Unnecessary, Avoidable Lengths of Stay: a Strategy for Clinician Empowerment and Effectiveness Evaluation

1. Background: In recent years an increasing trend in excessive lengths of stay has been recorded at the Parma University Hospital, compared with regional mean values. Excessive lengths of stay have been demonstrated to constitute not just an economic problem, but also a clinical and public health issue. Since the measures taken at our institution so far have not proven effective, the investigators carried out a literature review, which mostly detected observational studies, restricted to the assessment of the impact of a single intervention.
2. Objectives: This project intends to evaluate the effectiveness of a multifaceted strategy aiming to empower clinicians on the issues associated with excessively long and avoidable hospital stays, and enable them to identify corrective measures (according to the principles of clinical governance).
3. Study design: cluster-randomized, parallel group, open-label, community trial
4. Methods: trained personnel will periodically record causes for excessive lengths of stay in all participating wards using an ad hoc data collection sheet. In the wards randomized to the experimental group, interventions aimed to clinician empowerment - provision of reminders and periodical audits - will be implemented.
5. Expected results: A reduction in the experimental vs. the control arm unnecessary lengths of stay is expected, although the introduced measures will also presumably lead to improvement in the wards where they are not implemented.

Study Overview

• Status: Completed
• Conditions: Hospitalization; Length of Stay
• Intervention / Treatment: Behavioral: Multicomponent strategy to reduce avoidable length of stay; Other: No intervention

• Study Type: Interventional
• Enrollment (Actual): 3862
• Phase: Phase 3

Contacts and Locations

Study Locations

• Italy
  • Parma, Italy, 43126
    • Azienda Ospedaliero-Universitaria di Parma

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• patients present on the participating wards during one of 12 randomly selected index days (one for each month of data collection)

Exclusion Criteria:

• patients admitted or discharged on the index days
• patients with length of stay (interview date - admission date) > 90 days

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention	Behavioral: Multicomponent strategy to reduce avoidable length of stay; The strategy comprises two integrated components: Distribution of two monthly reports, one consisting in the list of patients who, through data collection performed, are classified to be present on the ward although their clinical status is considered compatible with discharge; the other featuring individual length of stay profiles for each physician operating in the intervention arm (information taken from administrative data), allowing comparisons with the rest of the medical staff;; Audits performed by professionals of each ward of the intervention arm designed to discuss cases judged to be compatible with discharge. The organization of this work are left to the wards, without any interference from the project team.
Other: Control; No Intervention	Other: No intervention; No interventions (reporting, auditing) are planned; nevertheless control ward physicians know study aims and are informed about their patient's data collection.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Percentage of patient-days compatible with discharge	12 month period [02/2008 - 02/2009] +1 follow up month [02/2010]

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Overall length of stay (in days)	Overall length of stay = discharge date - admission date	12 month period [02/2008 - 02/2009]

Collaborators and Investigators

• Sponsor: Azienda Ospedaliero-Universitaria di Parma
• Collaborators: Regione Emilia-Romagna
• Investigators: Principal Investigator: Caterina Caminiti, Azienda Ospedaliero-Universitaria di Parma

Publications and helpful links

General Publications

• Carey MR, Sheth H, Braithwaite RS. A prospective study of reasons for prolonged hospitalizations on a general medicine teaching service. J Gen Intern Med. 2005 Feb;20(2):108-15. doi: 10.1111/j.1525-1497.2005.40269.x.
• Lagoe RJ, Westert GP, Kendrick K, Morreale G, Mnich S. Managing hospital length of stay reduction: a multihospital approach. Health Care Manage Rev. 2005 Apr-Jun;30(2):82-92. doi: 10.1097/00004010-200504000-00002.
• Moro ML. Health care-associated infections. Surg Infect (Larchmt). 2006;7 Suppl 2:S21-3. doi: 10.1089/sur.2006.7.s2-21.
• Selker HP, Beshansky JR, Pauker SG, Kassirer JP. The epidemiology of delays in a teaching hospital. The development and use of a tool that detects unnecessary hospital days. Med Care. 1989 Feb;27(2):112-29. doi: 10.1097/00005650-198902000-00003. Erratum In: Med Care 1989 Aug;27(8):841.
• Setrakian JC, Flegel KM, Hutchinson TA, Charest S, Cote L, Edwardes MD, Corbett IB. A physician-centred intervention to shorten hospital stay: a pilot study. CMAJ. 1999 Jun 15;160(12):1735-7.
• Shojania KG, Wald H, Gross R. Understanding medical error and improving patient safety in the inpatient setting. Med Clin North Am. 2002 Jul;86(4):847-67. doi: 10.1016/s0025-7125(02)00016-0.
• Meschi T, Fiaccadori E, Cocconi S, Adorni G, Ridolo E, Stefani N, Schianchi T, Novarini A, Spagnoli G, Caminiti C, Pini M, Borghi L. [Analysis of the problem of "difficult hospital discharges" in the University Hospital of Parma]. Ann Ital Med Int. 2004 Apr-Jun;19(2):109-17. Italian.
• Caminiti C, Meschi T, Braglia L, Diodati F, Iezzi E, Marcomini B, Nouvenne A, Palermo E, Prati B, Schianchi T, Borghi L. Reducing unnecessary hospital days to improve quality of care through physician accountability: a cluster randomised trial. BMC Health Serv Res. 2013 Jan 10;13:14. doi: 10.1186/1472-6963-13-14.

Helpful Links

• Study sponsor's website [ita]
• Institution's web site

Study record dates

Study Major Dates

• Study Start: February 1, 2008
• Primary Completion (Actual): February 1, 2009
• Study Completion (Actual): February 1, 2010

Study Registration Dates

• First Submitted: August 23, 2011
• First Submitted That Met QC Criteria: August 23, 2011
• First Posted (Estimate): August 24, 2011

Study Record Updates

• Last Update Posted (Actual): July 3, 2018
• Last Update Submitted That Met QC Criteria: July 2, 2018
• Last Verified: July 1, 2018

More Information

Terms related to this study

• Keywords: Training; Public health; Policy
• Other Study ID Numbers: aopr-rct-los