Hospital stays: When less medicine is more
This year, 36.6 million people will be admitted to U.S. hospitals. Each patient will stay an average of 4.8 days, and the cost for all those hospitalizations will reach into the billions.
Is all that time spent in hospitals good for patients?
Hospitals, of course, are vital institutions that save lives. When someone needs intensive, around-the-clock care, there is no substitute. But as physicians and hospital staffs know well, the longer a patient stays in a hospital, the more perilous the hospitalization can become.
Patients can acquire infections during the course of being treated for other conditions. Muscles deteriorate when they’re not used, a particular problem for the frail and elderly. And there are other physical and psychological trade-offs.
Patients should stay in the hospital only as long as necessary, and not a moment longer. Hospitals can do better, and they’re learning.
A new mother today typically stays in the hospital for a day or two following an uncomplicated vaginal delivery — an event that might have kept her grandmother in the hospital for a week. Many lung-cancer patients now undergo a minimally invasive procedure instead of surgery with long chest incisions, which means they can leave the hospital in days rather than weeks.
We also can reduce the time people spend in hospitals by better focusing on the problem that brought them in in the first place. We don’t need to test every organ system in a patient’s body simply because advanced technology is at the ready. An estimated $700 billion is spent each year on care that can’t be shown to improve health outcomes, and a lot of that happens during hospitalizations.
Optimizing the length of hospital stays is good for patients and fundamental to the moral imperative of healthcare providers to do what is right while doing no harm.
And it will reduce healthcare costs. In the United States, nearly 1 of every 5 dollars goes to healthcare, and hospital costs consume almost a third of that money.
We know we can fix this problem. At my hospital, we have reduced lengths of stay by about 11% over the last two years by changing how we practice medicine, and the changes have also improved outcomes for patients. We’ve gotten better at coordinating diagnostic testing and evaluations, responding quicker to infections, engaging in smarter treatment planning from pre-admission to post-discharge, and we’re better at educating patients to prevent complications during recovery.
Such efforts offer a glimpse into the future of medicine as physicians and hospitals strive to deliver more efficient and higher-quality medical care, one of the cornerstones of the Affordable Care Act. Already, Medicare and insurance companies are taking steps to shift incentives from rewarding quantity of care to rewarding quality and keeping people healthy. Inappropriate hospitalizations will risk penalties under government-sponsored insurance programs.
We still have our work cut out for us, though. Unfortunately, some doctors and patients still cling to the “more is better” theory of medicine.
Physicians may determine that a patient is ready to go home but decide to delay discharge for one additional “just in case” day. Changes in the payment system are needed to encourage physicians to provide the best care without doing more than is needed.
Patients, too, sometimes push for an extra day under the watchful eye of a medical team. And family members might be anxious about taking over the bulk of managing medications or wounds at home.
We have a responsibility to avoid these situations. When patients are deemed stable, they should be discharged to their homes or nursing facilities. Planning for discharge should begin as early as possible during a hospital stay, with staff equipping patients and families with the tools they need to facilitate a successful recovery. The hospital also should engage in “active handoffs,” providing thorough information and follow-up after discharge while continuing to communicate with patients to ensure they are seeing their doctors, taking their medications and following instructions.
Patients should feel confident that their hospital teams have done everything possible to prepare them for recovery. It’s smart medicine and the right thing to do.
Glenn D. Braunstein is a physician and vice president of clinical innovation at Cedars-Sinai Medical Center in Los Angeles.
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