Associations Between Reduced Hospital Length of Stay and 30-Day Readmission Rate and Mortality: 14-Year Experience in 129 Veterans Affairs Hospitals
Associations Between Reduced Hospital Length of Stay and 30-Day Readmission Rate and Mortality: 14-Year Experience in 129 Veterans Affairs Hospitals
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DOI：
10.7326/0003-4819-157-12-201212180-00003
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发表时间：
2012-12-18
影响因子：
39.2
通讯作者：
Vaughan-Sarrazin, Mary
中科院分区：
文献类型：
--
作者：
Kaboli, Peter J.;Go, Jorge T.;Vaughan-Sarrazin, Mary
背景：减少住院时间 (LOS) 一直是医院和医疗保健系统的首要任务。然而，人们担心这种减少可能会导致再入院率增加。目的：确定退伍军人健康管理局中所有医疗诊断和 5 种特定常见诊断的医院 LOS 和 30 天再入院率的趋势。设计：1997 年至 2010 年的观察性研究。背景：美国所有 129 家退伍军人事务部急症护理医院。患者：4 124 907 名入院患者2 个慢性诊断（心力衰竭和慢性阻塞性肺病）和 3 个急性诊断（急性心肌梗塞、社区获得性肺炎和胃肠道出血）的子样本。测量：未调整的 LOS 和 30 天再入院率，通过多变量回归分析来调整患者人口特征、合并症和入院医院。结果：对于所有医疗诊断的总和，风险调整后的平均医院 LOS 减少了 1.46 天。 5.44 至 3.98 天，或每年 2% (P < 0.001)。 5 种特定常见诊断的 LOS 也有所减少，其中急性心肌梗死（2.85 天）和社区获得性肺炎（2.22 天）的减少幅度最大。 14 年来，所有医疗诊断的风险调整后 30 天再入院率从 16.5% 下降至 13.8% (P < 0.001)。 5 种特定常见诊断的再入院率也有所下降，其中急性心肌梗死（22.6% 至 19.8%）和慢性阻塞性肺病（17.9% 至 14.6%）的再入院率下降幅度最大。入院 90 天后的全因死亡率每年降低 3%。值得注意的是，平均风险调整 LOS 低于预期的医院的再入院率较高，这表明医院 LOS 和再入院之间存在适度的权衡（每天增加 6% 低于预期）。 局限性：本研究仅限于退伍军人健康管理系统；无法获得非退伍军人事务部的录取。没有使用再入院预防性的衡量标准。结论：退伍军人事务部医院在 14 年来表现出医院服务水平和再入院率同时改善，这表明随着服务水平的改善，医院再入院并没有增加。这很重要，因为再入院被用作质量指标，并可能带来付款激励。未来的工作应该探索这些关系，看看是否存在减少 LOS 和重新入院的临界点。
Background: Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions.Objective: To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration.Design: Observational study from 1997 to 2010.Setting: All 129 acute care Veterans Affairs hospitals in the United States.Patients: 4 124 907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage).Measurements: Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals.Results: For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected).Limitations: This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used.Conclusion: Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission.