible to ascertain the kind of research design that was employed.

The word “randomized” is used in the abbreviated description of the study, but the sample sizes are so unequal that one wonders if random allocation could really have been used. It is also not clear in which of the

three groups (if any) the patients who were ambulated

on the second postoperative day belong. Finally, no

LOS figures are given to allow one to determine

whether this was an early discharge program as well.

Similar problems are present in the study reported

by Kornhall and Olsson (101). They apparently compared a series of 54 patients operated on for hernia repair as outpatients with a matched sample of 54 patients randomly selected from among those who received their repairs as inpatients, with a mean hospital

stay of 3.4 days, though the report’s description of the

study design is vague. This is thus a comparison of

outpatient surgery with early discharge following inpatient surgery, a most interesting research question.

Unfortunately, the small sample size and the lack of

a truly random allocation procedure makes the result

of no difference in complications difficult to interpret.

The true RCTs are summarized in table B-1. Patients

in the first study (121) cited in the table were randomly allocated from a list of patients awaiting hernia repair after their general practitioners approved. The

study group was discharged after 1 night in the hospital

while the long-stay group was kept 5 to 6 days. No

actual LOS figures are given, but it is reported that

10 of the 11 short-stay patients with complications

prior to discharge were kept past the first postoperative

day. There were no statistically significant differences

in complications or recurrence rate (assessed at 1 year

in three-fourths of the patients in both groups). The

recurrence rate was 3 percent in the early group, 6 percent in the late. The study did document a significantly

increased use of general practitioners and nurses postoperatively by the short-stay group (2.4 visits per person v. 0.6).

The second study was performed in Cali, Colombia

(48). Its criteria for inclusion were very strict, resulting

in the elimination of 82 percent of patients before random assignment. It appears from the report that the

study design was needlessly complex. It required that

patients who passed the inclusion criteria be matched

on a large set of clinical and sociodemographic

variables. Then, one member of each pair created by

the matching was randomly assigned either to outpatient surgery or to regular inpatient postoperative care.

Some of the eligible population was excluded, because

no matched pair could be found. This helped to reduce

drastically the fraction of patients available for study

and rendered the results questionable since so many

patients were eliminated prior to random assignment.

Two other deficiencies compound this problem, First,

patients were eliminated from study if there was an
App. B—Length of Stay and Outcome: Elective Surgery ● 7 1

Table B-1 .—Randomized Clinical Trials in Outpatient and Short-Stay Elective Surgery

Stud y

a Study populations

1 Morris, 1968 .,- Men, 21 -65; hernia:

no chronic disease,

good home, referral

2 Echeverri, 1972 1-59; hernia, varicose veins:

no chronic disease; good home,

no post-op complications

3. Gerson, 197 6 No chronic disease; good home,

multiple diagnoses

4 Russell, 1977 18-70; hernia; hemorrhoids,

no chronic disease, good home

5 Simpson, 1977 Cholecystectomy; vagotomy;

no chronic disease,

simple surgery, good home

6 Adler, 197 8 18-64; hernia; varicose veins;

no chronic disease, good home

7 Ruckley, 1978 ., Over 60 only if fit, hernia,

varicose veins,

no chronic disease; good home

a see Reference tlst for complete cltat(ons of studies I n fable

bconvalescent hOSD(lal

Percent

Included

7

18

7

60

59

?

74

intraoperative or immediate postoperative complication or if a blood transfusion was used. Thus, it is not

known how many patients for whom outpatient surgery might be planned would be unable to be discharged immediately because of complications. Second, 13 of the 44 pairs were eliminated after surgery

due to errors in selection and matching. Thus, data

on convalescence are given for only 31 pairs. Complication data, however, are given for all 44 pairs. It is

not clear why the methodological problems were sufficient to eliminate 13 pairs from one analysis but not

the other. These methodological problems and the setting of this study —i.e., a socioeconomic environment

so different from that of the United States—make its

results of slight relevance to the present analysis.

The study reported by Gerson and Berry (54) has

few design flaws but several important analytical ones.

In this study, patients were randomly assigned to a

study group that was eligible to receive home care following discharge if the attending physician so desired

and to a control group that was treated by the usual

hospital postoperative stay. The authors included a

large number of surgical and a few medical conditions.

These illnesses were selected after a preliminary study

indicated that the selected conditions presented the best

opportunity for the substitution of home care for inpatient care. The study excluded patients with multiple diagnoses or complications that might extend LOS

and patients whose homes did not meet certain safety

standards. Eligible patients were randomly assigned

to study and control groups at a 2:1 ratio. The researchers either selected candidates poorly or did not

have the enthusiastic cooperation of attending physicians, because only 176 of 399 home care candidates

Protocols and (sample sizes) ComplicationsJ~O)

Early (E) Late (L) E L

Discharge 1 day – Discharge 5-6 days -

27 19

post-op (92) post-op (93)

Discharge 3-5 hrs. Regular Inpatient (44) 5 7

post-op (44)

Discharge early to Regular LOS (184) — —

home care (399)

Discharge 5-6 hr. Discharge 5-6 days 45 30

post-op (55) post-op (56)

Discharge by Discharge planned at 23 26

criteria (53) 10 days postop (47)

(LOS = 7.6 days) (LOS = 9.7 days)

Discharge 2 days Discharge 6-7 days 13 5

postop (117) postop (107)

Discharge 4-6 hr Discharge at 2 days home ward convb

postop (117) postop from ward (121) 36 24 39

from convb (122)

were actually referred to the home care program and,

presumably, discharged early. The remainder stayed

in the hospital for a usual postoperative or convalescent course.

Unfortunately, no LOS data are provided for the

study and control groups. Data are provided only for

those study patients who were discharged to home care

and for all the remaining patients (study patients remaining in the hospital without home care referral and

control patients). One cannot determine whether the

program succeeded in reducing overall LOS for all the

study patients without LOS data on the entire study

group. This study apparently squandered the ability

of random allocation to create comparable patient

groups by failing to analyze the correct data.

Instead, the authors proceeded to analyze five surgical conditions for which the subgroup of study patients had shorter LOS than the remaining combined

group. They found no differences in rates of return

to work among the study patients who received home

care, the study patients who did not receive home care,

and the control patients. They also found somewhat

better functioning at home in the study patients receiving home care and concluded that this might be a beneficial result of the program. This is a mistaken conclusion. While one might conclude that another study

should be done the candidates for which would be

drawn from among only those subgroups who actually

experienced shorter lengths of stay in conjunction with

the home care program, the study provides no information to suggest that the home care program was successful. It did not demonstrate that the home care program reduced overall LOS for eligible patients. From

an analytic point of view, it is fallacious only to eval-
72 ● Health Technology Case Study 24:: Variations in Hospital Length Of Stay: Their Relationship to Health Outcome s

uate those subgroups of an experimental population

which seemed to have derived a benefit from the experiment without also considering those apparently

suffering a negative result. The authors appear to have

done just that, It may well be that home care after

hospital discharge can produce benefits as a treatment

in and of itself. This study fails, however, in the effort to document that it can substitute for inpatient

convalescent care.

The study reported by Russell and colleagues (154)

is a trial of outpatient surgery and usual inpatient care

for nonelderly patients with hernias and hemorrhoids.

The requirements for absence of chronic illness and

for adequate home support for early discharge that are

typically present in these studies were also present

here. Nine patients were eliminated after random allocation because of medical problems identified by

family physicians (2) or inadequate home environments determined at preoperative interviews (7). Thirteen additional patients were eliminated from study

because their surgery did not take place for a variety

of reasons. Therefore, only 60 percent of the originally screened group entered the trial. The authors comment that although strict definitions of complications

were not employed, researchers were encouraged to

report all complications, “however slight .“ Due to

small sample sizes the large difference in complication

rate noted in table B-1 is not statistically significant

at the 5-percent level (p > 0.1). The authors comment

that the high rate of complications in the shortstay patients was the result of a large difference in the

hemorrhoid patients, an occurrence they attributed to

the postoperative use of a particular kind of dilator.

They reported anecdotally a decrease in complications

after use of this dilator was discontinued following the

conclusion of the study. The study did document a significant difference in the number of visits made by patients to their general practitioners or district nurses.

The short-stay patients made an average of eight visits

per person during an unspecified period of followup

while the long-stay patients made an average of four.

The study reported by Simpson and colleagues (161)

was a well-designed and well-executed RCT. They

studied the difference between employing a rigid notion of when postoperative discharge could occur (10

days) and the use of criteria to determine fitness for

discharge. Ten days was chosen as the fixed day of

discharge because it represented the modal discharge

day for uncomplicated patients receiving the two operations studied here: cholecystectomy and vagotomy.

The criteria included items describing healthy wound

appearance, adequate feeding, and freedom from complications. The study demonstrated a significant reduction in average LOS for the criteria-based discharge

group (7.6 v. 9.7 days) and a complication rate that

was no different. This study thus documented that flexible, clinically based criteria for discharge can result

in shorter lengths of stay for cholecystectomy and vagotomy patients when compared to a plan of discharge

fixed at the mode.

The sixth study summarized in table B-1 (3,4) is a

trial of short-stay versus more traditional stay, a design

similar to the first RCT. This study excluded the elderly and accepted referrals from general practitioners if

they considered their patients with hernia or varicose

veins to be medical and social candidates for early discharge. Patients were randomly assigned to discharge

at either 2 days or 1 week postoperatively, although

no actual LOS figures are given. The difference in complication rate, which is almost entirely due to a large

difference in complication rate for the varicose vein

patients (O v. 13 percent), is of borderline statistical

significance (p < 0.1). All of the complications were

felt to be of minor clinical significance, none apparently requiring readmission to hospital. This study also

is the only one that measured hernia recurrences in

terms of person-years at risk. The rates were an identical 0.02 per person-year at risk for the study and control groups assessed with an average followup of 2.3

years per patient.

This study also measured cost more carefully than

any other. Although its direct relevance to U.S. policy

is slight since it was carried out in Great Britain, the

general findings are instructive. The authors found a

definite saving in hospital costs. These savings were

all but offset, however, by an increased cost in the

study group due to longer time off from work and to

increased costs to patients and families in the shortstay group. The net social saving was, therefore, slight.

The difference in time from surgery to return to work

was accounted for entirely by the difference observed

in the male patients: 34.5 days for the long-stay group

v. 38.2 days for the short-stay group. This difference

is not statistically significant but turned out to be

economically significant in the savings calculations.

Patient satisfaction showed no differences between the

two groups, but the families of the short-stay patients

were significantly less pleased about the policy of early

discharge than the families of the long-stay patients

were about their relatives’ stays. General practitioners

approved the policy, despite the increase in their workload. Finally, this study is notable for having published

a report that deals solely with questions of methodology and the technical difficulty of performing such a

study (4).

The last study in this group (151) is a unique trial

of outpatient surgery and short-stay surgery for hernias and varicose veins. The study assessed three different modes of postoperative care: home, inpatient

surgical ward, and convalescent hospital. Patients were
App. B—Length of Stay and Outcome: Elective Surgery ● 7.1

—

randomly assigned to immediate home discharge (4 to

6 hours postoperatively), to 48 hours in hospital, or

to 48 hours in a convalescent hospital. Also unique

in this study is the fact that neither surgeons nor anesthetists were aware of which patients were assigned

to which groups. The study had the usual exclusion

criteria, not specified in detail prior to the study.

Significant differences were observed in complication rates, with the hospital ward patients experiencing the lowest rate of complications. The difference

among groups in total complication rate is significant

at the 5-percent level (chi-square 7.2, d.f. 2). Over half

of the complications were accounted for by delayed

wound healing. Only three patients assigned to the

convalescent hospital and two home care patients required postoperative hospital stays because of operative or anesthetic problems; all were discharged 1 day

postoperatively. Only three patients required readmission to the hospital during the followup period; all

three had been in the hospital group. As in the previous

studies in this group, the complications were regarded

by the authors as “medically trivial, ” and the large majority were managed on an outpatient basis. Patient

satisfaction was high, though precise data were not reported. Again, patients receiving outpatient surgery

required more attention from local physicians and

nurses than did patients kept in hospital.

Four of these seven studies tested outpatient shortstay surgery in various combinations and in a methodologicall y sound manner (3,121,151,154). The

results are remarkably consistent. In each case, a substantial number of patients were identified who could

undergo outpatient or short-stay surgery for their hernias, varicose veins, or hemorrhoids without serious

complications. In each case, the long-stay group had

fewer complications, but these were judged minor in

all studies. The results of these RCTs and the other

studies reviewed here have undoubtedly played a major role in the dramatic fall in LOS that has occurred

in the United States for hernia patients since 1968. Figure B-1 depicts the decrease by region. The U.S. average LOS has declined by 35 percent, that of the Northeast by 46 percent, the Northcentral by 28 percent, the

South by 21 percent, and the West by 42 percent.

These data suggest that an increasing number of U.S.

surgeons, particularly in the West, are discharging

more of their inguinal hernia patients at an earlier postoperative date. Many of these patients were probably

discharged on the second postoperative day, the most

common target for the early discharge programs reviewed here. Are they right? Should discharge on the

second day after inguinal herniorraphy be the rule instead of the exception?

At this point, the issue of statistical power once

again arises. Using herniorrhaphy as a model, it is clear

that the two most important outcome measures from

a clinical standpoint are operative mortality and recurrence rate. Operative mortality was reported in two

studies reviewed here (87,135). It was the same in both

of these large series: 0.05 percent. In order for a study

to have even a 50-percent chance of distinguishing a

doubling of this operative mortality, one would have

to randomly assign over 16,000 patients each to study

and control groups. It is thus highly unlikely that we

will ever have comparative data on operative mortality

from RCTs such as those reviewed here on which to

base decisions concerning appropriate postoperative

management. A sample size of 2,000 would be required

before one would expect even one operative death.

Clearly, studies with sample sizes of 90 to 120 cannot

observe anything useful regarding surgical mortality

in elective herniorrhaphy.

The story is similar, but not quite as hopeless, with

respect to recurrence rate. Assuming a 2-percent recurrence rate (greater than that achieved by the Shouldice

Clinic, but equal to that seen in one of the RCTs (54))

a study with a sample size of 120 would have only a

23-percent chance of rejecting the null hypothesis of

no difference if the true recurrence rate in a study

population of short-stay patients was 4 percent. If the

sample sizes were increased to about 400 in each group,

the power would increase to 0.5, or to 0.7 if the sample sizes were about 700. Such a study would be difficult and expensive to carry out, but is feasible.

The real issue here is whether such studies are worthwhile or whether we are willing to take the risk that

operative mortality and recurrence rates may be somewhat higher in early discharge or outpatient surgery

programs in order to reap their monetary benefits.

What are these benefits? The studies reviewed here that

did attempt to measure the benefits associated with

these programs concluded that a small net benefit is

present. It is difficult to assess how these studies might

have been different in this regard had they been performed in the United States. Higher hospital costs

might have increased the value of the net benefit, but

higher wages might decrease it, given slightly longer

convalescent times for short-stay patients.

Posing the question of whether the benefits are

worth the costs raises difficult issues of how to trade

off monetary savings for quality of medical care. In

this instance, it certainly seems from the RCTs just

reviewed that one trades a somewhat higher rate of

minor complications for the monetary savings. And

based on the statistical discussion just concluded, one

may also be trading an unknown increase in the small
Figure B-l.— Regional Trends in Length of Stay for

Patients With Inguinal Hernia

Northeast

0

1 I 1 I 1 1 1 1 I 1 1 1

1968 1971 1975 1980

Year

SOURCE Vital and Health Staff st(cs, series 13, Nos 2, 10, 14, 17, 19, 2326, 31, 41, 46, 55, 60, 64 (Washington, D C

National Center for Health Stat! stlcs, 1967-82)

but real risk of operative mortality or recurrence. Is lived. At best they seem minor annoyances, at worst

the increased minor complication rate an acceptable potentially serious and debilitating illnesses.

side effect of these programs? Precisely what kinds of How does one measure the cost of an additional 8

complications do these studies label as minor? The list to 15 percent incidence of complications of this kind?

is long. Morris (121) described chest and wound infec- Even were such a measure available, one would not

tions, hematomas of the wound, scrotum, and sperma- have a reliable figure for gross savings calculated from

tic cord, unexplained fever, and thrombophlebitis. a study performed in the United States. Does this lack

Ruckley (151) observed, in addition, a 23-percent rate of data and the possibility of increased operative morof delayed wound healing in the outpatient surgery tality or recurrence in programs of early discharge or

group as opposed to 14 percent in the hospitalized outpatient surgery justify further large and expensive

group. This usually consisted of a serous discharge RCTs? The studies reviewed here cannot provide anfrom the wound. It is not clear from any of the reports swers to these questions but have provided the data

how long these complications persisted or how much necessary to formulate them.

disability they caused. Presumably, all were short-
Appendix C.— Health Program Advisory Committee and

Acknowledgments

HEALTH PROGRAM ADVISORY COMMITTEE

Sidney S. Lee, Chair

Michael Reese Hospital and Medical Center

Stuart H. Altman*

Florence Heller School

Brandeis University

Carroll L. Estes

Department of Social and Behavioral Sciences

School of Nursing

University of California, San Francisco

Rashi Fein

Department of Social Medicine and Health Policy

Harvard Medical School

Melvin A. Glasser

Health Security Action Council

Committee for National Health Insurance

Patricia King

Georgetown Law Center

Joyce C. Lashof

School of Public Health

University of California,

Margaret Mahoney

Berkeley

The Commonwealth Fund

Frederick Mosteller

Department of Health Policy and Management

School of Public Health

Harvard University

Mitchell Rabkin*

Beth lsrael Hospital

Boston, Mass.

Dorothy P. Rice

Department of Social and Behavioral Sciences

School of Nursing

University of California, San Francisco

Richard K. Riegelman

George Washington University

School of Medicine

Walter L. Robb

Medical Systems Operations

General Electric

Milwaukee, Wis.

Frederick C. Robbins

Institute of Medicine

Rosemary Stevens

Department of History and Sociology Science

University of Pennsylvania

● L’ntll April 1983

75
76 ● Health Technology Case Study 24:: Variations in Hospital Length of Stay: Their Relationship to Health Outcomes

ACKNOWLEDGMENTS

The development of this case study was greatly aided by the advice and review of a number of people in

addition to the Advisory Panel for the assessment of Medical Technology and Costs of the Medicare Program

and the Health Program Advisory Committee. The case study author and OTA staff would like to express their

appreciation especially to the following individuals:

Robert Berenson, Washington, D.C.

Robert Brook, The Rand Corp., Washington, D.C.

Thomas Chalmers, The Mount Sinai Medical

Center, New York, N.Y.

Richard Crout, National Institutes of Health,

Public Health Service, Department of Health

and Human Services

John M. Eisenberg, Hospital of the University of

Pennsylvania, Philadelphia, Pa.

Peter L. Frommer, National Heart, Lung, and

Blood Institute, Public Health Service,

Department of Health and Human Services

Donald Goldstone, National Institutes of Health,

Public Health Service, Department of Health

and Human Services

Marian Gornick, Health Care Financing

Administration, Department of Health and

Human Services

Ruth Watson Lubic, Maternity Center Association,

New York, N.Y.

Bryan Luce, Office of Research and

Demonstrations, Health Care Financing

Administration, Department of Health and

Human Services

William Mayer, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

Department of Health and Human Services

Fitzhugh Mullen, National Institutes of Health,

Public Health Service, Department of Health

and Human Services

Albert G. Mulley, Massachusetts General Hospital,

Harvard Medical School

Noralou Roos, The University of Manitoba,

Winnipeg, Manitoba, Canada

Leonard Saxe, Boston University

Helen Smits, Yale University School of Medicine

Stephen B. Thacker, Centers for Disease Control,

Public Health Service, Department of Health

and Human Services

Donald A. Young, Health Care Financing

Administration, Department of Health and

Human Services
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