Hospital readmission: predicting the risk.

This approach focused on identifying specific variables that predict the likelihood of readmission. It involved clinical, utilization, and demographic variables that are generally available on hospital computer abstract databases. The approach included a process for identifying and comparing individual variables with the highest risk of readmission. It also contained a procedure for assembling risk populations including combinations of variables. The approach demonstrated the potential for using risk analysis to maximize the focus of clinical management on patient outcomes while reducing the amount of resources required for this process.

Combined benchmarking of hospital outcomes and utilization.

A strong case is made for developing quantitative benchmarks for hospital outcomes as well as utilization that includes both acute care re-admissions and lengths of stay. A number of hospitals in two distinctly different geographic health care environments [CA and NY] are studied as to the differences in outcomes and utilization for three of the most common high-cost DRGs. Unscheduled hospital readmissions (within 30 days of initial discharge) were employed as outcome indicators because they reflect both the quality of acute care and the need for case management in the post-discharge period. Benchmark targets were established for patients with a diagnosis of congestive heart failure, acute MI treated medically, or COPD using scattergrams that showed each hospital's mean acute LOS on the x axis and the re-admission rates on the y axis. "Benchmarks were identified as those points with the lowest values for both indicators, as demonstrated by points that were closest to the intersection of the two axes."

Hospital readmissions at the communitywide level: implications for case management.

This study describes the development of information concerning the distribution of hospital readmissions by diagnosis in seven different United States metropolitan areas. The data demonstrated that circulatory disorders were associated with the largest number of communitywide readmissions in all of the communities. It also showed that circulatory, respiratory, and digestive disorders accounted for a majority of readmissions in all of the areas. This information suggested that case management efforts to reduce readmissions can focus on a limited range of clinical diagnoses. This approach should enable the process to function effectively within resource constraints.

Analyzing hospital readmissions using statewide discharge databases.

Hospital readmissions are an important indicator of the outcomes of care as well as a source of unnecessary health care expenditures. This study focused on development of a uniform algorithm for identification of hospital readmission data. It involved development of a uniform definition of readmissions which could be applied to multiple statewide computer databases. Through this approach, comparable readmit data were generated for use in benchmarking and quality improvement activities.

Benchmarking hospital lengths of stay using histograms.

The authors demonstrated that length of stay histograms can provide considerably more benchmark information concerning hospital lengths of stay than numerical benchmarks. Examples of histograms described the complete distribution of hospital stays, as well as levels of outliers, rather than simple numerical averages. Gathering such data led to a clearer understanding of the significant LOS impact of certain DRG outliers in the two different hospitals in Syracuse, NY. Given that the other two communities represented, Seattle, Washington and San Diego, California, were more influenced by extensive managed care penetration, variations in histogram data were less in evidence there. Histograms were designed with bars to show LOS distributions at the 50th, 75th, and 90th percentiles for each of the above DRGs. The greatest variations could be shown when comparing the 1997 LOS data on the various DRGs at the two Syracuse hospitals. At both hospitals the presence of a large contingent of outliers (for different types of mostly medical patients) could be seen as the major factor in driving up their overall LOS.

Using health care data to improve utilization and outcomes. Introduction.

This article suggests that the information age has generated extensive amounts of additional health care data, but has not provided the tools to access this information. It identifies principles for development and use of health care data including clarity of sources, validity and consistency, importance and relevance, accessibility, and the human element.

Health care data and their sources.

This article outlines the types of health care data currently available from internal and external sources. It describes utilization, outcomes, and financial data. It focuses on information available through computer abstract hospital databases. It provides information concerning the sources and content of these databases.

Analyzing hospital admission rates at the community level.

This article describes the importance of hospital admission rates as utilization indicators and provides guidance on the development of related data. It identifies categories for analysis of hospital admission rates, including inpatient services, age groups, and geographic units. It describes how resident hospital admission rates can be developed from computer abstract data and contains examples of this information.

Using data to reduce hospital readmissions.

This article describes the importance and the development of data concerning hospital readmissions as an outcomes indicator. It emphasizes the need for consistent definition of readmissions according to time intervals and diagnostic categories. It describes the development of readmission information using computer abstract databases to ensure consistency of indicators. It also provides examples of data developed through this approach.

Basic statistics for clinical pathway evaluation.

Clinical pathways (using accepted benchmark goals) are among the most widespread tools used to enhance outcomes and contain costs within a constrained length of stay (LOS). The author describes the need for selection and use of designated basic statistics in the "definition and evaluation of the impact of clinical pathways in hospitals." The use of both the mean and median data on resource use and LOS information (to evaluate the effectiveness of various clinical pathways) is advised, as the influence of outlier data will thus be revealed. The ultimate goal of such evaluation is the identification of statistics that can be readily "understood by and communicated among providers and consumers of health care services." The correlation of statistical variables such as resource utilization (including ICU stays) and LOS, can reveal patterns not easily seen otherwise.

Development and implementation of clinical pathways for stroke on a multihospital basis.

This study describes the development and implementation of clinical pathways for stroke on a cooperative basis by three hospitals in the same community. The participating institutions developed separate pathways which met their respective organizational needs. This process occurred within separate hospital management structures with coordination among the institutions. They employed a common set of length of stay, quality and resource variables to evaluate the impact of the pathways.

Benchmarking and clinical pathway implementation on a multihospital basis.

Hospital utilization data for communities with high levels of managed care penetration can be readily used to develop utilization benchmarks in any proactive efforts to prepare for oncoming prospective pricing system (PPS) initiatives. In a cooperative effort among all four Syracuse, NY hospitals, the combined average hospital LOS for one surgical and three medical DRGs was compared with benchmarks derived from similar populations in three heavily managed care-penetrated west coast communities. Implementation of clinical or critical paths are a widely accepted approach to shortening hospital lengths of stay and improving both resource usage and clinical outcomes. After implementing clinical paths across all four institutions and revisiting their data a year later, a fairly dramatic reduction (28%) in mean LOS for total hip replacement procedures was achieved. Two of the three medical DRGs, stroke and acute MI, each showed a mean reduction of 17% in LOS.

Enlisting physician support for practice guidelines in hospitals.

Available experience indicates that physician support is crucial if clinical pathways are to support quality of care while reducing lengths of stay and resource use. Enlisting such support requires understanding of physician perspectives concerning the quality and delivery of health care. It also requires the development of data systems as a means of communication with physicians.

Excess acute care bed capacity and its causes: the experience of New York State.

OBJECTIVE: The study was developed to identify numbers of excess hospital medical-surgical and pediatric bed capacity and the variables that produce them in the counties of New York State. DATA SOURCES/STUDY SETTING: Data were collected from New York's Statewide Planning and Research Cooperative System (SPARCS) for 1991. This system includes data for all hospital discharges in New York State by county. The counties of New York State include a full range of urban, suburban, and rural settings. STUDY DESIGN: A methodology was developed for projecting excess numbers of acute medical-surgical and pediatric beds. The impact of utilization variables (such as hospital discharge rates and lengths of stay) on bed levels were analyzed, as well as the effects of demographic, social, and health care resource availability. DATA COLLECTION/EXTRACTION METHODS: Data were collected through discharge abstracts provided by hospitals in New York State. PRINCIPAL FINDINGS: The data demonstrated that hospital discharges and lengths of stay contributed to excess utilization at different levels in New York State counties. The data also identified relationships between lower incomes and educational levels, as well as larger supplies of physicians and high-variation discharges, and excess beds. CONCLUSIONS: The causes of excess hospital beds varied considerably among communities in New York State; each community must develop its own approach to this problem.

Development and implementation of a program to reduce hospital stays and manage resources on a community-wide basis.

The study describes an effort to reduce hospital stays and limit the use of expensive resources in the metropolitan area of Syracuse, New York. The program included the implementation of clinical pathways for a number of surgical procedures and medical diagnoses. The effort involved the identification of specific resource variables in a wide range of clinical disciplines. The program was important because it focused on cooperative efforts at length of stay and resource reduction by the staffs of all of the hospitals within a common service area.

The evaluation of hospital stays for total hip replacement.

The purpose of this study is to present four care experiments developed in the Netherlands and New York State that aim to reduce mean hospital stays for total hip replacement and thus increase efficiency of hospital utilization without adversely influencing quality of care. The major components of the programs and their impact on lengths of stay are described.

Adding nursing facility beds: impact on hospital nonacute care.

The study evaluated the impact of admitting 235 nonacute patients who had been backed up in hospitals to new nursing facility beds in the metropolitan area of Syracuse, New York, during a 12-month period. The data indicated that these admissions reduced the hospital nonacute census by 53 percent and produced substantial declines in numbers of nonacute patients with postacute stays longer than one month and with Medicaid as principal payer. Numbers of patients waiting for Medicaid eligibility were not affected by admissions to the new beds. The data also indicated that substantial numbers of new admissions were required to generate these changes.

Long-term care patients in acute care beds: a community-based analysis.

This paper describes an analysis of hospital utilization by alternate care patients, those who receive long-term care in hospital beds because postdischarge services are not available. During a 3-year period, the number of hospital beds occupied by these patients in Syracuse, New York reached 184, or 14% of the area's medical-surgical capacity. These patients were heterogeneous with respect to disposition, age, functional ability, and payor status. For this reason, the control of hospital alternate care should involve the management of admissions to nursing homes, home care, and elderly housing in a focused manner.

Changes in ambulatory surgery utilization 1983-88: a community-based analysis.

Changes in ambulatory surgery utilization in the metropolitan area of Syracuse, New York 1983-88 were identified. Total ambulatory surgery utilization rose from 12,479 to 24, 643 procedures. Approximately 69 percent of the increase was generated by freestanding surgery centers. Operations responsible for the largest additional volumes included lens procedures, certain cervical procedures, hernias, and excision of skin and breast lesions.

Relieving overcrowded emergency departments through ambulance diversion.

One city's solution to overcrowded emergency departments and a shortage of beds was the installation of an ambulance-diversion system, whereby ambulances carrying patients with relatively minor injuries were diverted, when necessary, from the city's busy emergency departments to less crowded ones in neighboring counties.