title: Has variation in length of stay in acute hospitals decreased? Analysing trends in the variation in LOS between and within Dutch hospitals.
abstract: BACKGROUND
  We aimed to get better insight into the development of the variation in length of stay (LOS) between and within hospitals over time, in order to assess the room for efficiency improvement in hospital care.
  
  
  METHODS
  Using Dutch national individual patient-level hospital admission data, we studied LOS for patients in nine groups of diagnoses and procedures between 1995 and 2010. We fitted linear mixed effects models to the log-transformed LOS to disentangle within and between hospital variation and to evaluate trends, adjusted for case-mix.
  
  
  RESULTS
  We found substantial differences between diagnoses and procedures in LOS variation and development over time, supporting our disease-specific approach. For none of the diagnoses, relative variance decreased on the log scale, suggesting room for further LOS reduction. Except for two procedures in the same specialty, LOS of individual hospitals did not correlate between diagnoses/procedures, indicating the absence of a hospital wide policy. We found within-hospital variance to be many times greater than between-hospital variance. This resulted in overlapping confidence intervals across most hospitals for individual hospitals' performances in terms of LOS.
  
  
  CONCLUSIONS
  The results suggest room for efficiency improvement implying lower costs per patient treated. It further implies a possibility to raise the number of patients treated using the same capacity or to downsize the capacity. Furthermore, policymakers and health care purchasers should take into account statistical uncertainty when benchmarking LOS between hospitals and identifying inefficient hospitals.
authors.affiliation: National Institute for Public Health and the Environment, Richard Heijink, P.O. Box 1, 3720, BA, Bilthoven, The Netherlands. aart.vandevijsel@xs4all.nl.
authors.forename: Aart R
authors.initials: AR
authors.lastname: van de Vijsel
authors.affiliation: National Institute for Public Health and the Environment, Richard Heijink, P.O. Box 1, 3720, BA, Bilthoven, The Netherlands. richard.heijink@rivm.nl.
authors.forename: Richard
authors.initials: R
authors.lastname: Heijink
authors.affiliation: National Institute for Public Health and the Environment, Richard Heijink, P.O. Box 1, 3720, BA, Bilthoven, The Netherlands. maarten.schipper@rivm.nl.
authors.forename: Maarten
authors.initials: M
authors.lastname: Schipper
mesh_terms: D000208:Acute Disease / Q000628:therapy*; D000328:Adult; D019985:Benchmarking / Q000706:statistics & numerical data; D003953:Diagnosis-Related Groups / Q000191:economics; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D016014:Linear Models; D008511:Medicine / Q000706:statistics & numerical data; D008875:Middle Aged; D009426:Netherlands; D010343:Patient Admission / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians'