Length of stay

Length of stay (LOS) is a term to describe the duration of a single episode of hospitalization.

Inpatient days are calculated by subtracting day of admission from day of discharge. (However, persons entering and leaving a hospital on the same day have a length of stay of one).

The clinical course of subarachnoid hemorrhage generates high health economics expenses.

Ridwan et al. highlighted possible cost drivers for in-hospital care expenses for the first year. Furthermore, results are compared with ischemic stroke treatment.

One hundred and one patients with aneurysmal subarachnoid hemorrhage treated in the University Hospital Bonn, from 2007 through 2009 were included. The Hunt and Hess (HH) scale, World Federation of Neurosurgical Societies (WFNS) scale, Fisher Scale, and further outcome-relevant data were recorded. Expenses were calculated using the German fixed case rate classification system consisting of Diagnosis-Related Groups (DRG) and the Operation and Procedure catalog (OPS). Overall acute length of stay (LOS) and LOS on the intensive care unit (ICU) were separately evaluated. Expenses were compared with formerly published first-year costs of ischemic stroke.

Fifty-four percent of the patients (median age 52 years, 69% females) received coiling and 46% clipping. Acute in-hospital treatment accounted for 82% of total in-hospital expenses, while consequential in-hospital treatment accounted only for 18%. Altogether, the total first-year in-hospital expenses for all patients were as high as €2,650,002, resulting in average SAH in-hospital treatment expenses of €26,238 per patient for the first year. Poor clinical condition on admission and longer stay in ICU are the main cost-driving factors. The impact of the aneurysm treatment method is debatable. Only a poor HH grade and longer ICU stay are independent cost-driving factors. SAH treatment expenses are far higher than treatment costs for ischemic stroke in the literature (€6,731 for first-year inpatient and €3,287 for outpatient treatment).

Clinical condition and length of stay (LOS) determine in-hospital expenses after subarachnoid hemorrhage. Aneurysmal subarachnoid hemorrhage prevalently results in a relevant economic impact on the health system exceeding formerly published treatment expenses for ischemic stroke 1).

Schipmann et al. performed a systematic literature review on quality indicators (QIs) that are presently used in this field, aiming to elucidate which QIs are scientifically founded and thus potentially justifiable as measures of quality. They found a total of 8 QIs, and methodologically evaluated published studies according to the AIRE (Appraisal of Indicators through Research and Evaluation) criteria. These criteria include length of hospital stay, all-cause readmission rate, and unplanned reoperation rate 2).

Using a comprehensive all-payer cohort of patients with brain tumors in New York State, Missios and Bekelis identified wide disparities at the hospital and the county level despite comprehensive risk-adjustment. Increased charges were not associated with shorter length of stay (LOS), or lower rates of death and unfavorable discharge 3).

Prolonged length of stay (pLOS), disease-related complications, and 30-day readmissions are important quality metrics under the Affordable Care Act.

Salas-Vega et al. sought to distinguish among the clinical and nonclinical drivers of patient length of stay (LOS) in the hospital following elective lumbar laminectomy-a common spinal surgery that may be reimbursed using bundled payments-and to understand their relationships with patient outcomes and costs.

Patients ≥ 18 years of age undergoing laminectomy surgery for degenerative lumbar spinal stenosis within the Cleveland Clinic health system between March 1, 2016, and February 1, 2019, were included in this analysis. Generalized linear modeling was used to assess the relationships between the day of surgery, patient discharge disposition, and hospital LOS, while adjusting for underlying patient health risks and other nonclinical factors, including the hospital surgery site and health insurance.

A total of 1359 eligible patients were included in the authors' analysis. The mean LOS ranged between 2.01 and 2.47 days for Monday and Friday cases, respectively. The LOS was also notably longer for patients who were ultimately discharged to a skilled nursing facility (SNF) or rehabilitation center. A prolonged LOS occurring later in the week was not associated with greater underlying health risks, yet it nevertheless resulted in greater costs of care: the average total surgical costs for lumbar laminectomy were 20% greater for Friday cases than for Monday cases, and 24% greater for late-week cases than for early-week cases ultimately transferred to SNFs or rehabilitation centers. A Poisson generalized linear model fit the data best and showed that the comorbidity burden, surgery at a tertiary care center versus a community hospital, and the incidence of any postoperative complication were associated with significantly longer hospital stays. Discharge to home healthcare, SNFs, or rehabilitation centers, and late-week surgery were significant nonclinical predictors of LOS prolongation, even after adjusting for underlying patient health risks and insurance, with LOSs that were, for instance, 1.55 and 1.61 times longer for patients undergoing their procedure on Thursday and Friday compared to Monday, respectively.

Late-week surgeries are associated with a prolonged LOS, particularly when discharge is to an SNF or rehabilitation center. These findings point to opportunities to lower costs and improve outcomes associated with elective surgical care. Interventions to optimize surgical scheduling and perioperative care coordination could help reduce prolonged LOSs, lower costs, and, ultimately, give service line management personnel greater flexibility over how to use existing resources as they remain ahead of health care reforms 4).

Reducing length of stay (LOS) in a safe manner has the potential to save significant costs for the care of patients undergoing elective lumbar spine surgery. Due to the relative absence on weekends of staff required for discharging patients to rehabilitation or nursing facilities, Sivaganesan et al. hypothesized that patients undergoing lumbar surgery later in the week have a longer LOS than their counterparts.

Patients undergoing surgery for lumbar degenerative disease were prospectively enrolled in the multicenter quality and outcomes database registry. A multivariable proportional odds regression model was built with LOS as the outcome of interest and patient and surgical variables as covariates.

A total of 11 897 patients were analyzed. Among those discharged home, the regression analysis demonstrated significantly higher odds of longer LOS for patients undergoing surgery on Friday as compared to Monday (P < .001). Among those discharged to a facility, there were significantly higher odds of longer LOS for patients undergoing surgery on Wednesday (P < .001), Thursday (P < .001), and Friday (P = .002) as compared to Monday.

The findings of this study suggest that lumbar patients undergoing fusions and those discharged to a facility have longer LOS when surgery is later in the week. Scheduling these patients for surgery earlier in the week and ensuring adequate resources for patient disposition on weekends may lead to LOS reduction and cost savings for hospitals, payers, and patients alike 5).

see Long length of stay.

Ridwan S, Urbach H, Greschus S, Hagen JV, Esche J, Boström A. Health Economic Aspects of Aneurysmal Subarachnoid Hemorrhage: Factors Determining First Year In-Hospital Treatment Expenses. J Neurol Surg A Cent Eur Neurosurg. 2021 Jan 24. doi: 10.1055/s-0040-1720982. Epub ahead of print. PMID: 33486751.
Schipmann S, Schwake M, Suero Molina E, Roeder N, Steudel WI, Warneke N, Stummer W. Quality Indicators in Cranial Neurosurgery: Which Are Presently Substantiated? A Systematic Review. World Neurosurg. 2017 Aug;104:104-112. doi: 10.1016/j.wneu.2017.03.111. Epub 2017 Apr 30. Review. PubMed PMID: 28465269.
Missios S, Bekelis K. Regional disparities in hospitalization charges for patients undergoing craniotomy for tumor resection in New York State: correlation with outcomes. J Neurooncol. 2016 Apr 12. [Epub ahead of print] PubMed PMID: 27072560.
Salas-Vega S, Chakravarthy VB, Winkelman RD, Grabowski MM, Habboub G, Savage JW, Steinmetz MP, Mroz TE. Late-week surgery and discharge to specialty care associated with higher costs and longer lengths of stay after elective lumbar laminectomy. J Neurosurg Spine. 2021 Apr 6:1-7. doi: 10.3171/2020.11.SPINE201403. Epub ahead of print. PMID: 33823491.
Sivaganesan A, Devin CJ, Khan I, Kerezoudis P, Nian H, Harrell FE Jr, Bydon M, Asher AL. Is Length of Stay Influenced by the Weekday On Which Lumbar Surgery is Performed? Neurosurgery. 2018 Aug 24. doi: 10.1093/neuros/nyy382. [Epub ahead of print] PubMed PMID: 30165453.
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