Lien entre durée de séjour et réadmissions en chirurgie et en obstétrique: étude de deux procédures à partir des données du PMSI = Using administrative data to assess the impact of length of stay on readmissions: study of two procedures in surgery and obstetrics

Position du problème: La mise en place de la tarification à l'activité pour les hôpitaux de court séjour pourrait entraîner une diminution des durées de séjour pour raisons financières. L'impact potentiel de ce phénomène sur la qualité des soins n'est pas connu. Les réadmissions identifiées à l'aide des données administratives hospitalières sont, pour certaines situations cliniques, des indicateurs de qualité des soins valides. Méthode: Étude rétrospective du lien entre la durée de séjour et la survenue de réadmissions imprévues liées au séjour initial, pour les cholécystectomies simples et les accouchements par voie basse sans complication, à partir des données du programme de médicalisation des systèmes d'information de l'Assistance publique-Hôpitaux de Paris des années 2002 à 2005. Résultats: Pour les deux procédures, la probabilité de réadmission suit une courbe en " J ". Après ajustement sur l'âge, le sexe, les comorbidités associées, l'hôpital et l'année d'admission, la probabilité de réadmission est plus élevée pour les durées de séjour les plus courtes : pour les cholécystectomies, odds ratio : 6,03 [IC95 % : 2,67-13,59] pour les hospitalisations d'un jour versus trois jours ; pour les accouchements, odds ratio : 1,74 [IC95 % : 1,05-2,91] pour les hospitalisations de deux jours versus trois jours. Conclusion: Pour deux pathologies communes, les durées de séjour les plus courtes sont associées à des probabilités de réadmission plus élevées. L'utilisation routinière des données du programme de médicalisation des systèmes d'information peut permettre d'assurer le suivi de la relation entre la réduction de la durée de séjour et les réadmissions. The prospective payment system for the French short-stay hospitals creates a financial incentive to reduce length of stay. The potential impact of the resulting decrease in length of stay on the quality of healthcare is unknown. Readmission rates are valid outcome indicators for some clinical procedures. Methods: Retrospective study of the association between length of stay and unplanned readmissions related to the initial stay, for two procedures: cholecystectomy and vaginal delivery. Data: Administrative diagnosis-related groups database of "Assistance publique-Hopitaux de Paris", a large teaching hospital, for years 2002 to 2005. Results: The risk of readmission according to length of stay, taking age, sex, comorbidity, hospital and year of admission into account, followed a J-shaped curve for both procedures. The probability of readmission was higher for very short stays, with odds ratios and 95% confidence intervals of 6.03 [2.67-13.59] for cholecystectomies (1- versus 3-night stays), and of 1.74 [1.05-2.91] for vaginal deliveries (2- versus 3-night stays). Conclusion: For both procedures, the shortest lengths of stay are associated with a higher readmission probability. Suitable indicators derived from administrative databases would enable monitoring of the association between length of stay and readmissions.

Integrating species distribution models (SDMs) and phylogeography for two species of Alpine Primula.

The major intention of the present study was to investigate whether an approach combining the use of niche-based palaeodistribution modeling and phylo-geography would support or modify hypotheses about the Quaternary distributional history derived from phylogeographic methods alone. Our study system comprised two closely related species of Alpine Primula. We used species distribution models based on the extant distribution of the species and last glacial maximum (LGM) climate models to predict the distribution of the two species during the LGM. Phylogeographic data were generated using amplified fragment length polymorphisms (AFLPs). In Primula hirsuta, models of past distribution and phylogeographic data are partly congruent and support the hypothesis of widespread nunatak survival in the Central Alps. Species distribution models (SDMs) allowed us to differentiate between alpine regions that harbor potential nunatak areas and regions that have been colonized from other areas. SDMs revealed that diversity is a good indicator for nunataks, while rarity is a good indicator for peripheral relict populations that were not source for the recolonization of the inner Alps. In P. daonensis, palaeo-distribution models and phylogeographic data are incongruent. Besides the uncertainty inherent to this type of modeling approach (e.g., relatively coarse 1-km grain size), disagreement of models and data may partly be caused by shifts of ecological niche in both species. Nevertheless, we demonstrate that the combination of palaeo-distribution modeling with phylogeographical approaches provides a more differentiated picture of the distributional history of species and partly supports (P. hirsuta) and partly modifies (P. daonensis and P. hirsuta) hypotheses of Quaternary distributional history. Some of the refugial area indicated by palaeodistribution models could not have been identified with phylogeographic data.