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The association of geographic dispersion with outcomes among hospitalized pulmonary service patients

Annals of the American Thoracic Society February 1, 2020

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Research Areas


Hospitals geographically localize clinically similar patients into wards to provide specialized care that improves patient outcomes and care, and lowers costs. When these wards exceed capacity, patients become “geographically dispersed” to alternate locations. For example, critically ill patients may “board” in emergency departments or alternate intensive care units (ICUs) when the clinically appropriate ICUs are at capacity. Such geographic dispersion has been demonstrated to be associated with increased hospital length of stay (LOS), ICU and in-hospital mortality, and incidence of hospital-acquired infections, in addition to lower adherence to quality metrics. In several single-center studies and a meta-analysis across the United States and Canada, geographic dispersion among general internal medicine ward patients was associated with increased in-hospital mortality and resident burnout, and among a mixed medical–surgical ward population with increased hospital LOS.

Geographic localization is particularly pertinent for pulmonary service patients, who may benefit from specialized care focused on their unique needs, such as frequent assessments by respiratory therapists. For example, within the University of Pennsylvania Health System (UPHS), the pulmonary services are staffed by a board-certified pulmonologist and internal medicine residents. The pulmonary wards have higher respiratory therapist–to-patient ratios; and oxygen, noninvasive ventilation, and high-flow nasal cannula capabilities that other wards do not.

However, variations in outcomes among pulmonary service patients who receive care on pulmonary wards as compared with those who are geographically dispersed have never been evaluated. Therefore, our objective was to determine if geographic dispersion is associated with adverse outcomes among hospitalized pulmonary service patients. We hypothesized that geographic dispersion would be associated with increased hospital LOS.


National Heart, Lung, and Blood Institute (NHLBI)
Agency for Healthcare Research and Quality (AHRQ)