A press release from the University of Maryland touts the findings of remarkable two studies: "Revenue-driven" surgery and poor planning apparently send some surgery patients home from the hospital prematurely.
Wow. Money was identified as an overriding driver of surgery discharges, and not what's in the best interest of patients' health?
I talked to Bruce Golden, PhD, a professor in management science at the University of Maryland's Robert H. Smith School of Business, about the two logistical studies he conducted. "Revenue-driven?" Pretty harsh, isn't it?
"Originally, I said 'incentive-driven,'" Golden told HealthLeaders Media, suggesting his comments were revised in the editing process. "Every incentive is aligned with performing," he says. "Economics and system-wide pressures dictate when surgery is done."
Whatever the word choice, one thing can be extrapolated from Golden's findings related to the studies of one large, unnamed hospital: Economics dictate how quickly some patients are released, if bed capacity is an issue.
Golden was principal researcher, with co-author David Anderson, also of the UMD Robert H. Smith School of Business, of two studies on this topic. They found that patients discharged from a large, academic medical center when the hospital was at its busiest, were 50% more likely to return for treatment within three days, compared to when the hospital was at lower utilization. That indicates that the patients' recovery was incomplete when first released, according to the report.
The studies examined the impact of hospital utilization on patient readmission rates, and the discharge practices of surgeons at a large medical center. They were published in the two most recent issues of the Health Care Management Science.
The researchers used surgical discharge data from fiscal year 2007, covering more than 7,800 surgery patients who collectively spent 35,500 nights at the facility. They tracked occupancy rates, days of the week, staffing levels and surgical volume.
"Surgeons adjust their discharge practice to accommodate the surgical schedule and number of available recovery beds," the report states. "We find higher discharge rates on days when utilization is high. Our findings suggest that discharge decisions are made with bed-capacity constraints in mind."
While the data shows that economics plays a role in when patients are discharged, Golden didn't wanted to give the impression that money was a key driver. Or the driver.
"You've got to keep in mind, these aren't 'greedy' doctors. Hospitals are really difficult, complex mechanisms, and if they don't bring in revenue, they have to close their doors eventually. The surgeon wants to operate; the patients don't want to be delayed. If a surgery is postponed, it has a ripple effect," he says.
"Patients often have to travel a great distance for the procedures, so hospital delays become expensive for both them and the care providers," he adds.
Golden proposes four solutions:
1.Add more flexibility in post-operative room assignments. While there is a standard post-operative ICU in each service line, "there might be other beds in the hospital that would be able to take a patient and allow the patient to recover more fully," Golden's report says.
Since patients with co-morbidities, for example, may have higher readmission rates, "patients discharged from a highly utilized unit are more likely to be readmitted to the hospital after surgery. Because the discharge rates increase when utilization is high, extra time in the post-operative unit for these patients might help lower the probability that they are readmitted."
Though such procedures may increase costs in the short run, discharging patients who then quickly return to the hospital offers no long-term savings, and decreases quality of care, he says.
2. Create a checklist for bed usage. While many hospital systems have begun to use checklists, Golden suggests that surgeons use them, too, before discharging patients. A list of questions would "force the surgeon to think about whether they were discharging the patient for the right reason," he says.
He noted that the checklist approach, which has been espoused by Peter Pronovost, MD, PhD, a professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, has been used successfully to reduce hospital bacterial infections. Golden says those procedures also can be applied in evaluating bed usage. "By standardizing the discharge process, it becomes more likely that each patient is fully ready to be transitioned out of the hospital at the time of discharge," he says.
3. Assign transition coaches. These coaches can look especially at patients at high risk for readmission. "By standardizing the discharge process, it becomes more likely that each patient is fully ready to be transitioned out of the hospital at the time of discharge," he writes. Golden refers to previous studies that show hiring social workers to check on patients and to coach them on treatment and rehabilitation lowers the readmission rate.
4. Align a surgeon's compensation with a patient's health outcome. This would reflect the move toward value-based care. Currently, surgeons are paid for performing surgeries and having high operating room utilizations. "By incorporating readmission rates into the compensation formula, we might impact the discharge decision process in a way that would lower the readmission rate," he says.
Golden spoke with me about his proposals, but he best summarized his findings in the press release, after all. "Patient traffic jams present hospitals and medical teams with major, practical concerns, but they can find better answers than sending the patient home at the earliest possible moment," he said in a statement.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
