A REGIONAL EVALUATION OF VARIATION IN LOW-SEVERITY HOSPITAL ADMISSIONS

OBJECTIVE: Determine patient and hospital-level variation In proportio ns of low-severity admissions. DESIGN: Retrospective cohort study. SET TING: Thirty hospitals in a large metropolitan region., PATIENTS: A to tal of 43,209 consecutive eligible patients discharged in 1991 through 1933 with congestive heart failure (n = 25,213) or pneumonia [n = 17, 996). MEASUREMENTS AND MAIN RESULTS: Admission severity of illness was measured from validated multivariable models that estimated the risk of in-hospital death: models were based on clinical data abstracted fr om patients' medical records, Admissions were categorized as ''low sev erity'' if the predicted risk of death was less than 1%. Nearly 15% of patients (n = 6,382) were categorized as low-severity admissions, Com pared with other patients, low-severity admissions were more likely (p < .001) to be nonwhite and to have Medicaid or be uninsured. Low-seve rity admissions had shorter median length of stay (4 vs 7 days: p < .0 01), but accounted for 10% of the total number of hospital days. For c ongestive heart failure, proportions of low-severity admissions across hospitals ranged from 10% to 25%; 12 hospitals had rates that were si gnificantly different (p < .01) than the overall rate of 17%. For pneu monia, proportions ranged from 3% to 22%: 12 hospitals had rates diffe rent from the overall rate of 12%, Variation across hospitals remained after adjusting for patient sociodemographic factors. CONCLUSIONS: Ra tes of low-severity admissions for congestive heart failure and pneumo nia varied across hospitals and were higher among nonwhite and poorly insured patients. Although the current study does not identify causes of this variability, possible explanations include differences in acce ss to ambulatory services, decisions to admit patients for clinical in dications unrelated to the risk of hospital mortality, and variability in admission practices of individual physicians and hospitals, The de velopment of protocols for ambulatory management of low-severity patie nts and improvement of access to outpatient care would most likely dec rease the utilization of more costly hospital services.