A cost-minimisation study of alternative discharge policies after hip fracture repair

It is widely assumed that health care costs can be reduced considerably by providing care in appropriate health care institutions without unnecessary technological overhead. This assumption has been tested in a prospective study. Conventional discharge after hip fracture surgery was compared with an early discharge policy in which patients were discharged to a nursing home with specialised facilities for rehabilitation. We compared costs for both strategies from a societal perspective, using comprehensive and detailed data on type of residence and all kinds of medical consumption during a 4-month follow-up period.As expected, early discharge reduced the hospital stay (with 13 days, p=0.001). More patients were discharged to a nursing home (76% versus 53%). Total medical costs during follow-up were reduced from an average of euro;15338 to euro;14281, representing relatively small and not significant savings (p=0.3). There are two explanations for this unexpected result. First, costs incurred by hip fracture patients were relatively less while in hospital. Hence, nursing home costs almost equalled hospital costs per admission day. Second, compared with the conventionally discharged group early discharged patients were subjected to more medical procedures during the first post-operative days. We conclude that: (1). early discharge shifted rather than reduced costs; (2). the details of costing have a major influence on the cost-effectiveness of alternative discharge policies.     

Hospital discharge decisions, health outcomes, and the use of unobserved information on case-mix severity.

Although implementation of the Medicare prospective payment system has been accompanied by significant decreases in hospital length of stay, the early discharge of some patients may lead to worse health outcomes, particularly if sufficient aftercare services following hospitalization are not available. This article develops an empirical model of the relationship between the choice of length of stay and patient outcome. The model incorporates information on the severity of a patient's medical condition known by the physician who chooses length of stay for a patient but generally not known by a researcher interested in the factors that affect length of stay and health outcome. Joint estimation of equations for length of stay and health outcome controls for unmeasured aspects of case severity that affect both variables. The ratio of nursing home beds to Medicare enrollees in the county is included as an exogenous variable in both equations to assess whether variation in nursing home bed availability is correlated with length of stay or health outcome. The model is estimated using billing data for Medicare patients admitted with congestive heart failure to New Jersey hospitals during 1982 and 1983. Two measures of outcome are used: (1) a discrete measure of survival time following admission, and (2) a categorical measure of whether or not the patient was discharged dead or died within six months after discharge. Empirical results show no evidence that longer lengths of stay for congestive heart failure patients lead to lower postadmission mortality. However, greater availability of nursing home beds may reduce length of stay and may shift the provision of terminal care away from a hospital setting. Therefore, policies to expand the nursing home bed supply may enable further decreases in hospital length of stay without deleterious effect on patient outcome.     

Variations in Nursing Home Discharge Rates for Urban and Rural Nursing Facility Residents With Hip Fracture

CONTEXT: The more limited availability and use of community-based long-term care services in rural areas may be a factor in higher rates of nursing home use among rural residents. PURPOSE: This study examined differences in the rates of nursing home discharge for older adults receiving posthospital care in a nursing facility. METHODS: The study sample was comprised of a cohort of rural and urban residents newly admitted to nursing home care in Maine following surgery for hip fracture. FINDINGS: The results indicated that rural residents who were hospitalized for hip fracture and subsequently admitted to a nursing facility for rehabilitation were significantly less likely than urban residents to be discharged within the first 30 days of their admission. Rural residents who stayed in the nursing facility beyond 30 days were also less likely to be discharged in the first 6 months. These geographic differences were not explained by service use and resident characteristics such as age, health, or functional status. CONCLUSIONS: The finding of lower discharge rates among rural nursing facility residents appears to be consistent with previous studies demonstrating higher rates of nursing home use among rural residents. There continues to be a need for a better understanding of the role that service supply and accessibility and other factors play in the patterns and outcomes of rural long-term care.     

Hospital swing-bed care in the United States.

As a result of federal legislation implemented in 1982, hospital beds that are used to provide both long-term care and acute care are now proliferating rapidly throughout the country. Termed swing beds, such beds are currently restricted to rural areas. However, due largely to the impacts of Medicare DRG reimbursement, pressure is mounting to expand the swing-bed approach to urban settings. Swing beds appear to fill a significant gap between the relatively intense medical needs of post-acute care patients (now discharged earlier) and the capacity of our current nursing home delivery system to meet such needs. The evolution of swing beds is marked by an unusual blend of experimentation, scientific investigation, and public policy response to community and personal health care needs. This article summarizes that evolution, highlighting research findings and key policy developments. It concludes with the current status of the national swing-bed program and issues pertinent to future directions.     

A cost study of a general practitioner hospital in the Netherlands

Objective: To perform a cost study of the first general practitioner (GP) hospital in the Netherlands.

Methods: We conducted a cost study in a GP hospital in the Netherlands. Data on healthcare utilisation from 218 patients were collected for a period of one year. The costs of admission to the GP hospital were compared with the expected costs of the alternative mode of care. In the GP hospital three types of bed categories were distinguished: GP beds (admission and discharge by GPs, n=131), rehabilitation beds (recovery from hospital surgery, n=62) and nursing home beds (hospital patients awaiting a vacancy in a nursing home, n=25). GPs were interviewed to indicate the best alternative form of healthcare for the GP bed patients in the absence of a GP hospital (dichotomised for this study into ‘hospital’ or ‘home care’). For the ‘rehabilitation’ and ‘nursing home’ patients the alternative care mode was admission to a hospital.

Results: The mean length of stay was 15 days for the GP beds, 31 days for the rehabilitation beds and 90 days for the nursing home beds. For the GP bed patients the costs were ?2533 per admission compared with ?3792 for hospital stay. For the group of GP bed patients for whom ‘home care’ was the best alternative, the costs were ?2494 for GP hospital days compared with ?2814, the average cost for home care of patients of 65 years and older. For rehabilitation patients the costs per patient were ?4744 compared with ?8041 in a hospital. For patients waiting for admission to a nursing home, these costs were ?13,143 and ?22,670, respectively.

Conclusion: The GP hospital might be a cost-saving alternative for elderly patients in need of intermediate medical and nursing care between hospital and home care. Further research on the cost-effectiveness of the GP hospital compared with home care and nursing home care is needed.     

Hospital DRGs and the need for long-term care services: an empirical analysis.

The Medicare DRG-based Prospective Payment System (PPS) encourages hospitals to reduce length of stay for elderly patients. Thus, discharges to long-term care services are expected to increase. Maryland hospital data for 1980 are used to identify those DRGs which most frequently represent patients discharged to nursing home and home health care services; explores the incentive to discharge earlier under PPS those patients needing long-term care versus short-term care; and describes characteristics of patients most likely to face increased pressure of earlier discharge to nursing homes and home health programs. Because only a limited set of patient characteristics are available from Maryland hospitals, data from a study of San Diego nursing homes are used to explore further the sociodemographic and health status measures associated with unusually long stays in a hospital prior to nursing home placement. This research suggests that the DRG reimbursement system gives hospitals a strong incentive for earlier discharge of patients needing long-term care services. However, hospitals that target only long-term care patients for early discharge will not substantially gain under PPS because these patients represent a small portion of the cases treated in the hospital and a small percentage of unreimbursed days.     

Hospitals in Utah reduce costs, improve use of facilities.

A serious problem in rural areas is low occupancy for acute care hospital beds and a desperate need for additional long-term care beds. In Utah, this problem has been solved through the "swing bed" concept. Under this program, underutilized acute care beds can be used for long-term care patients. As a result, all beds are more fully utilized, and long-term care patients in rural areas do not have to be moved to cities.     

Cost-effectiveness implications based on a comparison of nursing home and home health case mix.

Case-mix differences between 653 home health care patients and 650 nursing home patients, and between 455 Medicare home health patients and 447 Medicare nursing home patients were assessed using random samples selected from 20 home health agencies and 46 nursing homes in 12 states in 1982 and 1983. Home health patients were younger, had shorter lengths of stay, and were less functionally disabled than nursing home patients. Traditional long-term care problems requiring personal care were more common among nursing home patients, whereas problems requiring skilled nursing services were more prevalent among home health patients. Considering Medicare patients only, nursing home patients were much more likely to be dependent in activities of daily living (ADLs) than home health patients. Medicare nursing home and home health patients were relatively similar in terms of long-term care problems, and differences in medical problems were less pronounced than between all nursing home and all home health patients. From the standpoint of cost-effectiveness, it would appear that home health care might provide a substitute for acute care hospital use at the end of a hospital stay, and appears to be a more viable option in the care of patients who are not severely disabled and do not have profound functional problems. The Medicare skilled nursing facility, however, is likely to continue to have a crucial role in posthospital care as the treatment modality of choice for individuals who require both highly skilled care and functional assistance.     

Proximal femur fractures in the elderly in The Netherlands during the period 1991-2004: incidence, mortality, length of hospital stay and an estimate of the care capacity needed in the future

OBJECTIVE: To assess the incidence of operations for neck and pertrochanteric femur fractures during the last 15 years and to estimate the future demand for such operations in The Netherlands. DESIGN: Retrospective. METHOD: For the years 1991, 1995, 2000 and 2004, the following anonymised data were collected in the National Medical Registry of Prismant for all patients admitted to Dutch hospitals for a hip fracture: age-group, gender, length of pre- and postoperative hospital stay, destination after discharge and hospital mortality. These data were related to demographic data for the Dutch population from Statistics Netherlands (CBCS) and to estimates for the Dutch population in the future from Primos Prognostic Data. RESULTS: The average absolute increase in the period 1991-2004 was linear, with 230 fractures per year. Women were operated for a hip fracture 1.5-2 times as often as men in the same age range. The age-specific incidence remained constant over the years but the absolute number of elderly persons per age group increased. The average length of pre- and postoperative hospital stay was reduced by half during the period under investigation. The postoperative hospital mortality decreased from 8.1% in 1991 to 5.6% in 2004, and was 1.5 times as high for men aged 70 years or over as for women of the same age group. In 2004 as compared to 1991, 2.5 times as many patients were discharged to a nursing home. In view of the increasing age of the population, the total number of operated hip fractures can be expected to be 20,200 in the year 2010 and 23,900 in the year 2020. CONCLUSION: In the period 1991-2004 there was an annual increase of 230 operations for proximal femur fractures that was closely related to the ageing of the Dutch population. During the years under investigation, the incidence in the same age range was higher in women, but men had a higher hospital mortality. It is estimated that the decreasing hospital mortality and the decrease in the length of hospital stay will increase the need for nursing-home care for this category of patients.     

What are the costs of queuing for hip fracture surgery in Canada?

This paper investigates the effect of wait time for hip fracture surgery in Canada on post-surgery length of stay in hospital and inpatient mortality. After controlling for observed and unobserved patient and hospital characteristics, pre-surgery delay has little effect on either of the two outcome variables. Patients from higher income postal-codes experience only slightly shorter delays, and income has no substantial effect on post-surgery outcomes. For hip fracture patients surgery delay may lead to greater pre-surgery inpatient costs and more patient discomfort, but we find no evidence of a detrimental impact on post-surgery outcomes.     

Hospital admission for acute stroke: who,for how long,and to what effect?

Data from 976 patients registered in a community survey as suffering an acute stroke have been analysed to discover what factors are associated with admission to hospital, how long patients spend in hospital, and whether there are any specific benefits attributable to hospital admission. Six hundred and twenty-five patients were admitted on account of their index stroke. These patients were compared with the 249 who remained at home throughout the first six months after the stroke--the remaining patients were admitted for other reasons or had their stroke in hospital. Two major factors related to an increased chance of admission: having a more severe disability and not having a carer. The same factors were associated with a longer length of stay for those who returned home within six months. Nevertheless 26% of patients managed at home were severely disabled when first seen within seven days. Patients admitted had a median stay of seven days if they died, 19 days if they returned home, and 149 days if they needed alternative long-term accommodation. Patients from the study population of 215 000 people occupied an average of 11.4 beds/100 000 over the first six months after their stroke. After making allowance for the increased severity of disability seen in those admitted to hospital, no differences in functional, social or emotional outcome were found for either place of care.     

Introducing DRG-based financing in Hungary: a study into the relationship between supply of hospital beds and use of these beds under changing institutional circumstances

Most hospital reforms carried out in Europe over the past few decades concern the supply of hospital beds and hospital financing systems. In Hungary, financing was not tied to hospital input or output until a Diagnosis-Related-Group system was introduced. This change provided an opportunity to study the effect of the new system, taking the supply of hospital beds into account. We studied the effect of the financing system and bed supply on four output parameters, average length of stay; admission rate; occupancy; and case-mix. The incentives of the financing system influenced the length of stay (shorter) and the admission rate (more admissions). Although the case-mix did increase, occupancy was not affected. The supply of more beds resulted in higher admission rates and a slightly lower efficiency (a lower occupancy rate). No interaction effects of (variations in) the bed supply and the financing system were found.     

Is Home Health Care a Substitute for Hospital Care?

A previous study used aggregate (region-level) data to investigate whether home health care serves as a substitute for inpatient hospital care and concluded that “there is no evidence that services provided at home replace hospital services.” However, that study was based on a cross-section of regions observed at a single point of time and did not control for unobserved regional heterogeneity. In this article, state-level employment data are used to reexamine whether home health care serves as a substitute for inpatient hospital care. This analysis is based on longitudinal (panel) data—observations on states in two time periods—which enable the reduction or elimination of biases that arise from use of cross-sectional data. This study finds that states that had higher home health care employment growth during the period 1998–2008 tended to have lower hospital employment growth, controlling for changes in population. Moreover, states that had higher home health care payroll growth tended to have lower hospital payroll growth. The estimates indicate that the reduction in hospital payroll associated with a $1,000 increase in home health payroll is not less than $1,542, and may be as high as $2,315. This study does not find a significant relationship between growth in utilization of home health care and growth in utilization of nursing and residential care facilities. An important reason why home health care may serve as a substitute for hospital care is that the availability of home health care may allow patients to be discharged from the hospital earlier. Hospital discharge data from the Healthcare Cost and Utilization Project are used to test the hypothesis that use of home health care reduces the length of hospital stays. Major Diagnostic Categories with larger increases in the fraction of patients discharged to home health care tended to have larger declines in mean length of stay (LOS). Between 1998 and 2008, mean LOS declined by 4.1%, from 4.78 to 4.59 days. The estimates are consistent with the hypothesis that this was entirely due to the increase in the fraction of hospital patients discharged to home health care, from 6.4% in 1998 to 9.9% in 2008. The estimated reduction in 2008 hospital costs resulting from the rise in the fraction of hospital patients discharged to home health care may have been 36% larger than the increase in the payroll of the home health care industry.     

Is home health care a substitute for hospital care?

A previous study used aggregate (region-level) data to investigate whether home health care serves as a substitute for inpatient hospital care and concluded that "there is no evidence that services provided at home replace hospital services." However, that study was based on a cross-section of regions observed at a single point of time and did not control for unobserved regional heterogeneity. In this article, state-level employment data are used to reexamine whether home health care serves as a substitute for inpatient hospital care. This analysis is based on longitudinal (panel) data--observations on states in two time periods--which enable the reduction or elimination of biases that arise from use of cross-sectional data. This study finds that states that had higher home health care employment growth during the period 1998-2008 tended to have lower hospital employment growth, controlling for changes in population. Moreover, states that had higher home health care payroll growth tended to have lower hospital payroll growth. The estimates indicate that the reduction in hospital payroll associated with a $1,000 increase in home health payroll is not less than $1,542, and may be as high as $2,315. This study does not find a significant relationship between growth in utilization of home health care and growth in utilization of nursing and residential care facilities. An important reason why home health care may serve as a substitute for hospital care is that the availability of home health care may allow patients to be discharged from the hospital earlier. Hospital discharge data from the Healthcare Cost and Utilization Project are used to test the hypothesis that use of home health care reduces the length of hospital stays. Major Diagnostic Categories with larger increases in the fraction of patients discharged to home health care tended to have larger declines in mean length of stay (LOS). Between 1998 and 2008, mean LOS declined by 4.1%, from 4.78 to 4.59 days. The estimates are consistent with the hypothesis that this was entirely due to the increase in the fraction of hospital patients discharged to home health care, from 6.4% in 1998 to 9.9% in 2008. The estimated reduction in 2008 hospital costs resulting from the rise in the fraction of hospital patients discharged to home health care may have been 36% larger than the increase in the payroll of the home health care industry.     

Determinants of received long-term care – Individual responses to regional nursing home provisions

Existing literature analyzing the choice of received long-term care by frail elderly (65+ years) predominantly focuses on physical and psychological conditions of elderly people as factors that influence the decision for a particular type of care. Until now, however, the regional in-patient long-term care supply has been neglected as influential factor in this decision-making process. In this study, we analyze the determinants of received long-term care in Germany by explicitly taking the regional supply of nursing homes into account. We estimate a multinomial probit model to illustrate this decision-making process. Therefore, within this discrete choice setting we distinguish between all available types of long-term care in Germany, i.e. four different types of formal and informal care provision. We find that the decision for long-term in-patient care is significantly correlated with the regional supply of nursing home beds, while controlling for physical and psychological conditions of the individual.     

Do hospitals respond to decreasing prices by supplying more services?

Regulated prices are common in markets for medical care. We estimate the effect of changes in regulated reimbursement prices on volume of hospital care based on a reform of hospital financing in Germany. Uniquely, this reform changed the overall level of reimbursement—with increasing prices for some hospitals and decreasing prices for others—without directly affecting the relative prices for different groups of patients or types of treatment. Based on administrative data, we find that hospitals react to increasing prices by decreasing the service supply and to decreasing prices by increasing the service supply. Moreover, we find some evidence that volume changes for hospitals with different price changes are nonlinear. We interpret our findings as evidence for a negative income effect of prices on volume of care.     

Association of hospital resource use with comorbidity status and patient age among hip fracture patients in Japan

OBJECTIVES: This study examined the association of resource use with comorbidity status and patient age among hip fracture patients who underwent surgical treatment. DESIGN: We used a database from the Voluntary Hospitals of Japan Quality Indicator Project that involved 10 privately owned leading teaching hospitals in Japan. SETTING: Four of these hospitals in Japan. PARTICIPANTS: We selected 778 operable hip fracture patients aged 65 or older who were admitted to these hospitals between January 1996 and August 2000 (mean age: 80.3 +/- 7.3 years). MEASUREMENTS: A linear mixed model was performed to identify factors associated with the resource use, such as total length of stay (LOS), LOS before surgery, LOS after surgery, total hospital charges, charges for diagnostic examinations, charges for surgery, and length of theater time, among operable hip fracture patients. RESULTS: The mean LOS was 45.9 days, and the mean total hospital charges were US dollars 14,495.0. Results from linear mixed models revealed that higher age was significantly associated with shorter length of theater time (P < 0.01), and that the presence of comorbidity among hip fracture patients was significantly associated with longer total LOS (P < 0.01), longer LOS after surgery (P < 0.001), higher charges for diagnostic examinations (P < 0.001), and shorter length of theater time (P < 0.01). CONCLUSION: These results suggest that the presence of comorbidity among operable hip fracture patients requires greater resource use during their hospital stay, but higher age is not significantly associated with greater resource use at all.     

Home care before and after hospitalization for acute myocardial infarction in Alberta, Canada

Home care services are provided to about 10% of those admitted to hospital for acute myocardial infarction and about 20% of those discharged from hospital. The use of home care in patients with an acute myocardial infarction is growing in Alberta over the brief time span of this four year study. Those that received home care prior to a hospitalization for acute myocardial infarction were "old and frail" with a high mortality rate during and after hospitalization. The provision of home care after hospitalization selected those patients that stay in hospital longer and required more hospital care. BACKGROUND: The use of home care before and after hospitalization for acute myocardial infarction is described. METHODS: Hospital discharge abstracts were used to identify patients hospitalized in alberta, canada for acute myocardial infarction which were then linked to home care administrative data. RESULTS: There were 12,648 patients with acute myocardial infarction from April 1, 1995 until March 31, 1999. Home care within 60 days prior to hospitalization was provided for 8.7% of patients with acute myocardial infarctions (n = 1097) which significantly (p = 0.023) increased from 7.6% in the fiscal year 1995/6 to 9.5% in the fiscal year 1998/9. Home care within 60 days after hospitalization was provided to 16.4% of patients with acute myocardial infarctions (n = 2076) which significantly (p < 0.000) increased from 14.1% in the fiscal year 1995/6 to 18.1% in fiscal year 1998/9. Recipients of home care were significantly older, had more comorbidities, and greater severity of illness, but were less likely to undergo coronary artery revascularization during hospitalization. After multivariate adjustment, length of hospital stay, 60 day re-admissions, and mortality were higher in those receiving home care post hospitalization. Nearly half of those receiving home care prior to hospitalization died within one year. 80% of those receiving home care prior to admission also received home care services after hospitalization. CONCLUSION: Those patients who received home care prior to a hospitalization for acute myocardial infarction were "old and frail" with a high mortality rate during and after hospitalization. The provision of home care after hospitalization selected those patients that stay in hospital longer and required more hospital care.     

Effect of DRGs on three-month readmission rate of geriatric patients with congestive heart failure.

We reviewed the three-month hospital readmission rates of 410 patients ages 70 years or older discharged alive with a first time diagnosis of congestive heart failure during the period January 1983-June 1986. The mean age was 79.8 years, 59.5 per cent were women. Mean length of initial hospital stay decreased from 10.8 days in 1983 to 7.8 days in 1986. One hundred-nineteen patients (29 per cent) were rehospitalized at least once within three months of initial discharge. The readmission rates by year were: 1983, 40.0 per cent; 1984, 27.5 per cent; 1985, 21.4 per cent; 1986, 23.2 per cent. During this same interval, the percentage of patients referred for home health care services increased from 3.3 per cent in 1983 to 13.0 per cent in 1984, 5.8 per cent in 1985, and 12.5 per cent in 1986. Thus, decreased length of hospital stay was associated with a parallel decline in early readmission rate and increased utilization of home health care services. Although this study has important methodologic limitations, the data suggest that shorter hospital stays under the DRG system are not necessarily associated with an increased rate of early rehospitalization.     

The Balanced Budget Act (1997) and the supplyof nursing home subacute care

This article examines the impact of the Medicare prospective payment system (PPS) on the supply of subacute care services by nursing homes. A quasi-experimental interrupted time-series design using Heckman's two-stage regression model is employed to test for changes before and after the implementation of Medicare PPS. Our findings suggest that the change in Medicare reimbursement from cost-based to PPS under the Balanced Budget Act of 1997 resulted in a decrease of 1.7 percent in the supply of subacute care beds by nursing homes. However, this was a one-time, short-term negative effect. The supply of nursing home subacute care remained stable in the long-term. Other environmental factors, such as Medicare hospital discharges, hospital-based subacute care, Medicare managed care penetration, availability of home health, and per capita income were associated with nursing home subacute care supply. Organizational-level factors, such as occupancy rate, RN staff mix, and Medicare payer mix were also predictors of nursing home subacute care supply.