Response to Letter Regarding Article, “Effect of Short Call Admissions on Length of Stay and Quality of Care for Acute Decompensated Heart Failure”
Dr Kessler accurately observes that a number of factors contribute to differences in length of stay among patients and that a better understanding of the specific contributing factors will lead to better opportunities for meaningful improvement interventions. He raises an important concern that a potential confounding factor for the changes in length of stay observed between the short call and long call patients in our study1 could be systems related. Specifically, he is concerned with variables (eg, teaching conferences, attending rounds, and volume of orders) that may be differentially distributed between the long and short call patients owing to the time of day when short call admissions predominate.
We shared his concern that variables associated with time of admission may confound our findings. To address this potential confounder, we adjusted for time of admission in our analysis and found that short call was still associated with delays in care. Short call patients received fewer diuretic doses in the first 24 hours of hospitalization (1.80 versus 2.12, P=0.01) and had a longer median time to the second dose of loop diuretics compared with long call patients (17.9 hours versus 16.2 hours, P=0.04). Thus, in these data, it does not appear that system factors associated with the time of day explain the observed differences in length of stay between groups.
Still, we readily acknowledge his broader concern that, like all observational studies, residual confounding may yet explain our results. Even if confounding was not operant in our findings, additional studies are needed to explore the attributes of short call admissions that drove this finding. Finally, we embrace his caution about implementing remedies until this work has been shown to be robust through testing in other settings and after these possible remedies are carefully tested.
Sources of Funding
This material is based on work supported by the Department of Veterans Affairs, Office of Academic Affiliations with resources from and the use of facilities at VA Tennessee Valley Healthcare System, Nashville, Tenn: VA Geriatric Research, Education, and Clinical Center (Drs Schuberth, Elasy, Speroff, Dittus, and Roumie), HSR&D Targeted Research Enhancement Program, Center for Patient Healthcare Behavior 03–073 (Drs Schuberth, Elasy, Greevy, Speroff, Dittus, and Roumie), and VA Career Development Award 04–342–2 (Dr Roumie).