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01.12.2012 | Research article | Ausgabe 1/2012 Open Access

BMC Health Services Research 1/2012

Factors influencing hospital high length of stay outliers

BMC Health Services Research > Ausgabe 1/2012
Alberto Freitas, Tiago Silva-Costa, Fernando Lopes, Isabel Garcia-Lema, Armando Teixeira-Pinto, Pavel Brazdil, Altamiro Costa-Pereira
Wichtige Hinweise

Competing interests

The authors have no competing interests to disclose.

Authors’ contributions

AF conceived the study, performed statistical analyses, and drafted the manuscript. TSC assisted in data preparation and in drafting the manuscript. FL and IL assisted in ICD-9-CM and other classification/coding aspects, and in drafting the manuscript. ATP assisted in the statistical analyses. PB assisted in drafting the manuscript. ACP assisted in drafting the manuscript. All authors have approved the final version of the manuscript.



The study of length of stay (LOS) outliers is important for the management and financing of hospitals. Our aim was to study variables associated with high LOS outliers and their evolution over time.


We used hospital administrative data from inpatient episodes in public acute care hospitals in the Portuguese National Health Service (NHS), with discharges between years 2000 and 2009, together with some hospital characteristics. The dependent variable, LOS outliers, was calculated for each diagnosis related group (DRG) using a trim point defined for each year by the geometric mean plus two standard deviations. Hospitals were classified on the basis of administrative, economic and teaching characteristics. We also studied the influence of comorbidities and readmissions. Logistic regression models, including a multivariable logistic regression, were used in the analysis. All the logistic regressions were fitted using generalized estimating equations (GEE).


In near nine million inpatient episodes analysed we found a proportion of 3.9% high LOS outliers, accounting for 19.2% of total inpatient days. The number of hospital patient discharges increased between years 2000 and 2005 and slightly decreased after that. The proportion of outliers ranged between the lowest value of 3.6% (in years 2001 and 2002) and the highest value of 4.3% in 2009. Teaching hospitals with over 1,000 beds have significantly more outliers than other hospitals, even after adjustment to readmissions and several patient characteristics.


In the last years both average LOS and high LOS outliers are increasing in Portuguese NHS hospitals. As high LOS outliers represent an important proportion in the total inpatient days, this should be seen as an important alert for the management of hospitals and for national health policies. As expected, age, type of admission, and hospital type were significantly associated with high LOS outliers. The proportion of high outliers does not seem to be related to their financial coverage; they should be studied in order to highlight areas for further investigation. The increasing complexity of both hospitals and patients may be the single most important determinant of high LOS outliers and must therefore be taken into account by health managers when considering hospital costs.
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