• Mortality.
• Severe adverse events (emergency calls to medical team only).
• Length of stay.

Mortality

Alameda 2009 is in a very specific population (congestive heart failure and cardiac arrhythmia patients), which may not be generalisable to other patient groups and also is of low quality and should therefore not be used.

Evidence from Stowell 2013 is of very low quality. This study compared control cases with outlying patients using a matched pair design based on age, sex and reason for admission. However, it is likely that patients who are less severely ill are admitted to outlying wards and are therefore less likely to die, so the study may have underestimated the effect of outlying status on mortality.

Perimal-Lewis 2013 and Serafini 2015 were the best quality studies (moderate) and were in a more generalisable population. The effect sizes seem realistic and had no serious imprecision. These studies should be used to inform the economic model.

These studies showed a modest but expected increase in mortality for medical outliers. This could be an underestimate though due to the nature of the observational studies where the more acutely ill patients are less likely to be medical outliers.

Severe adverse events

Santamaria 2014 was the only study to adjust for all 3 confounders and was moderate quality and no serious imprecision around the point estimate. Serious adverse events were defined as call outs for the emergency medical team. It is likely that medical emergency teams are variable in staff makeup both nationally and internationally. Therefore the evidence may not be generalisable to the UK.

Evidence from Stowell 2013 is of very low quality. This study compared control cases with outlying patients using a matched pair design based on age, sex and reason for admission. However, it is likely that patients who are less severely ill are admitted to outlying wards and are therefore less likely to require transfer to the ICU, so the study (which showed no effect of outlier status) may have underestimated the effect of outlying status on serious adverse events defined as transfer to ICU. Alameda 2009 is in a very specific population (congestive heart failure and cardiac arrhythmia patients), which may not be generalisable to other patient groups and also is of low quality with serious imprecision around the point estimate and should therefore not be used.

The subgroup considered that overall, there appears to be an increase in serious adverse event rate in outlying patients.

Length of stay

Alameda 2009 is in a very specific population (congestive heart failure and cardiac arrhythmia patients), which may not be generalisable to other patient groups. However, the study was the only one to report mean differences in length of stay and provided moderate quality evidence. The evidence suggested that outlying patients have a longer length of stay, which the subgroup felt fitted with clinical experience. However, the results of this study may not generalisable to the entire AME population, as these patients may require specialised tests prior to discharge, which are more difficult to arrange from an outlying ward.

The subgroup expected an increase in length of stay for medical outliers as these patients are seen less and it will take longer for them to be discharged, however this increase is difficult to quantify from the evidence.

• The analysis is likely to underestimate the true financial cost of outlying.
• Cancelled elective surgeries are likely to occur if a medical patient is outlying on a surgical ward.
• There will be additional time constraints on ward rounds for an outlying patient. Staff will need to cover more patients in their ward rounds with outlying patients having a greater effect on this. It is more time consuming to undertake a ward round on a different ward to your own and is not just an additional patients worth of time.
• It is likely an outlying patient will be seen at the end of a ward round which may cause problems. The timing of the ward round may not fit in with routine and could occur at detrimental times to efficiency for example, at a nurse handover time slot
• Geographical constraints of being on a different ward could mean that discharge time is affected for example, a patient may not be assessed to be ready for discharge until late in the day due to staffing locations which could lead to an extra overnight stay
• Boarding patients is seldom a deliberate process. The existence of medical outliers is an indicator of high occupancy that could lead to detrimental effects on patients and flow due to prioritisation of tasks, especially for outlying patients.
• Opportunity cost of emergency medical team – impact on hospital staffing and other patients who need their help.
• Medical outliers may start on the correct ward and then move out to their ‘outlying’ ward rather than the perceived traditional assumption that outlying is at the start of a patients stay.
• At what point in their pathway a patient becomes an outlier may affect their outcomes for example, if they are moved from their ‘home’ ward to a ward where they are defined as an outlier rather than admission straight to an outlying ward, they may have a lower acuity.
• Transferring elderly patients to different wards can cause them to become confused, especially if they experience multiple moves. This can make their condition worse and lead to a longer length of stay, creating a vicious cycle.
• The committee agreed that outlying is inevitable in most hospitals and is associated with worse patient outcomes. The cost of preventing medical outliers would be great, therefore practical steps should be taken to mitigate the risks and ensure that care for outlying patients is not compromised. For example, accepting temporal changes in occupancy parameters and making appropriate allowances.

Patients perspective:

For patients, being on a ward that doesn’t specialise in their condition is associated with feelings of anxiety and fear that they will not receive the best treatment or that they are being forgotten by the appropriate specialists. In some circumstances, patients can feel embarrassed if they have a different condition from other patients on the ward as the other patients may not understand their symptoms. It may also be emotionally insensitive to board certain patients in certain wards. Patients would like there to be recommendations in place to aid outlying patient care.