title: Extended length of stay after surgery: complications, inefficient practice, or sick patients?
abstract: OBJECTIVE
  With the health policy focus on shifting risk to hospitals and physicians, hospital leaders are increasing efforts to reduce excessive resource use, such as patients with extended length of stay (LOS) after surgery. However, the degree to which extended LOS represents complications, patient illness, or inefficient practice style is unclear.
  
  
  OBJECTIVE
  To examine the influence of complications on the variance in hospitals' extended LOS rates after colorectal resections.
  
  
  METHODS
  In this retrospective cohort study performed from January 1 through December 31, 2009, we analyzed data from the 2009 American College of Surgeons National Surgical Quality Improvement Program. Study participants were 22 664 adults undergoing colorectal resections in 199 hospitals.
  
  
  METHODS
  Inpatient complications recorded in the American College of Surgeons National Surgical Quality Improvement Program registry. Inpatient complications were identified by the association of the complication's postoperative date with the patient's surgical discharge date.
  
  
  METHODS
  Hospitals' risk-adjusted extended LOS rates, defined as the proportion of patients with a hospital stay greater than the 75th percentile for the entire cohort.
  
  
  RESULTS
  A total of 2177 patients (42.8%) with extended LOSs did not have a documented inpatient complication. Although there was wide variation in risk-adjusted extended LOS (14.5%-35.3%) and risk-adjusted inpatient complication (12.1%-28.5%) rates, there was only a weak correlation (Spearman ρ = 0.56, P < .001) between the two. Only 52.0% of the variation in hospitals' extended LOS rates was attributable to hospitals' inpatient complication rates.
  
  
  CONCLUSIONS
  Much of the variation in hospitals' risk-adjusted extended LOS rates is not attributable to patient illness or complications and therefore most likely represents differences in practice style. Efforts to reduce excess resource use should focus on efficiency of care, such as increased adoption of enhanced recovery pathways.
authors: Department of Surgery, University of Michigan Health System, Ann Arbor.
authors: Robert W
authors: RW
authors: Krell
authors: Department of Surgery, University of Michigan Health System, Ann Arbor.
authors: Micah E
authors: ME
authors: Girotti
authors: Department of Surgery, University of Michigan Health System, Ann Arbor.
authors: Justin B
authors: JB
authors: Dimick
mesh_terms: D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D003108:Colonic Diseases / Q000150:complications / Q000473:pathology / Q000601:surgery*; D005260:Female; D006304:Health Status; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011787:Quality of Health Care; D012002:Rectal Diseases / Q000150:complications / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors