Profit-Driven Patient Discharge Practices

Research by Bruce Golden

Surgeons discharge patients to ensure that their surgeries will not be cancelled for a lack of recovery beds.

Surgeons have a great deal of freedom in when they schedule surgeries, and they are also in charge of releasing their patients. As post-operative recovery beds fill up and there is less space available, do surgeons release patients earlier than they otherwise would, in order to empty those beds? They do, according to a study by Bruce Golden, France-Merrick Chair in Management Science, and his PhD student David Anderson.

A large mid-Atlantic hospital center provided surgical discharge data for more than 7,800 patients from the 2007 fiscal year who stayed overnight in the hospital, for a total of about 35,500 overnight stays. Golden and Anderson had access to information about patient age, surgical severity level, date and time of surgery, and the dates when the patient was admitted to recovery and subsequently discharged.

Statistical analysis of the data showed that when more recovery beds were full, more patients were released from the hospital, even when controlling for factors like day of the week, staffing levels and surgical volume. The results suggest that surgeons discharge patients to ensure that their future surgeries will not be cancelled for a lack of recovery beds.

“It could be that the doctors think If the hospital isn’t full, I’ll keep my patient another day, it doesn’t hurt anything,” said Golden. “Based on just this data, we can’t say for certain whether doctors are just keeping patients longer when the hospital is empty, or whether they are releasing more patients when the hospital is full.”

But further research is leading Golden and Anderson to suspect that at some level, a profit-driven motive is at work. Surgeons are paid for each operation they perform. Hospitals also generate revenue when surgeons perform surgery. If the hospital does not have staffed beds available for post-operative recovery, surgeons can’t operate, and both the surgeon and the hospital lose income.

Releasing patients in order to empty recovery beds may be good business, but it is also a potential public health concern if it negatively impacts patient health. In a second paper based on this research, Golden and Anderson tracked patients who were released when recovery beds were near-full, and found that almost half of those patients returned to the hospital within three days, suggesting that their recovery was incomplete when they were released.

“It’s in everyone’s interest to do surgery. But it is also in everyone’s interest to make sure that patients are completely recovered before they return home,” says Golden.

Hospital administrators must work with surgeons to manage this complex logistics problem in a way that brings a net benefit to patients, surgeons and the hospital itself. This might be as simple as instituting a checklist when the hospital is full, says Golden. “When the hospital is full, surgeons could go through the checklist before discharging the patient. They know better than we do what questions should be asked—questions that would force the surgeon to think about whether they were discharging the patient for the right reason.”

Careful attention to the scheduling of surgeries might help better manage bed occupancy. Increasing the flexibility of where patients go post-surgery—allowing patients to be placed in beds in other units with empty beds, for example—could also lesson early discharges.

This study may be eye-opening for policy-makers, who are increasingly concerned with issues related to the cost and quality of healthcare. Keeping surgical patients in recovery longer will increase costs, but discharging patients who then quickly return to the hospital also raises costs, as well as decreases the quality of care.

Hospitals may also find the study helpful as a springboard to re-examining their practices in regard to patient releases. Hospital administrators may have had a sense that patients were being released early, but there is a difference between believing something and then seeing statistical evidence of the fact based on a large dataset at a major hospital, Golden says. So the authors have sent this research to chief medical officers at hospitals around the country, to draw their attention to the issue.

“Examining the discharge practices of surgeons at a large medical center” was published in the journal Health Care Management Science. For more information, contact Bruce Golden.