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J Thorac Cardiovasc Surg 2003;126:1018-1025
© 2003 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Is discharge policy a balanced decision between clinical considerations and hospital ownership policy? The CABG example

Noya Galai, PhDa,b,*, Avi Israeli, MDc,d, Yana Zitser-Gurevich, MD, MPHb,c, Elisheva Simchen, MD, MPHb,c

a Department of Epidemiology, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
b Department of Health Services, Research, Ministry of Health, Jerusalem, Israel
c Hadassah-Hebrew University School of Public Health, Jerusalem, Israel
d Hadassah Medical Organization, Jerusalem, Israel

Received for publication February 20, 2002; revisions received April 18, 2002; accepted for publication April 15, 2003.

* Address for reprints: Noya Galai, PhD, Department of Health Services Research, Ministry of Health, 29 Rivka Street, Jerusalem 91010, Israel
ngalai{at}bgumail.bgu.ac.il

OBJECTIVES: To explore to what extent patient discharge from the hospital is a balanced decision between clinical considerations and management policy; specifically: (1) to assess the role of patient risk as a determinant of discharge in comparison with administrative factors such as hospital ownership; (2) to evaluate whether variations in discharge policy were translated into differences in clinical outcomes.

METHODS: A national study of coronary artery bypass surgery was used as an example. The population included 4778 patients undergoing coronary artery bypass surgery in 14 institutions. The mode of discharge day, rather than the mean, was used as the best indicator of discharge policy. Parametric survival model was used to assess factors associated with the day of discharge.

RESULTS: The mode of discharge day varied widely among institutions. This variation between 4 and 7 days after surgery corresponded to hospital ownership. The mode of discharge day was almost invariant to the patients' risk, but serious postoperative complications resulted in prolonged stay for a minority of the patients. The influence of hospital ownership prevailed over patient insurance carriers. Differences in discharge policies were not associated with increased risk of late mortality or rehospitalization.

CONCLUSIONS: Discharge policy beyond the rare occurrence of dramatic patient postoperative complications was mainly dependent on hospital owner's cost-effectiveness considerations. However, despite the weight given to administrative factors in the decision-making process, it did not affect the outcome of care.






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