Revenue-Driven Surgery Drives Patients Home Too Early

Smith School Logistics Studies Link Bed Shortages and Hospital Readmissions

Financial considerations and poor planning drive some surgery patients home too early, concludes a pair of logistical studies conducted by researchers at the University of Maryland’s Robert H. Smith School of Business.

The studies show a correlation between readmission rates and how full the hospital was at the time of discharge, suggesting that patients went home before they were healthy enough. The researchers recommend better planning and other logistical solutions to avoid these problems.

The studies appear in the two most recent issues of the peer-reviewed journal Health Care Management Science:

• “The impact of hospital utilization on patient readmission rate”
• “Examining the discharge practices of surgeons at a large medical center”

“Discharge decisions are made with bed-capacity constraints in mind,” says Bruce Golden, the Smith School’s France-Merrick Chair in Management Science who conducted the research with Ph.D. student David Anderson and other colleagues. “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.”

Surgeons and hospitals are incentive-driven to perform surgical procedures, Golden explains. "If the hospital says 'sorry there are no beds available,' there's a lot of tension and pressure from both sides to keep things moving,” he says. “The hospital has to maintain revenue levels to meet its financial obligations. Surgeons are working to save lives and earn a livelihood. It’s what they do.”

In their studies, Golden and Anderson tracked patient movement at a large, academic medical center located in the United States. They found patients discharged when the hospital was busiest were 50 percent more likely to return for treatment within three days. This indicates recovery was incomplete when patients were first released, the researchers say. The study tracks occupancy rates, day of the week, staffing levels and surgical volume.

These findings cover surgical discharge data from fiscal year 2007 at the unidentified hospital for more than 7,800 surgery patients who collectively spent 35,500 nights in the facility.

“This gives us a good snapshot of the pressures at work in a busy facility,” Golden adds. “Other institutions may handle the challenges somewhat differently, but the pressures are widespread and these results call for some introspection.”

BETTER LOGISTICS

The problem is much more likely at large hospitals, Golden adds. These facilities tend to provide more advanced, specialized surgeries not accessible at smaller, community hospital. Patients often have to travel a great distance for the procedures, so hospital delays become expensive for both them and the care providers.

“Too often, the biggest problem is that hospitals just don’t plan ahead, and this is what gets them in trouble,” Golden says. “There are logistical alternatives to sending a patient home too soon.”

He suggests that surgeons use checklists before discharging the patient. “They know better than we do about what questions should be asked – questions that would force the surgeon to think about whether they were discharging the patient for the right reason.” Recently, for example this approach has been used successfully to reduce hospital bacterial infections, Golden points out.

Also, he suggests that hospitals increase the flexibility of where patients go post-surgery. Allowing them to be moved to units with empty beds, for example, could also lessen premature discharges. Though, this may increase costs in the short run, discharging patients who then quickly return to the hospital offers no long-term savings, and decreases the quality of care, Golden adds.