Decreasing length of maternal hospital stay is not associated with increased readmission rates

Objective: To investigate changes in maternal length of postnatal stay by mode of birth and hospital type, and examine concurrent maternal readmission rates and reasons for readmission. Methods: Linked birth and hospital separation data were used to investigated mothers’ birth admissions (n=597,475) and readmissions (n=19,094) in the six weeks post‐birth in New South Wales, 2001–2007. Outcomes were postnatal length of stay (mean days) and rate of readmission per 100 deliveries. Poisson regression was used to investigate annual readmission rates and Wilcoxon‐Mann‐Whitney test was used to compare length of readmission stays. Results: The overall mean postnatal length of stay declined from 3.7 days in 2001 to 3.4 days in 2007. Private hospitals had longer stays after Caesarean and vaginal deliveries, but mean length of stay fell for both private and public hospitals, and both modes of birth. The maternal readmission rate fell from 3.4% in 2001 to 3.0% in 2007. Leading primary diagnoses at readmission following vaginal birth were postpartum haemorrhage and breast/ lactation complications and following Caesarean section were wound complications and breast/ lactation complications. Conclusions: Despite the decrease in mean length of stay for birth admissions, there was no increase, and in fact a decrease, in the rate of postnatal readmissions. Implications: Current practices in hospital length of stay and care for women giving birth do not appear to be having serious adverse health effects as measured by readmissions.     

Increased length of hospital stay in underweight and overweight patients at hospital admission: a controlled population study

BACKGROUND: Reduced lean tissue as well as high fat mass may be independent nutritional risk factors resulting in increased length of hospital stay (LOS). This controlled population study (1707 patients, 1707 volunteers) aimed to evaluate the association between LOS in Geneva and Berlin patients at hospital admission and high fat mass index (FMI, kg/m2) and low fat-free mass index (FFMI, kg/m2), and the respective value of body mass index (BMI) and of FFMI and FMI for nutritional assessment. METHODS: Patients (891 men, 816 women) were prospectively recruited at hospital admission and compared to gender-, age- and height-matched healthy volunteers. Fat-free mass and fat mass, determined at admission by 50 kHz-bioelectrical impedance analysis, were expressed as indices (FFMI and FMI-kg/m2) to normalize for height. Patients were classified in four groups: normal, low FFMI, high FMI, or low FFMI and high FMI. Logistic regressions were used to determine the association between body composition and LOS. RESULTS: Higher FMI and lower FFMI were found in patients at hospital admission than in sex- and age-matched healthy volunteers. Low FFMI, high FMI, and low FFMI/high FMI combined, adjusted for age, were all significantly associated with longer LOS (high FFMI: 1-5 days OR 2.4, CI 2.0-2.9; 6-10 days OR 2.3, CI 1.8-3.0; 11 days OR 2.8, CI 2.2-3.5); low FMI: 1-5 days OR 1.9, CI 1.6-2.2; 6-10 days OR 2.7, CI 2.0-3.5, 11 days OR 2.1, CI 1.7-2.7; low FFMI/high FMI: 1-5 days OR 7.8, CI 5.3-11.4; 6-10 days OR 13.6, CI 7.8-23.5, 11 days OR 11.8, CI 7.0-19.8). CONCLUSION: Increased LOS is associated with adiposity (high FMI) and low muscle mass (low FFMI). The current study shows that both depletion of lean tissue and excess of fat mass negatively affect the LOS. Finally, we found that excess fat mass reduces the sensitivity of BMI to detect nutritional depletion.     

Exploring if day and time of admission is associated with average length of stay among inpatients from a tertiary hospital in Singapore: an analytic study based on routine admission data

Background  

It has been postulated that patients admitted on weekends or after office hours may experience delays in clinical management and consequently have longer length of stay (LOS). We investigated if day and time of admission is associated with LOS in Tan Tock Seng Hospital (TTSH), a 1,400 bed acute care tertiary hospital serving the central and northern regions of Singapore.     

Hyperglycemia is associated with relatively lower lean body mass in older adults

Background/Objectives

Older adults with known diabetes are vulnerable to accelerated loss of lean body mass. However, the relationship of hyperglycemia per se with lean body mass is not fully understood. We sought to examine the independent relationship of hyperglycemia with relative lean body mass in older persons without a reported history of diabetes.

Design

Cross-sectional nationally representative survey.

Setting

United States.

Participants

We studied U.S. adults >50 years without known diabetes (n=5434) in the National Health and Nutrition Examination Survey (1999–2004).

Measurements

In linear regression models, we studied the relationship of measured HbA1c (<5.0%, 5.0–5.4%, 5.5–5.9%, 6.0–6.4%, ≥6.5%) with percent lean body mass, measured by dual-energy x-ray absorptiometry, after accounting for potential confounders.

Results

Among older U.S. men and women, progressively higher HbA1c was associated with relatively lower total, appendicular, and trunk percent lean mass, independent of demographics and height (all p<0.05). Accounting for physical activity, C-reactive protein, and diabetes-related comorbidities (heart disease, peripheral arterial disease, arthritis, neuropathy, hip fracture, amputation, cancer, pulmonary disease), undiagnosed diabetes (i.e. HbA1c ≥6.5%) versus reference (<5.0%) in both men and women was associated with lower total (?3.5±0.8% and ?2.9±0.8%), appendicular (?1.8±0.5% and ?1.2±0.4%), and trunk percent lean mass (?1.2±0.4% and ?1.3±0.5%), respectively (all p<0.05). Persons at increased risk for diabetes (i.e. HbA1c 6.0–6.4%) also had significant decrements at these sites versus reference.

Conclusions

Hyperglycemia is associated with relatively lower lean mass in a nationally representative population of older adults without history of diabetes. Future longitudinal studies are needed to investigate the relationship of hyperglycemia with the accelerated decline of skeletal muscle mass in older persons.     

Dietary protein intake is associated with lean body mass in community-dwelling older adults

Lean body mass (LBM) is important to maintain physical function during aging. We hypothesized that dietary protein intake and leisure-time physical activity are associated with LBM in community-dwelling older adults. To test the hypothesis, participants (n = 237; age, 65-92 years) did 3-day weighed food records and reported physical activity. Body composition was assessed using dual-energy x-ray absorptiometry. Protein intake was 0.98 ± 0.28 and 0.95 ± 0.29 g/kg body weight in male and female participants, respectively. Protein intake (in grams per kilogram of body weight) was associated with LBM (in kilograms); that is, the differences in LBM were 2.3 kg (P < .05) and 2.0 kg (P = .054) between the fourth vs the first and the fourth vs the second quartiles of protein intake, respectively. Only a minor part of this association was explained by increased energy intake, which follows an increased protein intake. Our study shows that dietary protein intake was positively associated with LBM in older adults with a mean protein intake higher than the current recommended daily allowance of 0.8 g/kg per day. Leisure-time physical activity, predominantly consisting of endurance type exercises, was not related to LBM in this group.     

Frailty is associated with longer hospital stay and increased mortality in hospitalized older patients

Introduction

With the onset of frailty, there is often a rapid, progressive, and self-perpetuating downward spiral towards death. Frailty has enormous impact on acute hospital care and has been shown to be a more effective predictor of mortality than conventional clinical measures.

Methods

Hospitalized older patients admitted in medical wards at a teaching public hospital were studied to determine the prevalence of frailty; its association with anemia, congestive heart failure, clinically active tuberculosis and cognitive impairment; as well as its impact upon short-term outcome.

Results

A total of 250 older hospitalized patients were included, and their frailty status was assessed using Fried??s criteria. Of these, 83 (33.2%) patients were frail, with frailty found to be significantly associated with increasing age. A lower mean level of haemoglobin (p, 0.002), higher chance of congestive heart failure (p, <0.001), lower mean MMSE score (p, <0.001), was found in frail older patients. Frail subjects had a higher median hospital stay. There were total of 5 deaths, all among the frail group.

Conclusion

Our study showed that almost a third of hospitalized older patients are frail, and have anemia, higher frequency of CHF, cognitive impairment, longer hospital stay and higher mortality.     

Increased neonatal readmission rate associated with decreased length of hospital stay at birth in Canada

PURPOSE: To assess the potential impact of early post birth discharge in Canada. METHODS: Neonatal readmission was examined, based on hospital discharge data from the Canadian Institute for Health Information, with a total of 2,144,205 infants from fiscal year 1989/90 to fiscal year 1996/97. RESULTS: Neonatal readmission rates increased from 27.3 per 1,000 in 1989/90 to 38.0 per 1,000 in 1996/97, while mean length of hospital stay at birth decreased from 4.2 days to 2.7 days during the same period. The increase in readmission rate was more evident for dehydration and jaundice. The provinces and territories with decreased length of hospital stay at birth usually had increased neonatal readmission rate and earlier age at readmission. Between 1994/95 and 1996/97, compared with Newfoundland, the risks for neonatal readmission for dehydration were 5.7 and 5.5, and for jaundice were 4.5 and 2.7, respectively, for Alberta and Ontario. CONCLUSION: Neonatal readmission rates for several conditions have increased substantially, associated with early post birth discharge policies adopted in Canada.     

Concurrent prediction of hospital mortality and length of stay from risk factors on admission

OBJECTIVE: To develop a method for predicting concurrently both hospital survival and length of stay (LOS) for seriously ill or injured patients, with particular attention to the competing risks of death or discharge alive as determinants of LOS. DATA SOURCES: Previously collected 1995-1996 registry data on 2,646 cases of injured patients from three trauma centers in Maine. STUDY DESIGN: Time intervals were determined for which the rates of discharge or death were relatively constant. Poisson regression was used to develop a model for each type of terminal event, with risk factors on admission contributing proportionately to the subsequent rates for each outcome in each interval. Mean LOS and cumulative survival were calculated from a combination of the resulting piecewise exponential models. PRINCIPAL FINDINGS: Age, Glasgow Coma Scale, Abbreviated Injury Scores, and specific mechanisms of injury were significant predictors of the rates of death and discharge, with effects that were variable in different time intervals. Predicted probability of survival and mean LOS from the model were similar to actual values for categorized patient groups. CONCLUSIONS: Piecewise exponential models may be useful in predicting LOS, especially if determinants of mortality are separated from determinants of discharge alive.     

Fifty ways to reduce length of stay: an inventory of how hospital staff would reduce the length of stay in their hospital

PURPOSE AND SETTING: In this study we present a bottom up approach to developing interventions to shorten lengths of stay. Between 1999 and 2009 we applied the approach in 21 Dutch clinical wards in 12 hospitals. We present the complete inventory of all interventions. DESIGN: We organised, on the hospital ward level, structured meetings with the staff in order to first identify barriers to reduce the length of stay and then later to link them to interventions. The key components of the approach were a benchmark with the fifteenth percentile and the use of a matrix, that on one side was arranged along the main phases of the care process--the admission, stay and discharge--and on the other side to the degree to which the length of stay could be shortened by the medical specialists and nurses themselves or by involving others. FINDINGS AND CONCLUSIONS: The matrix consists of a wide variety of interventions that mainly cover what we found in published research. As a bottom up approach is more likely to succeed, we would advise wards that have to reduce length of stay to make the inventory themselves, using appropriate benchmark data, and by using the matrix.     

Nutrition status and risk factors associated with length of hospital stay for surgical patients

Objective: To diagnose the nutrition status of hospitalized patients and identify the risk factors associated with hospital length of stay (LOS). Methods: The subjective approach and the body mass index (BMI) were used to classify the nutrition status, and other indicators (anthropometry, biochemistry, and energy intake) were analyzed regarding their association with length of hospital stay of 350 patients. The chi‐square test was used to compare proportions, and the Mann‐Whitney or Kruskal‐Wallis test was used to compare continuous measures. Linear association was verified using Spearman's rank correlation coefficient. Cox's regression model was used to investigate factors associated with LOS. Results: Disease was the factor that influenced LOS the most in the studied population. Longer LOS prevailed in males (P < .0001), patients aged ≥60 years (P = .0008), patients with neoplasms (P < .0001), patients who lost weight during their hospital stay (P < .0001), and malnourished patients (P = .0034). There was a negative and significant, but weak, correlation between LOS and nutrition indicators (calf circumference, arm circumference, triceps skinfold thickness, subscapular skinfold thickness, arm fat area, lymphocyte count, and hemoglobin). Among adults, well‐nourished patients were 3 times more likely to be discharged sooner (P = .0002, RR = 3.3 [1.7–6.2]) than those who had some degree of malnutrition. Well‐nourished patients with digestive tract diseases (DTD) were also discharged sooner than malnourished patients with the same condition (P = .02, RR = 2.5 [1.1–5.8]). In patients with neoplasms, arm circumference was an independent risk factor to assess LOS (P = .009, RR = 1.1 [1.0–1.1]). Conclusions: LOS was associated with disease and nutrition status. Among the more common diseases, nutrition status according to the subjective approach determined the LOS for patients with DTD and nutrition status according to arm circumference determined the LOS for patients with neoplasms.     

老年营养风险指数与老年癌症及非癌症患者住院时间的关系研究

目的 应用老年营养风险指数(GNRI)评估患者的营养风险,探讨其与老年癌症及非癌症患者住院时间的关系。方法 选择老年住院患者37 267例,将其分为癌症组和非癌症组,应用GNRI评估患者入院时的营养风险;以患者死亡及出院为观察终点,住院时间(d)作为临床结局指标,采用边际结构模型探讨GNRI与老年癌症及非癌症患者住院时间的关联性。结果 超过一半(56.3%)的老年住院患者具有不同程度的营养风险;与非癌症患者相比,癌症患者GNRI水平(91.0±10.2)及无营养风险患者的比例(26.8%)更低,而具有低(24.6%)、中(29.0%)、高(19.7%)营养风险患者的比例均更高,差异均具有统计学意义(P＜0.05)。在控制其他混杂因素后,边际结构模型分析结果显示在癌症和非癌症患者中,住院时间均随营养风险程度的升高而延长,具有高营养风险的癌症患者住院时间最长,高达19.1(95% CI:17.5~20.8)d;在不同的营养风险分组中,癌症患者住院时间(14.5~19.1 d)均高于非癌症患者(10.1~15.2 d),差异均具有统计学意义(P＜0.05)。结论 GNRI 适用于老年癌症及非癌症患者的营养风险筛查评估,由GNRI评估的营养风险越高,患者住院时间越长。     

Impact of specialist rehabilitation services on hospital length of stay and associated costs

Background

Provision of specialist rehabilitation services in North Yorkshire and Humberside may be suboptimal. Local commissioning bodies need to prioritise investments in health care, but previous studies provide limited evidence to inform the decision to expand existing services on the basis of cost-effectiveness. We examine the impact of specialist rehabilitation services in the subregion on hospital length of stay (LoS) and associated costs compared to routine care.

Methods

Comparison of hospital LoS and associated costs in centres with greater access (Hull) and limited access (i.e. routine care, York and Northern Lincolnshire), to specialist rehabilitation services for patients with complex disabilities following illness or injury, using Hospital Episodes Statistics data.

Results

Average LoS and duration costs by Healthcare Resource Group (HRG) were lower for the majority of patients with greater access to specialist rehabilitation compared to routine care. Difference in LoS between groups widened with level of complexity within each HRG. For the more frequent HRG codes, the LoS difference was as high as 34 days longer for York compared to Hull and £7900 more costly.

Conclusion

Rehabilitation patients within York and Northern Lincolnshire areas appear to have longer LoS and higher associated costs compared to those admitted to the Hull Trust. This analysis suggests that specialist rehabilitation may be cost saving compared to routine care and supports the case for expansion of the existing services to improve coverage in the area.

     

Predicting length of stay for Medicare patients at a teaching hospital.

This research examines how the patients' characteristics and clinical indicators affect length of stay for the top five Diagnosis-Related-Groups (DRGs) for Medicare patients at a teaching hospital in the United States. The top DRGs were selected on the basis of volume per year. Teaching hospitals in the United States devote a significant amount of their resources to research and teaching, while providing treatment for patients. The ability to predict length of stay can substantially improve a teaching hospital's capacity utilization, while ensuring that resources are available to meet the health care needs of the Medicare population. Multiple regression models are developed to predict the length of stay using the patients' characteristics and clinical indicators as independent variables. The results indicate that approximately 60 percent (R(2)) of the variance in the length of stay is explained by the patients' characteristics and clinical indicators for these DRGs. The Mortality and Severity indices are found to be the strongest predictors for length of stay in all DRGs. Other patients' characteristics and clinical indicators such as age, gender, race/ethnicity, marital status, admission type and admission source are also significant predictors for some DRGs. In addition, most of these variables affect the length of stay in the same manner as shown in previous studies, even though the previous studies do not have the DRG specificity of this study.     

Greater appetite control associated with an increased frequency of eating in lean males

Eight healthy males of age 22.9+/-4.2 years (mean+/-SD) and body weight 73.26+/-11.50 kg, with BMI of 23.11+/-2.84 kg/m(2)underwent two different eating meal frequency patterns on 2 separate days. On both days they were fed approximately 33.3% of their average daily energy requirements as a breakfast pre-load meal: served either as a single meal (SINGLE) or divided into five equal portions (served hourly) (MULTI). Five and a half hours after the initial meal, an ad libitum meal was served. Venous blood was tested to determine plasma glucose and serum insulin concentrations every hour until the ad libitum lunch, and at 15-, 45- and 75-min after lunch. Visual analogue scales (VAS) were completed every hour until the ad libitum lunch, and at 15-, 45- and 75-min after lunch as a measure to determine hunger, appetite and satiety indices. Although both groups were fed isocaloric and identical macronutrient "breakfast pre-loads" (3450+/-466 kJ), the SINGLE group consumed 26.6% more (p<0.02) energy in the ad libitum lunch (5111+/-1502 kJ vs. 3752+/-893 kJ) than the MULTI group did. The pre-load feeding pattern had no effect on blood glucose responses throughout the trial. Following the larger SINGLE pre-load, serum insulin concentration rose to a higher (p<0.01) level compared to the first of the MULTI pre-load meals (123.04+/-61.51 microIU/ml vs. 37. 30+/-26.65 microIU/ml SINGLE vs. MULTI, respectively). Serum insulin rose to a higher (p<0.01) level following the fifth and final of the MULTI pre-load meals compared to the serum insulin levels in the SINGLE group at the same time into the trial (74. 21+/-51.64 microIU/ml vs. 24.98+/-13.46 microIU/ml MULTI vs. SINGLE, respectively). Despite consuming more energy in the ad libitum lunch, the SINGLE group showed no difference in serum insulin concentration following the ad libitum lunch compared to the insulin response of the MULTI group. These data suggest that when the nutrient load was spread into equal amounts and consumed evenly through the day in lean healthy males, there was an enhanced control of appetite. This greater control of satiety when consuming smaller multiple meals may possibly be linked to an attenuation in insulin response although clearly both other physical (gastric stretch) and physiological (release of gastric hormones) factors may also be affected by the periodicity of eating.     

Prolonged postpartum length of hospital stay among women with disabilities

BackgroundPrior studies have found higher proportions of cesarean deliveries and longer postpartum hospital stays among women with disabilities compared to women without disabilities. However, no research has assessed how length of stay may differ for women with different types of disability while also considering mode of delivery.ObjectiveTo examine the association of disability status and disability type with length of stay, taking into account disability-related differences in mode of delivery.MethodsWe conducted a retrospective cohort study using linked maternal and infant hospital discharge and vital records data for all births in California between 2000 and 2012 (n = 6,745,201). We used multivariable regression analyses to assess association of disability status and type with prolonged length of stay (>2 days for vaginal delivery or >4 days for cesarean) while controlling for covariates.ResultsWomen with disabilities had significantly elevated adjusted odds of prolonged length of stay compared to women without disabilities (aOR = 1.40, 95% CI = 1.32–1.49). Adjusted odds were highest for women with vision disabilities (aOR = 1.67, 95% CI = 1.46–1.90), followed by women with IDD (aOR = 1.53, 95% CI = 1.30–1.80), and women with physical disabilities (aOR = 1.41, 95% CI = 1.32–1.50). Women with hearing disability had the lowest adjusted odds of prolonged length of stay (aOR = 1.17, 95% CI = 1.03–1.33).ConclusionsProlonged length of stay did not appear to be due solely to the higher proportion of cesarean deliveries in this population. Further research is needed to better understand the reasons for prolonged length of stay among women with disabilities and develop strategies to assist women with disabilities in preparing for and recovering from childbirth.