Length of Stay and Hospital Bed Misutilization

Under the now virtually universal hospital bed utilization review requirements of government and third parties in the United States, by far the greatest emphasis has been upon the control of “long-stay” or “extended duration” hospitalization. While unnecessarily protracted stays are demonstrably important from a cost viewpoint and are frequently presumed to be the result of unavailability of accommodations at lower levels of care, much less attention has been paid to misutilization among patients hospitalized for shorter periods. The misutilization in these cases would most likely be due, a priori, to unnecessary admission in the first place or to delays in performing in-hospital procedures. The opportunity to study the matter of the relationships between length of hospitalization and 1) misutilization, 2) reason for misutilization, and 3) appropriate level of care for misutilizers was provided by an accumulation of data from the on-going sample utilization review system instituted in July, 1966, as required by Medicare regulations, at the Strong Memorial Hospital of the University of Rochester. This paper will describe and analyze these relationships by hospital service and for the entire hospital. The basic review methodology involved is that of two independent physician-reviewer observations made on each of a random sample of hospitalized patients, regardless of length of stay, with professional judgments as to appropriateness of hospitalization on the day of review. On patients considered to be misutilizers, further judgments were made as to the reason for inappropriateness and as to what the most appropriate level of care should have been. The paired independent observations allowed for an assessment of interobserver reliability, which will also be discussed. Various aspects of this and related methods of utilization review have been presented previously by the author, particularly in respect to review design and interobserver reliability.8-11