A 73-year-old woman presents with syncope, generalized weakness, and frequent falls on a Friday afternoon. Past medical history includes coronary artery disease, aortic stenosis, atrial fibrillation treated with apixaban, type 2 diabetes mellitus, and hypothyroidism. Emergency department evaluation reveals sepsis secondary to a urinary tract infection. A CT scan of the head yields no acute findings. An echocardiogram was ordered due to syncope in the context of a history of aortic stenosis. The hospitalization was otherwise uneventful, and physical therapy (PT) was consulted for her generalized weakness and falls. On the morning of day three, both the echocardiogram and PT evaluation remained pending. PT ultimately recommended subacute rehabilitation placement on the afternoon of day three. Social work provided a list of facilities on day three, but patient preferences were not communicated until day four; insurance authorization was sought and obtained on day five, culminating in the patient’s discharge.
This case illustrates a length of stay (LOS) increase of two days that was attributable to avoidable delays in testing and obtaining a PT evaluation, as well as the need to obtain insurance authorization.
Operational efficiency, cost containment, quality of care, and overall hospital performance can impact LOS. Medicare’s inpatient prospective payment system for reimbursing hospital care, which began in the 1980s, spurred a focus on shorter lengths of stay by paying the same amount for procedures or diagnosis-related groups, regardless of days spent in the hospital. Current trends in healthcare, such as the shift toward value-based care and alternative payment models, continue to emphasize the importance of efficient and high-quality care delivery. This article examines whether LOS is an appropriate performance metric for individual hospitalists or hospitalist groups. Although hospitalists are central to the management of inpatient care and can implement strategies to streamline and optimize patient care, LOS is impacted by many other aspects of the healthcare network and social system.
Most hospitals closely follow LOS metrics, and average LOS (ALOS) and risk-adjusted LOS are often available monthly through third-party vendors. Also commonly referenced is geometric mean length of stay (GMLOS). While performance on LOS metrics can usually be attributed to the hospitalist group involved in a patient’s care, assigning attribution to an individual hospitalist is more challenging due to the number of providers participating in the patient’s care during the episode of care. Alternatively, discharge efficiency, which is a surrogate marker for LOS, can be attributed to individual providers and could have implications for individual performance. While ALOS is often reported, we prefer risk-adjusted LOS metrics like observed-to-expected LOS.
While hospitalists do not have absolute control over the progression of patient care, they can influence it in many ways. Making a correct and timely diagnosis and providing appropriate treatments are the foundation of optimal LOS. Hospitalists are a pivotal part of interdisciplinary rounds, in which they identify relevant social determinants of health and potential discharge barriers while collaborating with consultants, community primary care physicians, case managers, social workers, and family members. Addressing barriers with the care team contributes to a smoother and more efficient discharge process. Clear and frequent communication with patients, families, and consultants about the in-hospital care and post-discharge plans helps to ensure patients are agreeable to discharge once medically cleared.
Within the realm of utilization management, hospitalists evaluate and prioritize the appropriateness of inpatient tests, procedures, and consultations to prevent unnecessary delays in the progression of care caused by redundant and low-value interventions. Finally, complete and accurate documentation of co-morbidities and complications impacts expected LOS and/or GMLOS, and therefore risk-adjusted LOS.
Length of stay is often influenced by factors outside the hospitalist’s control. These factors contribute to excess days, the difference between the patient’s actual length of stay and GMLOS for the corresponding diagnosis-related group. These include resource limitations, unexpected complications, and procedural schedules. Mental health conditions, the availability of caregiver and social support networks, financial constraints, cultural and language barriers, health literacy, and substance use disorders can all contribute to the duration of a patient’s hospital stay. Discharges for the uninsured population may be delayed due to apprehensions about unsafe discharges, primarily driven by uncertainties about follow-up care.
At the hospital resource level, the length of stay can be influenced by factors such as equipment availability (e.g., one CT scan machine versus two), staffing levels for ancillary services, insurance status, disposition barriers, and the need for prior authorizations (e.g., medications, tube feeds). Discharge delays encompass various challenges, including waiting for the delivery of durable medical equipment for discharge, and waiting for acceptance and insurance authorization for subacute rehabilitation.
It is in the best interest of patients to minimize LOS, as prolonged stays are associated with increased morbidity, mortality, and the risk of hospital-acquired infections.1,2 Nevertheless, an emphasis on optimizing LOS can have an impact on other aspects of patient care, as well as other metrics. The pressure to discharge patients swiftly can have repercussions on the overall patient experience.3,4 Additionally, there is some evidence that longer LOS can lead to a reduction in readmission rates.5
While there are elements outside of our control, a hospitalist can impact LOS with better communication and stewardship of high-value care. Individual attribution is not possible or recommended, but ALOS or risk-adjusted LOS is a metric that hospitalist groups should follow.
Tracking avoidable days is an actionable item to help hospitals pinpoint issues that the administration can address, such as the availability of resources as demonstrated in the case above. We should continue to work with patient-care teams to progress care efficiently by following care pathways, participating in multidisciplinary rounds, and identifying and escalating barriers to discharge.
For the LOS detailed table and more references, visit the SHM Practice Management – Quality Measures homepage at hospitalmedicine.org/practice-management/QualityMeasures.
References
- Lingsma HF, Bottle A, et al. Evaluation of hospital outcomes: the relation between length-of-stay, readmission, and mortality in a large international administrative database. BMC Health Serv Res. 2018;18(1):116.
- Stewart S, Robertson C, et al. Impact of healthcare-associated infection on length of stay. J Hosp Infect. 2021;114:23-31.
- Diwan W, Nakonezny PA, et al. The effect of length of hospital stay and patient factors on patient satisfaction in an academic hospital. Orthopedics. 2020;43(6):373-9.
- Park HN, Park DJ, et al. Effect of inpatient experiences on patient satisfaction and the willingness to recommend a hospital: The mediating role of patient satisfaction: A cross-sectional study. Health Sci Rep. 2022;5(6):e925. doi: 10.1002/hsr2.925.
- Carey K, Lin MY. Hospital length of stay and readmission: an early investigation. Med Care Res Rev. 2014;71(1):99-111.
Dr. Abbasi
Dr. Gershfield
Dr. Golla
Dr. Jih
Dr. Abbasi is the associate chief medical officer and medical director of the hospitalist service at Stony Brook Medicine, and associate professor of clinical medicine at Renaissance School of Medicine at Stony Brook University, both in Stony Brook, N.Y. Dr. Gershfield is a hospitalist at Sequoia Hospital in Redwood City, Calif., and director of quality and performance for hospital medicine at Vituity. She is also a member of The Hospitalist’s editorial board. Dr. Golla is a clinical assistant professor in the department of internal medicine at UT Southwestern Medical Center and a physician advisor of utilization management and chair of the performance measurement committee for the Parkland Health & Hospital System, both in Dallas. Dr. Jih is a hospitalist and assistant professor at Rutgers Health’s Robert Wood Johnson University Hospital in New Brunswick, N.J. SHM’s Performance Measurement and Reporting Committee periodically contributes articles demystifying performance measures for healthcare professionals.