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The American Journal of Managed Care July 2018
Differences in Spending on Provider-Administered Chemotherapy by Site of Care in Medicare
Yamini Kalidindi, MHA; Jeah Jung, PhD; and Roger Feldman, PhD
The Development of Diabetes Complications in GP-Centered Healthcare
Kateryna Karimova, MSc; Lorenz Uhlmann, MSc; Marc Hammer, MPH; Corina Guethlin, PhD; Ferdinand M. Gerlach, MD, MPH; and Martin Beyer, MSc
Value-Based Health Insurance Design: How Much Does Socioeconomic Status Matter?
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Insights on Site-of-Care Cancer Research: Both Quality and Cost Information Are Necessary to Guide Policy
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Examining Differential Performance of 3 Medical Home Recognition Programs
Ammarah Mahmud, MPH; Justin W. Timbie, PhD; Rosalie Malsberger, MS; Claude M. Setodji, PhD; Amii Kress, PhD; Liisa Hiatt, MS; Peter Mendel, PhD; and Katherine L. Kahn, MD
Prices for Physician Services in Medicare Advantage Versus Traditional Medicare
Julius L. Chen, PhD; Andrew L. Hicks, MS; and Michael E. Chernew, PhD
Forgotten Patients: ACO Attribution Omits Those With Low Service Use and the Dying
Mariétou H. Ouayogodé, PhD; Ellen Meara, PhD; Chiang-Hua Chang, PhD; Stephanie R. Raymond, BA; Julie P.W. Bynum, MD, MPH; Valerie A. Lewis, PhD; and Carrie H. Colla, PhD
Postdischarge Engagement Decreased Hospital Readmissions in Medicaid Populations
Wanzhen Gao, PhD; David Keleti, PhD; Thomas P. Donia, RPh; Jim Jones, MBA; Karen E. Michael, MSN, MBA, RN; and Andrea D. Gelzer, MD, MS, FACP
ACOs With Risk-Bearing Experience Are Likely Taking Steps to Reduce Low-Value Medical Services
Margje H. Haverkamp, MD, PhD; David Peiris, MD, PhD; Alexander J. Mainor, JD, MPH; Gert P. Westert, PhD; Meredith B. Rosenthal, PhD; Thomas D. Sequist, MD, MPH; and Carrie H. Colla, PhD
Trends in Primary Care Encounters Across Professional Roles in PCMH
Ann M. Annis, PhD, RN; Marcelline Harris, PhD, RN; Hyungjin Myra Kim, ScD; Ann-Marie Rosland, MD, MS; and Sarah L. Krein, PhD, RN
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Inpatient Placement: Associations With Mortality, Cost, and Length of Stay
Daniel A. Handel, MD, MBA, MPH; Zemin Su, MS; Nancy Hendry, MSN; and Patrick Mauldin, PhD

Inpatient Placement: Associations With Mortality, Cost, and Length of Stay

Daniel A. Handel, MD, MBA, MPH; Zemin Su, MS; Nancy Hendry, MSN; and Patrick Mauldin, PhD
Placement of patients in an inpatient hospital setting is associated with lower length of stay and mortality at the expense of higher costs.

Objectives: Tertiary referral centers have created inpatient units to meet the needs of specific patient populations but sometimes are forced to place patients on other units that, although having the basic necessary skillsets for treating the patient, are not focused on that diagnosis area. The objective of this study was to look at outcomes of patients admitted to these different inpatient settings.

Study Design: Retrospective review of patient data from a single tertiary academic medical center from August 1, 2014, to June 30, 2015, comparing patients admitted to primary versus secondary inpatient services. Patients admitted to the inpatient children’s hospital, psychiatric hospital, labor and delivery unit, or subacute transitional care unit were excluded.

Methods: Demographics of patients in the primary versus secondary units were compared to look for systematic differences between the 2 patient populations. To control for confounding variables, a gamma regression analysis was conducted for length of stay (LOS) and total cost, whereas a logistic regression was conducted for mortality.

Results: Admitting to the primary unit resulted in 5.5% lower observed LOS, controlling for other patient variables, but it came at a 17.8% higher total cost of care provided compared with secondary units. Mortality was also found to be lower on primary units (odds ratio, 0.864) but did not cross the threshold of statistical significance (P = .101).

Conclusions: Patients admitted to the primary unit had a lower LOS with higher costs of care. There was a trend toward improved mortality, although it was not statistically significant.

Am J Manag Care. 2018;24(7):e230-e233
Takeaway Points

This is a retrospective analysis of outcomes for patients admitted to 1 tertiary academic medical center to either the primary or secondary specialized unit of their admitting diagnosis.
  • After controlling for patient acuity, admitting to the primary specialized unit resulted in a 5.5% lower observed length of stay in the hospital compared with other units.
  • Costs were found to be 17.8% higher on primary units compared with secondary units.
  • Although not statistically significant (P = .101), mortality was lower on primary units (odds ratio, 0.864).
  • This study suggests that admitting patients in a referral center to an inpatient unit designed to focus on their specific disease condition might have a positive impact on their outcomes.
  • The decision to admit to a specific unit must be balanced with the potential for boarding of patients in noninpatient settings when inpatient capacity rates are high.
As healthcare becomes increasingly complex, patients admitted to the hospital require specialized services from both a physician and nursing perspective. Many hospitals have developed specific inpatient units to meet the needs of unique patient populations. However, with inpatient occupancy rates up in many tertiary referral centers,1 hospitals may not be able to place patients on the primary specialty unit to meet the specific needs of their medical condition. This must be balanced with the fact that increasing inpatient occupancy rates have been shown to lead to adverse outcomes.2-6 Therefore, patients may need to be placed on secondary specialty units to optimize capacity demands to compensate for resource constraints of the inpatient setting.

When no inpatient beds are available, patients may be delayed in the emergency department (ED), leading to the boarding of patients, which occurs when a patient has been accepted to an inpatient service but remains located in a noninpatient setting, usually in the ED. Boarding has been found to increase the length of stay (LOS) for both patients awaiting admission and those eventually discharged from the ED.7 Increased ED occupancy rates have also been found to lead to increased morbidity and mortality rates. One study found that the highest quartile of ED occupancy ratios—the total number of patient beds divided by the number of licensed ED beds—compared with the lowest quartile was associated with significantly increased odds of 1-day (odds ratio [OR], 1.42), 2-day (OR, 1.31), and 3-day (OR, 1.27) mortality.8 Another study's findings demonstrated a 3% increase in mortality with a 10% increase in ED bed occupancy, along with a 3% increase in hospital admission during a return visit to the ED.9

Another patient population affected by high inpatient occupancy rates is those awaiting transfers from lower-acuity medical/surgical units to the intensive care unit (ICU) or from outside facilities. Delays in transfer to an ICU setting when clinically indicated due to a lack of inpatient capacity have been found to increase mortality.10 Conversely, a lack of medical/surgical beds may result in patients boarding in the ICU setting.

To date, no study has looked at the impact of admitting a patient based on the primary disease focus of a particular unit. There is existing evidence that trauma patients do best when cared for on a trauma unit.11 One study from a French hospital found longer LOS and higher readmission rates for patients not admitted to the primary specialty unit.12 However, no existing study has explored LOS and readmissions across all specialties in an American inpatient population. This study looked at the impact on patient outcomes based on the initial placement of a patient admitted to an inpatient setting and that placement’s impact on LOS, mortality, and total cost of care delivered.


Study Design

This study is a retrospective review of all inpatient admissions to the Medical University of South Carolina Medical Center, a single tertiary academic medical center in Charleston, South Carolina, from August 1, 2014, to June 30, 2015. Institutional review board approval was obtained for this study. Patient information and all variables were extracted from the electronic health record (Epic Systems; Verona, Wisconsin). Expected LOS for patients was provided based on benchmarking data by Vizient, Inc (Irving, Texas). Patients admitted to the inpatient children’s hospital, psychiatric hospital, labor and delivery unit, or subacute transitional care unit were excluded from the analysis because no alternative inpatient units were available to them at the time of admission. Patients were considered to be admitted to a primary specialty unit versus a secondary unit based on an algorithm used by a centralized bed management team. This algorithm was agreed on by nursing and hospital leadership to ensure that the minimum core competencies required to take care of patients were also available on secondary units, even if not their primary disease focus. Although all units to which the patients were admitted had the appropriate basic nursing skillsets and technological support to meet the needs of the patients, primary specialty units had greater focus on these particular types of patients and handled a higher volume of them on a regular basis. In our institution, there are units focused on neurologic, musculoskeletal, oncology, gastrointestinal, transplant, trauma, cardiovascular, and general medicine admitting diagnoses. Any unit can be a primary or secondary unit, depending on the patient’s primary admitting diagnosis and service. Providers preferred to have their patients on these primary specialty units to help cohort their inpatient service in close proximity  and maximize their efficiencies to deliver care, but the teams of providers taking care of these patients did not alter the care delivered whether the patient was on the primary or secondary unit.

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