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Achanta 2019
Achanta 2019
Aditya Achanta, BS, Ask Nordestgaard, BA, Napaporn Kongkaewpaisan, MD, Kelsey Han, BA,
April Mendoza, MD, MPH, Noelle Saillant, MD, Martin Rosenthal, MD, Peter Fagenholz, MD,
George Velmahos, MD, PhD, and Haytham M.A. Kaafarani, MD, MPH, Boston, Massachusetts
BACKGROUND: Hospital length of stay (LOS) is currently recognized as a key quality indicator. We sought to investigate how much of the LOS
variation in the high-risk group of patients undergoing Emergency general surgery could be explained by clinical versus nonclin-
ical factors.
METHODS: Using the 2007 to 2015 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database,
we included all patients who underwent an emergency appendectomy, cholecystectomy, colectomy, small intestine resection,
enterolysis, or hernia repair. American College of Surgeons National Surgical Quality Improvement Program defines emergency
surgery as one that is performed no later than 12 hours after admission or symptom onset. Using all the ACS-NSQIP demo-
graphic, preoperative (comorbidities, laboratory variables), intraoperative (e.g., duration of surgery, wound classification), and
postoperative variables (i.e., complications), we created multivariable linear regression models to predict LOS. LOS was treated
as a continuous variable, and the degree to which the models could explain the variation in LOS for each type of surgery was
measured using the coefficient of determination (R2).
RESULTS: A total of 215,724 patients were included. The mean age was 47.1 years; 52.0% were female. In summary, the median LOS
ranged between 1 day for appendectomies (n = 124, 426) and cholecystectomies (n = 21,699) and 8 days for colectomies
(n = 19,557) and small intestine resections (n = 7,782). The R2 for all clinical factors ranged between 0.28 for cholecystectomy
and 0.44 for hernia repair, suggesting that 56% to 72% of the LOS variation for each of the six procedures studied cannot be ex-
plained by the wide range of clinical factors included in ACS-NSQIP.
CONCLUSION: Most of the LOS variation is not explained by clinical factors and may be explained by nonclinical factors (e.g., logistical delays,
insurance type). Further studies should evaluate these nonclinical factors to identify target areas for quality improvement.
(J Trauma Acute Care Surg. 2019;87: 408–412. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)
LEVELS OF EVIDENCE: Epidemiological study, level III.
KEY WORDS: Length of stay; emergency general surgery; clinical variation; ACS-NSQIP.
is still important to capture, understand, and address from the measure at least at the individual clinician, department or even
system's perspective, in addition to examining in depth the pa- hospital level.9 Because our results suggest that nonclinical
tients with very prolonged LOS. drivers are key to understand LOS, it is essential to explore the
The fact that more of the variation in LOS is explained by accountability of hospitals versus regions and states before utilizing
nonclinical factors is of great importance, but perhaps not sur- LOS as an indicator of hospital or department performance. For
prising to many clinicians. Hwabejire et al.5 previously reported example, the availability of sufficient rehabilitation beds and high
that clinical deterioration was the cause of an extended LOS in rates of underserved patients with difficult discharge destinations
only 20% of trauma patients. Similarly, Krell et al.4 found that, may be some of the drivers of increased LOS, with both having
for 43% of surgery patients with an extended LOS, there was more to do with societal support structures at large rather than fac-
no recorded postoperative complications that explain the pro- tors related to the patient's care. The hospital in question has prob-
longed LOS. In both aforementioned studies, the findings could ably little influence on these societal support factors, and as such,
theoretically be due to differences in the type of procedures an- LOS might not be reflective of the quality of care provided.
alyzed (e.g., EGS vs. non-EGS) and due to studying LOS as a Alternatively, with 56% to 72% of the variation in LOS of
binary variable versus a continuous variable.4,5 Still, this key EGS patients being not related to the clinical situation and clin-
finding in our study, namely, that only a small percentage of ical care, a quality improvement opportunity arises. Some of the
the variation in LOS is clinical in etiology, highlights two impor- system-related factors might be difficult to change, but still nec-
tant themes: (1) the role that inefficiencies and inequity in the essary to tackle at the hospital and provider-level, such as creat-
healthcare system might be playing in LOS variation within hos- ing social support systems for discharged patients, streamlining
pitals, and more importantly across different hospitals; and (2) the payer-related negotiations, and optimizing staffing models
the wisdom or controversy of using LOS as a quality metric for EGS.10 Standardizing the care processes to decrease the
for benchmarking clinical care. Prior studies have suggested that number of complications can also lead to substantial decreases
LOS is too influenced by nonclinical factors, such as insurance in LOS variation, as most of the explained clinical LOS variation
type and discharge destination, to be an appropriate quality mea- is postoperative in nature.
sure.9 By the same rationale, others have argued that it is exactly Some policy experts, clinicians and researchers argue that
that characteristic that makes it a measure of quality perfor- decreasing the LOS might result in an automatic increase in re-
mance at the system level. We tend to agree that it is important admissions. However, it is becoming clearer that the two are not
to look in more depth at the underlying nonclinical drivers of necessarily inversely correlated.11 It is possible to decrease var-
the variation in LOS before fully endorsing LOS as a quality iation in surgical LOS and remove inefficiencies through the