Measuring and visualizing healthcare process variability

Abstract

Importance: Understanding factors that contribute to clinical variability in patient care is critical, as unwarranted variability can lead to increased adverse events and prolonged hospital stays. Determining when this variability becomes excessive can be a step in optimizing patient outcomes and healthcare efficiency.

Objective: Explore the association between clinical variation and clinical outcomes. This study aims to identify the point in time when the relationship between clinical variation and length of stay (LOS) becomes significant.

Methods: This cohort study uses MIMIC-IV, a dataset collecting electronic health records of the Beth Israel Deaconess Medical Center in the United States. We focused on adult patients who underwent elective coronary bypass surgery, generating 847 patient observations. Demographic factors such as age, race, insurance type, and the Charlson Comorbidity Index (CCI) were recorded. We performed a variability analysis where patients' clinical processes are represented as sequences of events. The data was segmented based on the initial day of recorded activity to establish observation windows. Using a regression analysis, we identified the temporal window where variability's impact on LOS becomes independently significant.

Result: Regression analysis revealed that patients in the top 20 % of the variability distance group experienced an 81 % increase in LOS (95 % CI: 1.72 to 1.91, p < 0.001). Insurance types, such as Medicare and Other, were associated with 18 % (95 % CI: 0.73 to 0.92, p < 0.001) and 21 % (95 % CI: 0.71 to 0.88, p < 0.001) decreases in LOS, respectively. Neither age nor race significantly affected LOS, but a higher CCI was associated with a 3.3 % increase in LOS (95 % CI: 1.02 to 1.05, p < 0.001). These findings indicate that higher variability and CCI significantly influence LOS, with insurance type also playing a crucial role.

Conclusion: In the studied cohort, patient journeys with greater variability were associated with longer LOS with a dose-response relationship: the higher the variability, the longer LOS. This study presents a standardized way to measure and visualize variability in clinical processes and measure its impact on patient-relevant outcomes.

Keywords: Clinical pathways; Clinical process; Process mining; Unwarranted clinical variation; Value-based care; Variability analysis; Variability visualization.