Does severity explain differences in hospital length of stay for pneumonia patients?
OBJECTIVE
In the USA, the role of patient severity in determining hospital resource use has been questioned since Medicare adopted prospective hospital payment based on diagnosis-related groups (DRGs). Exactly how to measure severity, however, remains unclear. We examined whether assessments of severity-adjusted hospital lengths of stay (LOS) varied when different measures were used for severity adjustment.


METHODS
The complete study sample included 18,016 patients receiving medical treatment for pneumonia at 105 acute care hospitals. We studied 11 severity measures, nine based on patient demographic and diagnosis and procedure code information and two derived from clinical findings from the medical record. For each severity measure, LOS was regressed on patient age, sex, DRG, and severity score. Analyses were performed on trimmed and untrimmed data. Trimming eliminated cases with LOS more than three standard deviations from the mean on a log scale.


RESULTS
The trimmed data set contained 17,976 admissions with a mean (S.D.) LOS of 8.9 (6.1) days. Average LOS ranged from 5.0-11.8 days among the 105 hospitals. Using trimmed data, the 11 severity measures produced R-squared values ranging from 0.098-0.169 for explaining LOS for individual patients. Across all severity measures, predicted average hospital LOS varied much less than the observed LOS, with predicted mean hospital LOS ranging from about 8.4-9.8 days.


CONCLUSIONS
No severity measure explained the two-fold differences among hospitals in average LOS. Other patient characteristics, practice patterns, or institutional factors may cause the wide differences across hospitals in LOS.
Iezzoni
L I
LI
Division of General Medicine and Primary Care, Beth Israel Hospital, Boston, MA, USA.
Shwartz
M
M
Ash
A S
AS
Mackiernan
Y D
YD
D014487:Centers for Medicare and Medicaid Services, U.S.; D003953:Diagnosis-Related Groups / Q000145:classification; D005544:Forecasting; D019538:Health Care Surveys; D006302:Health Services Research / Q000379:methods; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008962:Models, Theoretical; D017063:Outcome Assessment, Health Care; D011014:Pneumonia / Q000145:classification* / Q000503:physiopathology*; D012044:Regression Analysis; D012720:Severity of Illness Index; D014481:United States