Prolonged hospital stay and the resident duty hour rules of 2003

Abstract

Background: Resident duty hour reforms of 2003 had the potential to create a major impact on the delivery of inpatient care.

Objective: We examine whether the reforms influenced the probability of a patient experiencing a prolonged hospital length of stay (PLOS), a measure reflecting either inefficiency of care or the development of complications that may slow the rate of discharge.

Research design: Conditional logistic models to compare PLOS in more versus less teaching-intensive hospitals before and after the reform, adjusting for patient comorbidities, common time trends, and hospital site.

Subjects: Medicare (N = 6,059,015) and Veterans Affairs (VA) (N = 210,276) patients admitted for medical conditions (acute myocardial infarction, heart failure, stroke, or gastrointestinal bleeding) or surgical procedures (general, orthopedic, and vascular) from July 2000 to June 2005.

Measures: Prolonged length of stay.

Results: Modeling all medical conditions together, the odds of prolonged stay in the first year post reform at more versus less teaching intensive hospitals was 1.01 (95% CI: 0.97-1.05) for Medicare and 1.07 (0.94-1.20) for the VA. Results were similarly negative in the second year post reform. For "combined surgery" the post year 1 odds ratios were 1.04 (0.98-1.09) and 0.94 (0.78-1.14) for Medicare and the VA respectively, and similarly unchanged in post year 2. Isolated increases in the probability of prolonged stay did occur for some vascular surgery procedures.

Conclusions: Hospitals generally found ways to cope with duty hour reform without increasing the prevalence of prolonged hospital stays, a marker of either inefficient care or complications.

FIGURE 1. Conditional Length of Stay after being prolonged for Congestive Heart Failure Admissions at the Veterans Affairs Hospitals

For a typical condition, like the example shown below for CHF, the rate of discharge increases until a point in the hospital stay defined as the “prolongation point.”. For CHF the prolongation point was day 3, hence patients were considered prolonged if they exceeded a 3-day stay. Hospitals stays beyond the prolongation point display a declining rate of discharge, as displayed below. Each Kaplan-Meier curve below is based on a cohort of patients still in the hospital beyond the prolongation point, with successive curves starting at 0, 4, 8 and 12 days beyond the prolongation point. Patients who have stayed beyond the prolongation point (starting at “Prolongation + 0 days”) have a discharge curve below those who have stayed beyond the “Prolongation + 4 days” curve, suggesting the rate of discharge in the group staying at least 4 days beyond the prolongation point is lower than the group that has stayed just beyond the prolongation point. This represents the clinical situation where, after being prolonged, “the longer one has stayed, the slower one will be discharged or the longer one will stay.” After the prolongation point, each successive cohort beyond the prolongation point (that is, +4, then +8, then +12) will display curves below one another, implying a declining rate of discharge.

Figure 2

Prolonged Stay for Medicare and VA Patients by Teaching Status by Year for Combined Medical Conditions and Combined Surgical Procedures