Background
Methods
Overall mixed methods study design
Study population and data sources
Qualitative phase
Sampling
Analysis
Admission type | Definition |
---|---|
Complex medical | Patient admitted for one or more medical issues, not requiring surgery, chemotherapy, or radiation |
Emergent surgery | Patient admitted for and received emergency unscheduled surgical intervention, not related to a trauma |
Elective surgery | Patient admitted for previously scheduled correction of a medical problem |
Trauma | Patient admitted for management of a traumatic injury (including falls from standing height) |
Cancer with chemotherapy/radiation | Patient admitted for treatment of a cancer with chemotherapy or radiation |
Social | Patient admitted for purely disposition issues |
Maternal | Patient admitted for management of a peri-partum/pregnancy related issue |
Quantitative phase
Key variables
Statistical analyses
Results
Qualtitative phase
Delays in patient disposition were identified when length of stay was prolonged by greater than 24 h due to a delay in finding an appropriate discharge location after acute medical issues had resolved. Anecdotally, most patients who required additional ongoing care on discharge from hospital (i.e. homecare, long-term care) had a delay in discharge due to issues with disposition. For example:A 69 year-old woman was admitted for induction chemotherapy for newly diagnosed acute myeloid leukemia. After about a week in hospital, she developed febrile neutropenia due to a central line infection. She was treated with broad-spectrum antibiotics, with empiric antifungal agents added later due to ongoing fevers. Two weeks into the admission, she developed acute kidney injury necessitating placement of a hemodialysis catheter. Following the line insertion the patient developed an unstable tachyarrhythmia resulting in hypotension and shock. She was transferred to ICU where she required vasopressors and intubation. She was electrically cardioverted with no improvement in blood pressure. Soon after admission to ICU, a family meeting was held and it was decided to change goals of care to focus on comfort measures. The patient died later that day after withdrawing life-sustaining therapies.
Service delays were defined as a delay in the provision of required hospital services by greater than 24 h, which likely contributed to an increase in overall cost. Anecdotally, the leading two causes of service delays were due to delays in transferring patients between various acuities of care (i.e. ICU to regular ward, regular ward to rehabilitation), and in delays due to waiting for allied health (i.e. physiotherapy, speech-language pathology). An example where service delays increased the cost of a hospitalization:An 86 year-old woman was transferred from a community hospital for fluid overload secondary to end stage renal disease. She was started on hemodialysis and her volume status improved in less than one week. The remainder of her one-month stay was spent waiting for transfer to a long-term care facility that could provide her with regular dialysis. Her application to long-term care had been started in the community hospital more than a month prior when it was first identified she would likely require more care.
Inefficient clinical decision-making was when the length of stay was prolonged by greater than 24 h because of a missed diagnosis, sequential single systems approach, or narrow differential diagnosis considered by healthcare providers. An example of a case where inefficient decision-making led to increased cost:A 77 year-old man was admitted for unilateral lower extremity weakness resulting in falls. Neuro-imaging with CT and MRI revealed a tumor in the left temporal lobe of the brain. The admitting team decided to obtain a biopsy, however there was a delay of four days before the patient was taken to the operating room for the biopsy. Following the biopsy, there was a delay of five days while waiting for biopsy results. Radiation oncology was subsequently consulted, and a decision was made to pursue treatment with palliative radiation therapy. The patient waited for one week before he was transferred to a different campus of the hospital for initiation of treatment.
For illustrative purposes, we chose the above vignettes for each of our contributors to length of stay as they are clear examples of a single contributing factor. However, the majority of charts that we reviewed contained multiple contributors as exemplified by the following case:A 60 year-old man was transferred from a community hospital for resection of an oral cancer. He had been initially admitted to a community hospital for a hip fracture requiring surgery. There he had been treated with warfarin as prophylaxis for venous thromboembolic disease; heparins were not used due to a local reaction to injections. At our hospital, his surgery was delayed by one week because of excessively thinned blood (elevated international normalized ratio (INR)). The hematology inpatient service was consulted and recommended administering parenteral vitamin K to reverse his coagulopathy – which took several days.
Very few high-cost cases had none of the four contributors identified above. An example of such a case:An 83 year-old woman was admitted for fatigue, peripheral edema, and declining function at her retirement home. Although one member of the attending service noted that the most likely cause of the edema was poor nutrition, the team undertook an extensive series of investigations for conditions with much lower clinical likelihood, beginning with an echocardiogram to investigate for heart failure. When the echocardiogram was reported as normal, urinary biochemistry studies to pursue unlikely diagnoses such as carcinoid tumour was undertaken. After one week of serial testing, the inpatient gastroenterology team was consulted for assistance [inefficient clinical decision-making]. The GI team elected to perform an esophago-gastro-duodenoscopy, which showed delayed gastric emptying; there was a one-week wait for this test due to a lack of urgent indication, with the endoscopy suite running at full capacity [service delay]. After being diagnosed with delayed gastric emptying and malnutrition, the patient was seen by the geriatric rehabilitation service who determined that she was not a suitable candidate. The decision was made to transfer her to long-term care, with a subsequent one-month wait in the acute care hospital [disposition delay].
A 66 year-old female was admitted for elective endovascular repair of an infra-renal abdominal aortic aneurism measuring 5.9 cm. The patient spent a few days in hospital for recovery, and was subsequently discharged with no complications.
Quantitative phase
Cost in CDN dollars Mean (SD) | |
---|---|
Total Cost | $49,923 (45,773) |
Total Indirect Cost | $13,566 (12,625) |
Total Direct Cost | $36,358 (33,501) |
Direct Costs per costing Category | |
Health Professionals | $2600 (4787) |
Imaging | $1069 (1428) |
Lab | $1923 (1709) |
Nursing | $16,378 (16,735) |
Operating room | $1192 (1819) |
Surgical Implants | $907 (2821) |
Post anaesthesia care unit | $307 (590) |
Pharmacy | $3273 (4157) |
Special Care Unit | $7502 (16,929) |
Endoscopy | $72 (223) |
Food Services | $1134 (1247) |
Variable | High cost admissions | |
---|---|---|
n = 200 | ||
Age at Admission – Mean (SD), years | 69 (15) | |
Male | 92 (46%) | |
Admitted route | Emergent | 146 (73%) |
Urgent | 20 (10%) | |
Elective | 34 (17%) | |
Elixhauser Comorbidity Score - Mean (SD) | 7.1 (6.6) | |
Total LOS (days) - Median (IQR) | 27 (18–48) | |
Acute LOS (days) - Median (IQR) | 21 (14–31) | |
ICU Days | >0 | 58 (29%) |
Median (IQR) | 9 (6–14) | |
ALC Days | >0 | 65 (33%) |
Median (IQR) | 29 (17–40) | |
Total Cost (CDN) - Median (IQR) | $35,438 ($23,963–$54,075) | |
Discharge disposition | Died | 28 (14%) |
Home | 38 (19%) | |
Home with supportive services | 53 (27%) | |
Other acute care facility | 16 (8%) | |
Long-term care | 62 (31%) | |
Other | 3 (2%) | |
Reason for admission | Cancer | 12 (6%) |
Complex medical | 98 (49%) | |
Elective surgery | 28 (14%) | |
Emergent surgery | 28 (14%) | |
Maternal | 2 (1%) | |
Social | 9 (5%) | |
Trauma | 23 (12%) | |
Complications | 119 (60%) | |
Services delay | 78 (39%) | |
Disposition delay | 105 (53%) | |
Inefficient clinical decision-making | 25 (13%) | |
Inpatient encounters in 365 days post discharge | Total accumulated inpatient days - Mean (SD) | 15 (33) |
0 visits | 112 (56%) | |
1 visit | 51 (26%) | |
2 visits | 19 (10%) | |
3 visits | 12 (6%) | |
4+ visits | 6 (3%) |
Variablea
| Reason for admission | ||||
---|---|---|---|---|---|
Complex medical (n = 98) | Elective surgery (n = 28) | Emergent surgery (n = 28) | Trauma (n = 23) | ||
Age at admission - Mean (SD), years | 70 (15) | 67 (12) | 64 (14) | 75 (15) | |
Male | 44 (45%) | 18 (64%) | 15 (54%) | 8 (35%) | |
Admitted route | Emergent | 84 (86%) | 5 (18%) | 23 (82%) | 23 (100%) |
Elective | 5 (5%) | 21 (75%) | 2 (7%) | 0 (0%) | |
Urgent | 9 (9%) | 2 (7%) | 3 (11%) | 0 (0%) | |
Elixhauser Comorbidity Score - Mean (SD) | 8.5 (6.6) | 5.2 (5.7) | 3.4 (4.1) | 5.7 (5.5) | |
Total LOS (days) - Median (IQR) | 24 (19–47) | 16 (10–28) | 31 (15–51) | 29 (22–58) | |
Acute LOS (days) – Median (IQR) | 21 (15–28) | 16 (10–28) | 25 (14–46) | 21 (19–29) | |
ICU Days | >0 | 34 (35%) | 6 (21%) | 11 (39%) | 4 (17%) |
Median (IQR) | 9 (7–13) | 7 (3–8) | 8 (4–24) | 5 (3–11) | |
ALC Days | >0 | 36 (37%) | 0 (0%) | 8 (29%) | 12 (52%) |
Median (IQR) | 28 (17–38) | 0 | 18 (13–35) | 27 (13–62) | |
Total Cost (CDN) – Median (IQR) | $34,680 (23,969–54,258) | $34,137 (23,844–45,713) | $41,738 (23,475–83,092) | $38,529 (23,958–53,893) | |
Discharge Disposition | Died | 20 (20%) | 1 (4%) | 4 (14%) | 2 (9%) |
Home | 18 (18%) | 9 (32%) | 6 (21%) | 0 (0%) | |
Home with supportive services | 22 (22%) | 14 (50%) | 7 (25%) | 6 (26%) | |
Other acute care facility | 6 (6%) | 2 (7%) | 4 (14%) | 3 (13%) | |
Long-term care | 29 (30%) | 2 (7%) | 7 (25%) | 12 (52%) | |
Other | 3 (3%) | 0 (0%) | 0 (0%) | 0 (0%) | |
Complications | 62 (63%) | 17 (61%) | 19 (68%) | 8 (35%) | |
Services delay | 42 (43%) | 5 (18%) | 12 (43%) | 14 (61%) | |
Disposition delay | 54 (55%) | 3 (11%) | 15 (54%) | 20 (87%) | |
Inefficient clinical decision-making | 19 (19%) | 2 (7%) | 2 (7%) | 2 (9%) | |
Inpatient encounters in 365 days post discharge | Total accumulated inpatient days Mean (SD) | 14 (36) | 12 (18) | 16 (29) | 18 (40) |
0 visits | 59 (60%) | 14 (50%) | 14 (50%) | 13 (57%) | |
1 visit | 22 (22%) | 6 (21%) | 7 (25%) | 9 (39%) | |
2 visits | 9 (9%) | 6 (21%) | 2 (7%) | 0 (0%) | |
3 visits | 5 (5%) | 2 (7%) | 4 (14%) | 0 (0%) | |
4+ visits | 3 (3%) | 0 (0%) | 1 (4%) | 1 (4%) |