title: The quality metric prolonged length of stay misses clinically important adverse events.
abstract: BACKGROUND
  The National Quality Forum endorses prolonged length of stay of more than 14 days (PLOS) as a quality metric for lobectomy for lung cancer. Because PLOS rates are lower than complication rates, we hypothesized that PLOS misses a significant proportion of clinically important events.
  
  
  METHODS
  A retrospective study was performed on patients undergoing lobectomy (2000 to 2009). The severity of adverse events was based on the National Cancer Institute common terminology criteria for adverse events (grade 2 or higher indicates symptoms or need for medical intervention; grade 5 indicates death).
  
  
  RESULTS
  Among 2,667 patients, 163 (6%) experienced PLOS and 773 (29%) experienced an adverse event. Although the frequency of adverse events was higher among the PLOS group (99% [161 of 163] versus 24% [612 of 2504]), 79% (612 of 773) of adverse events occurred in the non-PLOS group. Whereas PLOS was associated with more severe events, 89% of those in the non-PLOS group experienced a grade 2 or higher event. Likewise, although PLOS was associated with the lowest 5-year survival rate (31%), patients in the non-PLOS group who had an adverse event had significantly lower survival rates than patients in the non-PLOS group who did not have any adverse events (55% versus 68%, p<0.001; adjusted hazard ratio 1.3 [95% confidence interval: 1.1 to 1.6]).
  
  
  CONCLUSIONS
  The PLOS missed a high proportion of adverse events defined by the need for ongoing inpatient therapy and an association with poor long-term survival. These findings have implications for efficient and fair performance assessment in the setting of a quality improvement program.
authors: Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
authors: Farhood
authors: F
authors: Farjah
authors: Feiran
authors: F
authors: Lou
authors: Valerie W
authors: VW
authors: Rusch
authors: Nabil P
authors: NP
authors: Rizk
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002173:Cancer Care Facilities; D002423:Cause of Death; D015331:Cohort Studies; D016001:Confidence Intervals; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008175:Lung Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D009519:New York City; D017063:Outcome Assessment, Health Care; D011013:Pneumonectomy / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D011183:Postoperative Complications / Q000453:epidemiology* / Q000473:pathology / Q000628:therapy; D058996:Quality Improvement; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D013997:Time Factors; D055815:Young Adult