New study challenges the value of reducing patients’ length of stay
Reduce costs on the front end of hospital stays
Reducing length of stay (LOS) in hospitals has been a bone of contention among medical personnel and consumers for more than a decade.
Now, a new study, published in the Journal of the American College of Surgeons (JACS), suggests that LOS has little impact on the cost of hospital admission. The authors contend that the "costs directly attributable to the last day of a hospital stay are an economically insignificant component of total costs." In addition, the authors contend, much of the expenses attributable to LOS are fixed hospital overhead costs.1
"In looking for reduced costs, early changes in LOS might have accomplished that," says Kathryn Clinefelter, MSN, MBA, CPHQ, FNAHQ, president-elect of the National Association for Healthcare Quality in Glenview, IL. "When the first impetus came along from Medicare, it meant a quite severe reduction in LOS for many hospitals. Along with that, came many alarming anecdotal incidents resulting from early discharge and reported in the media." But she adds that reduced LOS and any resulting medical consequences have leveled off. "Right now we need to look at the overall picture and see how we can improve our care."
The researchers, who are all associated with the University of Michigan Medical Center, reviewed the cost-accounting records of all surviving patients discharged from their medical center during 1998 with LOS of four days or more. They state that "incremental costs incurred by patients on their last full day of hospital stay were $420 per day on average or just 2.4% of the $17,734 mean total cost of stay for all 12,365 patients."
"I don’t think hospitals, and especially physicians anywhere in the United States, are discharging patients who need to be in the hospital," says Ruth Ann Frey, MSHA, CPHQ, FNAHQ, director of quality management at Southside Regional Medical Center in Petersburg, VA.
"One of the reasons for LOS reductions originally was that we were keeping Medicare patients in the hospital longer than was really necessary medically when we could let them go without doing any harm to the patient. I don’t think any hospital anywhere would discharge a patient if
he were unstable. We may be discharging patients quicker and sicker, but there are other resources such as home health care that are being used,"
she says.
The study shows that the most expensive days for a hospital stay are the first days, when tests and procedures such as biopsies, radiology tests, and surgeries are part of the stay. After that, the expense for a patient drops dramatically and mostly can be attributed to fixed hospital costs.
Clinefelter agrees. "Fixed costs are a major part of the expense in LOS. "The article in the JACS took the position that hospitals should include nurse staffing as part of fixed costs, and I tend to agree with that," she says. "It’s very difficult to staff nursing care, but it’s imperative to have minimal staff at all times."
Focus efforts on overhead
While the article implies that there is an argument for keeping surgery patients an extra day or two, Clinefelter mentions studies that show that early discharge is beneficial for heart patients. "One thing LOS reduction has done is accelerate the post-op process for coronary bypass surgery," she says. "By moving these patients out more quickly, they were ambulated and actually demonstrated real improvement. In fact, by keeping them on a ventilator or in the hospital, we expose them to other risks such as infection."
Frey agrees with that assessment. "I don’t feel we should keep a surgery patient here an extra day when it’s not medically necessary. I feel it’s better to discharge them as soon as possible to reduce the likelihood of infection or medical errors.
"Yet, every hospital I know of is struggling to provide quality care in a cost-effective manner. Hospitals are diligent about working on this, and physicians are cooperative in reaching these goals. Quality of care must and does come first," she explains. "If an insurance company says we aren’t going to pay after midnight tonight,’ we review the patient’s record. If we feel we must keep the patient, we do. If the insurer continues to deny payment after the patient goes home, we ask for an independent review or we appeal and ask the doctor to call the insurance company to see if we can have the decision reversed. If there’s a complete denial, we absorb the cost. But we don’t discharge patients who we feel need additional care."
The study suggests that if LOS is no longer saving costs to any significant extent, providers should refocus their efforts by "making better use of hospital capacity and overhead, which account for the majority of inpatient costs." By recruiting new patients, hospitals can reduce their costs and spread their overhead over a larger patient base. Also, the authors state, "physicians must work to reduce costs in the early stages of their patients’ care." Since the early stage of hospitalization accounts for the heavy end of patient cost, trimming those costs could be beneficial to the bottom line.
The article contends that "most of the progress that providers have made in reducing LOS occurred during the mid-1980s, and since then LOS has declined little despite a continued emphasis on that objective."
"Frankly," Clinefelter says, "we’ve gotten what we really need in the way of cost reduction from LOS. Now we need to focus on improving services. We need to be looking at improved delivery of care while protecting our quality."
Reference
- Taheri P, Butz D, Greenfield L. J Am Coll Surg 2000; 191:123.
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