CAN PRACTICE GUIDELINES SAFELY REDUCE HOSPITAL LENGTH OF STAY - RESULTS FROM A MULTICENTER INTERVENTIONAL STUDY

BACKGROUND: Although practice guidelines about appropriate lengths of stay have been widely promulgated, their effects on patient outcomes a re not clear. Our objective was to study the effects of length of stay practice guidelines on patient outcomes. PATIENTS AND METHODS: We per formed a prospective, nonrandomized, interventional trial in six geogr aphically distributed hospitals, among consecutively hospitalized ''lo w-risk'' patients with total hip replacement, hip fracture, or knee re placement. Case managers provided physicians with patient risk informa tion based on guideline recommendations. We measured length of stay, c ompliance with recommended guideline length of stay, health status, ho spital readmission rates, return to emergency department, return to wo rk and recreation, and patient satisfaction. RESULTS: A total of 560 p atients were included in;he study. For patients with knee replacement, there was a statistically significant increase in practice guideline compliance (2.7% baseline versus 53% intervention, P<0.0001) and reduc tion in length of stay (5.2 days versus 4.6 days, P <0.001) when compa red with the baseline period. For hip replacement patients, there simi larly was an increase in practice guideline compliance (66% baseline v ersus 82% intervention, P = 0.01) and reduction in length of stay (5.1 days versus 4.8 days, P = 0.03). Significant reductions in length of stay were not observed for patients recovering after hip fracture desp ite a significant increase in guideline compliance. There were few sta tistically significant changes in patient outcomes related to reductio ns in lengths of stay, including health status, hospital readmission r ates, return to emergency department, return to work and recreation, a nd patient satisfaction. For patients undergoing hip replacement, very short lengths of stay (shorter than the guideline recommendation) wer e associated with an increased rate of discharging patients to nursing homes and rehabilitation facilities (21% versus 7%, P = 0.OI), and hi p fracture patients with very short lengths of stay required more visi ts to the doctor after discharge (56% versts 25%, P = 0.04). CONCLUSIO N: Reductions in lengths of stay were most often associated with no si gnificant change in patient outcomes. However, very short lengths of s tay were associated with increased intensity of care following dischar ge for patients undergoing hip surgery, indicating possible cost shift ing (the cost incurred by transferring patients to rehabilitation faci lities may have been greater than had the patients remained in the acu te care hospital for an additional 1 or 2 days and been sent directly home). These results emphasize the importance of monitoring the effect s of cost containment and other systematic efforts to change patient c are at the local level. (C) 1998 by Excerpta Medica, Inc.