In published studies, excessively prolonged hospitalization has been linked with higher clinical risks and increased costs. Some studies have suggested that increases in clinical risks—such as nosocomial infections, DVT, drug reactions, medication errors, and other adverse events—are directly related to the length of time spent in the hospital. “Hospital length of stay (LOS) has been identified as one of the major drivers of resource consumption,” says George C. Velmahos, MD, PhD, MSEd. “Hospital costs can increase because beds and human personnel are occupied by patients who have excessively prolonged hospital-izations.” He adds that there are also significant
societal costs that result from these patients due to lost productivity.

Exploring Reasons

In JAMA Surgery, Dr. Velmahos and colleagues had a study published that identified trauma patients with excessively prolonged hospitalizations and explored the reasons for these occurrences. “This information can be beneficial to policy makers who are striving to understand the medical system and associated costs of long hospitalizations,” Dr. Velmahos says. He notes that the burden of injury, significant comorbidities, and postoperative complications are likely to be causes of excessively prolonged hospitalization, but other factors may also be at play.

Dysfunctional-Hospital-Stay-Callout

For the study, investigators reviewed a trauma registry, billing databases, and medical records of trauma admissions at a level I academic trauma center. Patients with excessively prolonged hospitalizations were older, more likely to have blunt trauma, and more likely to be self-payers or covered by Medicare or Medicaid. They were also more likely to be discharged to post–acute care facilities than home and had higher hospitalization costs. “Only 5% of patients in our study had excessively prolonged hospitalizations, but the costs of caring for these patients were three times higher than costs for others,” notes Dr. Velmahos.

The study identified several independent predictors of mortality in a multivariate analysis, including discharge to a rehabilitation facility or other post-acute care facility. Other predictors included Medicare or Medicaid insurance or self-pay (Table 1). There were no differences in the prevalence of comorbidities or the incidence of in-hospital complications between the two groups in the study.

 

“Excessively prolonged hospitalizations are a major driver of increased hospital resource utilization and healthcare costs, and they also have a negative financial impact on trauma centers.”

 

An important finding, according to Dr. Velmahos, is that the reasons for discharge delays in patients with excessively prolonged hospitalizations were clinical in only 20% of cases. The remaining discharges were excessively delayed because of difficulties in rehabilitation facility placement, in-hospital operational delays, or payer-related issues (Table 2). “Severity of illness and medical care are commonly believed to be the main causes for prolonged hospital stays, but our study shows that delays in discharge are typically not caused by medical factors,” says Dr. Velmahos. “In most cases, excessively prolonged hospitalizations were related to administrative issues, predominantly the inability to place patients in appropriate rehabilitation facilities, as well as operational and insurance issues.”

Important Implications

As the healthcare system strives to become safer, more effective, and patient-centered, there has also been increased scrutiny toward enhancing quality, reducing costs, and improving the timeliness and efficiency of care. “Efforts are needed to identify important opportunities for reducing hospital LOS in trauma patients,” Dr. Velmahos says. “Our study further supports the notion that we need better systems of care that enable us to tailor interventions based on the resources that are available.”

Importantly, the observed increases in costs and payments for excessively prolonged hospitalizations did not result in higher profits for the hospital. Patients with these long hospitalizations had a net margin lower than that of other patients in the study by nearly 50%. “Excessively prolonged hospitalizations are a major driver of increased hospital resource utilization and healthcare costs, and they also have a negative financial impact on trauma centers,” says Dr. Velmahos. “Based on the reasons for excessively prolonged hospitalizations identified in our study, it’s possible that LOS and costs can be reduced without compromising the quality of trauma care that is delivered.”

Considering that about 80% of excessively prolonged hospitalization cases were not related to clinical issues in the study, Dr. Velmahos says it is important to initiate efforts to avoid these hospitalizations in the future. “By reducing the number of excessively prolonged hospitalizations by overcoming systems-related issues, hospitals could potentially see significant cost savings,” he says. “The problem isn’t that trauma patients who stay for excessively prolonged periods in the hospital are severely injured, physiologically compromised, or old. The problem is they simply stay in the hospital because of unresolved insurance issues, difficult-to-find rehabilitation beds, and in-hospital operational breakdowns. The key is to engage healthcare policy makers to shift the focus toward reducing excessive hospital stays and costs in trauma patients.”

References

Hwabejire JO, Kaafarani HM, Imam AM, et al. Excessively long hospital stays after trauma are not related to the severity of illness: let’s aim to the right target! JAMA Surg. 2013;148:956-961. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1730488.

Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Costs of adverse events in intensive care units. Crit Care Med. 2007;35:2479-2483.

de Jong JD, Westert GP, Lagoe R, Groenewegen PP. Variation in hospital length of stay: do physicians adapt their length of stay decisions to what is usual in the hospital where they work? Health Serv Res. 2006;41:374-394.

Kramer AA, Zimmerman JE. A predictive model for the early identification of patients at risk for a prolonged intensive care unit length of stay. BMC Med Inform Decis Mak. 2010;10:27.

Brasel KJ, Rasmussen J, Cauley C,Weigelt JA. Reasons for delayed discharge of trauma patients. J Surg Res. 2002;107:223-226.