Managed Care - July 2008 - (Page 44) lengths of stay, and it benefits hospitals by minimizing the effect of uncontrollable and unusual admissions that have very long lengths of stay. Robinson says the Leapfrog measure has some limitations. In small hospitals or when a hospital has a limited number of admissions for a particular category, the average length of stay remains susceptible to the influence of unusual observations even after the dampening effect of using the log length of stay. In addition, hospitals must report all admissions within a category, even when the condition, such as pneumonia, is secondary to another primary diagnosis. The percentage of stays with such a secondary diagnosis status affects the expected length of stay. Robinson advised Leapfrog to consider these issues in future refinements. At present, Leapfrog does not require hospitals with fewer than 10 cases to report on this measure. Validation The Leapfrog Group has submitted the LOS measure to the National Quality Forum for approval as a voluntary standard. That approval will boost the credibility of the measure and help overcome potential criticism. “We want this measure to be totally transparent to hospitals. That is why we contracted with the university to develop it and issue a white paper, and why we submitted it to NQF,” says Karen Linscott, a Leapfrog executive. More than 1,350 hospitals across the countr y already participate voluntarily in Leapfrog’s survey, so the measure will be officer of Seattle’s widely used and tested this year. The partic- Virginia Mason Not preventable ipating hospitals make up over 25 percent of Medical Center. Rudolph says Leapfrog’s measure is not the acute care hospitals in the country. Based on this initially intended to drive down the LOS and costs wide participation, Leapfrog has touted its LOS for routine admissions. “There is only so much you measure as the first resource usage measure to be can shave off of length of stay without negatively afincluded in a national hospital quality survey. The fecting quality. The cost savings on inpatient care Centers for Medicare & Medicaid Services and Joint comes from decreasing readmissions and reducing Commission measures still focus only on quality. the length of stay for outliers. Some of the really long lengths of stay are not preventable, but others are. We’re trying to get at the excess stay that is due Raising the bar to lower quality care.” The LOS measure has been added to existing Gary Kaplan, MD, chairman and chief executive quality and safety measures in the Leapfrog hospiofficer of Seattle’s Virginia Mason Medical Center, tal survey. Those measures include medication says that in hospitals, “Quality and efficiency go hand safety, high-risk treatments such as aneurysm repair in hand because complications often are the results and bariatric surgery, intensivist staffing in ICUs, of inefficient care. The longer a patient stays in the and safety practices such as preventing infections. “Hospitals will now be evaluated simultaneously on two sets of measures, quality and resource utilization, which together we define as efficiency.” To be ranked high and to be considered efficient, hospitals must be in the upper-right quartile of a scattergram with quality on one axis and efficiency on the other. That presents a challenge to hospital chief medical officers. Robinson found that many risk factors drive up the LOS. The statistically significant risk factors he identified for each category of admissions explain longer-than-average stays less than 30 percent of the time. That means 70 percent of the time, a long stay is because of complications other than the major risk factors. Some of these factors are not controllable; others are. James Schibanoff, MD, editor of Milliman’s inpatient care guidelines, which specify a goal length of stay for most inpatient conditions, says, “For community-acquired pneumonia [a subset of Leapfrog’s pneumonia measure], the target length of stay is two days. Only 19 percent that reported met the target. Among the states reporting, Washington does the best with 28 percent of the admissions meeting the target; and for the best group of hospitals, 43 percent of the admissions [have a “Quality and two day length of stay].” Milliman’s goal efficiency go lengths of stay are based on a combination of hand in hand,” says reported cases and evidence-based medicine. Gary Kaplan, MD, In the Leapfrog survey, the expected length of chairman and stay is based on actual hospital admissions. chief executive 44 MANAGED CARE / JULY 2008
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