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Relevance of length of stay reductions
Editorials Editorials represent the opinions of the authors only, not those of the American College of Surgeons.
Relevance of Length of Stay Reductions Jeffrey ST Barkun, MD, FRCSC, Montreal, Quebec, Canada
more acutely ill patient may represent a “loss of opportunity,” of what would be a better use of that bed, both for the institution itself and for its health care environment. Such a patient may even be more remunerative for the hospital, depending on the existing payers’ agreement.3 In another context LOS reductions that can be applied as closure of several beds or even one whole unit may lead to reallocation of that space or its resources, depending on the payers’ agreement, underlying union contracts, or both. It is unfortunate, as stated by the authors themselves, that not factoring in such opportunity costs is both a limitation of their analysis and the source of often contentious interpretations. Perhaps the most important conclusion of this paper is the demonstration that reduction in LOS is not the ultimate benchmark, as has been the mantra in the past two decades. It suggests that we are at risk of striding so far from original cost-effective precepts that the “effectiveness” component (ie, quality of dispensed care) may be totally forgotten to save but a few hundred dollars per patient. Occasionally “effectiveness” may be difficult to measure, but the governmental necessity to regulate the length of maternity stays across the US in 1997 was a grim reminder that it must be done and that clinicians must be the ones to do this. Unlike what we are occasionally led to believe, expenditures are but the flip side of the health care coin, where health status, clinical outcomes, and patient satisfaction are the too often feeble reminders of our primary purpose.
During the past several years a plethora of publications by clinicians and economists has attempted to describe the costs of various surgical procedures or practice habits. Many of these publications have helped to outline the details of what, in effect, happens to our health care dollars but few have had the audacity to challenge the usefulness of such sacrosanct economic benchmarks as total hospital admissions per capita, or “length of stay” (LOS).1 Taheri and coworkers2 in this issue aim to demystify obsessions with LOS reductions by demonstrating the limited relevance of latter-day hospital stay reductions on the overall cost of the episodes of hospital care. The authors begin by effectively reviewing the differences among variable direct costs, fixed direct costs, and indirect costs. Their whole costing exercise, in fact, addresses solely the variable direct cost component, while including nursing-related expenditures in the latter. Although not explicitly stated, the perspective from which the analysis is performed is mostly that of the clinician’s unit, and this is important in interpreting their findings. They show first in a general population, and subsequently in more specific subgroups defined by their pattern of resource utilization (operated trauma patients, patients with short or long hospital stays), that the costs related to the last day of hospitalization are consistently minute, both as a percentage of overall cost, and in absolute numbers. A breakdown by severity of illness of patients would also have been useful, because a number of these patients have been excluded from the analysis as nonsurvivors. The authors correctly conclude that “the bulk of health care expenses takes the form of overhead, or is incurred early in patients’ hospital days.” This conclusion is intuitively in keeping with any clinician’s experience, but it represents only part of the overall costing equation. In a fully occupied hospital, the inability to fill a potential bed with a © 2000 by the American College of Surgeons Published by Elsevier Science Inc.
References 1. Reinhardt UE. Spending more through “cost control”: our obsessive quest to gut the hospital. Nursing Outlook 45:156–160. 2. Taheri PA, Butz DA, Greenfield LJ. Length of stay has minimal impact on the cost of hospital admission. J Am Coll Surg 2000; 191:123–130. 3. Taheri PA, Butz DA, Watts CM, et al. Trauma services: a profit center? J Am Coll Surg 1999;188:349–354.
192
ISSN 1072-7515/00/$21.00 PII 1072-7515(00)00338-0
Relevance of Length of Stay Reductions Jeffrey ST Barkun, MD, FRCSC, Montreal, Quebec, Canada
more acutely ill patient may represent a “loss of opportunity,” of what would be a better use of that bed, both for the institution itself and for its health care environment. Such a patient may even be more remunerative for the hospital, depending on the existing payers’ agreement.3 In another context LOS reductions that can be applied as closure of several beds or even one whole unit may lead to reallocation of that space or its resources, depending on the payers’ agreement, underlying union contracts, or both. It is unfortunate, as stated by the authors themselves, that not factoring in such opportunity costs is both a limitation of their analysis and the source of often contentious interpretations. Perhaps the most important conclusion of this paper is the demonstration that reduction in LOS is not the ultimate benchmark, as has been the mantra in the past two decades. It suggests that we are at risk of striding so far from original cost-effective precepts that the “effectiveness” component (ie, quality of dispensed care) may be totally forgotten to save but a few hundred dollars per patient. Occasionally “effectiveness” may be difficult to measure, but the governmental necessity to regulate the length of maternity stays across the US in 1997 was a grim reminder that it must be done and that clinicians must be the ones to do this. Unlike what we are occasionally led to believe, expenditures are but the flip side of the health care coin, where health status, clinical outcomes, and patient satisfaction are the too often feeble reminders of our primary purpose.
During the past several years a plethora of publications by clinicians and economists has attempted to describe the costs of various surgical procedures or practice habits. Many of these publications have helped to outline the details of what, in effect, happens to our health care dollars but few have had the audacity to challenge the usefulness of such sacrosanct economic benchmarks as total hospital admissions per capita, or “length of stay” (LOS).1 Taheri and coworkers2 in this issue aim to demystify obsessions with LOS reductions by demonstrating the limited relevance of latter-day hospital stay reductions on the overall cost of the episodes of hospital care. The authors begin by effectively reviewing the differences among variable direct costs, fixed direct costs, and indirect costs. Their whole costing exercise, in fact, addresses solely the variable direct cost component, while including nursing-related expenditures in the latter. Although not explicitly stated, the perspective from which the analysis is performed is mostly that of the clinician’s unit, and this is important in interpreting their findings. They show first in a general population, and subsequently in more specific subgroups defined by their pattern of resource utilization (operated trauma patients, patients with short or long hospital stays), that the costs related to the last day of hospitalization are consistently minute, both as a percentage of overall cost, and in absolute numbers. A breakdown by severity of illness of patients would also have been useful, because a number of these patients have been excluded from the analysis as nonsurvivors. The authors correctly conclude that “the bulk of health care expenses takes the form of overhead, or is incurred early in patients’ hospital days.” This conclusion is intuitively in keeping with any clinician’s experience, but it represents only part of the overall costing equation. In a fully occupied hospital, the inability to fill a potential bed with a © 2000 by the American College of Surgeons Published by Elsevier Science Inc.
References 1. Reinhardt UE. Spending more through “cost control”: our obsessive quest to gut the hospital. Nursing Outlook 45:156–160. 2. Taheri PA, Butz DA, Greenfield LJ. Length of stay has minimal impact on the cost of hospital admission. J Am Coll Surg 2000; 191:123–130. 3. Taheri PA, Butz DA, Watts CM, et al. Trauma services: a profit center? J Am Coll Surg 1999;188:349–354.
192
ISSN 1072-7515/00/$21.00 PII 1072-7515(00)00338-0