Pediatric length of stay guidelines and routine practice - The case of Milliman and Robertson

Background: Guidelines for inpatient length of stay (LOS) have been develop ed by Milliman and Robertson (M&R) and are widely applied by health plans. This study was designed to compare LOS for several pediatric conditions wit h the M&R LOS criteria using recent data and to determine if concordance of actual practice with M&R LOS criteria varied between children and adults. Design: Administrative data from Pennsylvania hospitals from 1996 through 1 998 were used to examine LOS for hospital discharges for 12 selected diagno ses for which M&R published guidelines for children and adults. Patients: Discharge data for all patients discharged from public and privat e hospitals in Pennsylvania for which 1 of 12 selected diagnoses were exami ned. Main Outcome Measure: Length of stay. Results: In Pennsylvania hospitals from 1996 through 1998, pediatric LOS wa s divergent for all conditions examined, although not to the extent found i n a previous study examining data from New York State. Of note, median LOS for some conditions was shorter than M&R LOS criteria. The percentage of pe diatric hospital discharges that exceeded the M&R LOS criteria ranged from 25% for pneumonia to 84% for meningitis. Adult hospital discharges exceeded M&R LOS criteria to a greater extent than did pediatric discharges for all conditions except for sickle cell crisis and meningitis. Conclusions: The M&R LOS criteria were divergent from routine practice for both children and adults. Greater divergence of adult discharges illustrate s the need to consider comorbid conditions when implementing these guidelin es. Thus, patient care may suffer if guidelines are implemented in an uninf ormed way. These findings emphasize the importance of using the best possib le science when producing guidelines such as these.