Safely and effectively reducing inpatient length of stay: a controlled study of the General Internal Medicine Care Transformation Initiative

Abstract

PurposeWhether improving the efficiency of hospital care will worsen post-discharge outcomes is unclear. We designed this study to evaluate the General Internal Medicine (GIM) Care Transformation Initiative implemented at one of the seven teaching hospitals in the Canadian province of Alberta.MethodsControlled before–after study of GIM patients hospitalised at the University of Alberta Hospital (UAH, intervention site, n=1896) or the six other teaching hospitals in Alberta—three in Edmonton (intra-regional controls (IRC), n=4550) and three in Calgary (extra-regional controls (ERC), n=4095). The primary effectiveness outcome was risk-adjusted length of stay (LOS) and the primary safety outcome was ‘mortality during index hospitalisation or all-cause readmission or death within 30-days of discharge’.ResultsLOS for GIM patients decreased by 0.68 days at Alberta teaching hospitals between 2009 and 2012; GIM patients hospitalised at the UAH exhibited a further 20% relative decline in adjusted LOS (total reduction=1.43 days, 95% CI 0.94 to 1.92 days) from PRE to POST. Interrupted time series (ITS) confirmed that the 1.43 day reduction at the UAH was statistically significant (level change p=0.003), while the declines at the IRC (p=0.37) and ERC (p=0.45) were not. Our safety outcome did not change for UAH patients (18.4% PRE-intervention vs 17.8% POST-intervention, adjusted OR 1.02 (95%CI 0.80 to 1.31), p=0.42 on ITS), nor for those hospitalised at the IRC (p=0.33) or the ERC (p=0.73) sites.ConclusionsThe Care Transformation Initiative was associated with substantial reductions in LOS without increasing post-discharge events commonly quoted as proxies for quality.

Patient characteristics, resource use and outcomes associated with general internal medicine hospital care: the General Medicine Inpatient Initiative (GEMINI) retrospective cohort study

“…In 2 studies, both involving about 10 000 patients at 7 teaching hospitals in Alberta, the most prevalent discharge diagnoses were chronic obstructive pulmonary disease, pneumonia, heart failure, urinary tract infection and venous thromboembolism, and the in-hospital death rate ranged from 3.9% to 7.4% across hospitals. 29,30 The median length of stay in our study was 4.6 days, similar to that in studies in the United States and Europe (4.0). 31,32 Patients admitted to §Readmission to general internal medicine service at 1 of the participating hospitals within 30 days of discharge.…”

“…Third, our study was conducted in 7 teaching hospitals in Canada's largest metropolitan area. Our patient sample is broadly similar to that in other studies in general internal medicine in Canada, the US and Europe, [29][30][31][32] and our findings are likely generalizable to other urban and suburban academic health centres and large community hospitals, but the sample may not be representative of patients or practices in other settings. Fourth, we were able to capture readmission to general internal medicine only at hospitals within our network.…”

Physician experience and outcomes among patients admitted to general internal medicine teaching wards

“…31, 2012 (the 12 months after the change). As previously reported, 12 the General Internal Medicine Care Transformation did not affect our primary outcome: in-hospital mortality and rate of death or readmission in the first 30 days postdischarge. All 7 teaching hospitals are located in either Edmonton (4) or Calgary (3).…”

The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions

“…Secondary outcomes included the proportion of patients with an all-cause emergency department visit or hospital admission, the individual components of the primary outcome, hospital length of stay for those hospitalized, 30-day readmission rates after hospital discharge and 30-day repeat emergency department visits, using previously published definitions. 17 All events for each patient were counted, but visits to the emergency department that resulted in a hospital admission during the same encounter or transfers between emergency departments or hospitals in the same episode of care were counted as only 1 event.…”