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Excessively Long Hospital Stays after Trauma Are Not Related To the Severity of Illness
*John O. Hwabejire, *Haytham M.A. Kaafarani, *Ayesha M. Imam, *Carolina V. Solis, *Justin Verge, *Nancy M. Sullivan, Hasan B. Alam, George C. Velmahos
Massachusetts General Hospital, Boston, MA

Objective: Identify the causes of excessively prolonged hospitalization in trauma patients, considered to be outliers in terms of hospital stay.
Design: Retrospective study.
Setting: Level I academic trauma center.
Patients: Trauma Registry, billing databases, and medical records of trauma admissions (1/1/2006 - 12/31/2010) were reviewed, and compared against a unique Potentially-Avoidable-Days database, used by the hospital’s case managers to track discharge delays. Outliers were defined as patients whose hospital stay exceeded the DRG-based trim point, the standard method by which insurers define excessively prolonged hospitalization.
Main Outcome Measures: Outlier status, hospital cost.
Results: Of 3,237 patients, 155 (4.8%) were outliers. Compared to non-outliers, outliers were older (53 ± 21 vs. 47 ± 22 years; p=0.001), more likely to have blunt trauma (92% vs. 84%; p=0.03), more likely to be self-payers or covered by Medicare/Medicaid (13% vs. 11 %, 41% vs. 30%; p=0.02), more likely to be discharged to post-acute facilities than home (65% vs. 35%; p<0.001), and had higher hospitalization cost ($190,194 vs. $77,050; p<0.001). Both groups had similar injury severity scores, revised trauma scores, baseline co-morbidities, and in-hospital complication rates. Reasons for discharge delays were clinical in only 20% of the cases. The remaining discharges were delayed because of difficulties in rehabilitation facility placement (47%), in-hospital operational delays (26%), and payer-related issues (7%).
Independent predictors of outlier statusOdds ratio (95% CI)p-value
Need for rehabilitation facility4.66 (2.71-8.00)<0.001
Need for other post-acute care facility5.04 (2.52-10.05)<0.001
Self-pay2.43 (1.35-4.37)0.003
Medicare/Medicaid insurance1.70 (1.06-2.72)0.03

Conclusions: System-related issues, not severity of illness, prolong hospital stay excessively. Cost reduction efforts should target operational bottlenecks between acute and post-acute care.

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