Are medical outliers associated with worse patient outcomes? A retrospective study within a regional NHS hospital using routine data

Abstract

ObjectiveTo explore the quality and safety of patients’ healthcare provision by identifying whether being a medical outlier is associated with worse patient outcomes. A medical outlier is a hospital inpatient who is classified as a medical patient for an episode within a spell of care and has at least one non-medical ward placement within that spell.Data sourcesSecondary data from the Patient Administration System of a district general hospital were provided for the financial years 2013/2014–2015/2016. The data included 71 038 medical patient spells for the 3-year period.Study designThis research was based on a retrospective, cross-sectional observational study design. Multivariate logistic regression and zero-truncated negative binomial regression were used to explore patient outcomes (in-hospital mortality, 30-day mortality, readmissions and length of stay (LOS)) while adjusting for several confounding factors.Principal findingsUnivariate analysis indicated that an outlying medical in-hospital patient has higher odds for readmission, double the odds of staying longer in the hospital but no significant difference in the odds of in-hospital and 30-day mortality. Multivariable analysis indicates that being a medical outlier does not affect mortality outcomes or readmission, but it does prolong LOS in the hospital.ConclusionsAfter adjusting for other factors, medical outliers are associated with an increased LOS while mortality or readmissions are not worse than patients treated in appropriate specialty wards. This is in line with existing but limited literature that such patients experience worse patient outcomes. Hospitals may need to revisit their policies regarding outlying patients as increased LOS is associated with an increased likelihood of harm events, worse quality of care and increased healthcare costs.

Inpatient bedspacing: could a common response to hospital crowding cause increased patient mortality?

“…While the Charlson scores, length of stay and in-hospital mortality rates in their study are similar to those reported from other Canadian university hospitals with similar GIM service distributions,12 this study definitely needs to be replicated in other settings. While one American study13 reported that localising GIM patients to home wards improved workflow efficiency but increased length of stay and mortality, we12 found that cohorting our GIM patients on home wards rather than having them bedspaced throughout our institution resulted in substantially shorter lengths of stay without any impact on mortality—similar to a study in a UK district general hospital 6. Interestingly, we also found no impact on ED wait times or crowding metrics, suggesting that the potential benefits of inpatient bedspacing for EDs are smaller than assumed 14…”

A qualitative exploration of escalation of care in the acute ward setting

“…Observed care delays in outliers and patients with multiple care teams were a result of confusion regarding plans, responsibilities, and delayed decisions. These factors may partially explain why there is evidence that outliers have higher readmission rates and length of stay . There may be value in identifying high‐risk patients (complex patients, outliers, or patients with multiple teams) and mitigating this with a systematic approach to care, such as clear documentation or pre‐planned care escalation pathways.…”

What Quality and Safety of Care for Patients Admitted to Clinically Inappropriate Wards: a Systematic Review

“…Santamaria et al 8 reported a mortality increase among outliers in general and Perimal-Lewis et al 6 among outliers affected by dementia. These data were refuted by Stowell et al 10 and by Stylianou et al 1 on large numbers (over 70,000 admissions in 3 years of observation) and by Alameda et al 13 among outliers with heart failure. Stowell et al 10 and Stylianou et al 1 examined also 30-day mortality without finding any increase; Perimal et al 6,9 instead revealed a nonsignificant increase in outliers.…”

“…The so-called outlier, out-lying hospital in-patient, overflow, sleep-out, or boarder [1][2][3] is a patient who, because of unavailability of hospital beds in his/her clinically appropriate ward, is admitted wherever an unoccupied bed is. In such a case, clinical management is provided by the medical staff of the clinically appropriate ward (generally, internal medicine), but care is delivered by nursing staff of the hosting ward.…”