Decreased length of stay and cumulative hospitalized days despite increased patient admissions and readmissions in an area of urban poverty

Abstract

Background: Length of stay at US acute care hospitals has been steadily decreasing since 1960, and there is ongoing concern that increasing financial pressures on hospitals with high proportions of Medicaid patients may be causing unduly short lengths of stay.

Objective: To study temporal trends in hospital utilization on internal medicine services at Temple University Hospital, which has the highest percentage of Medicaid and uninsured patients in the state of Pennsylvania.

Design: Examination of temporal changes in hospital practice over three time periods spanning 13 years.

Measurements: Numbers of discharges, 1- and 12-month re-admission rates, and lengths of stay. US census data from 1990 to 2000 were examined for the eight major zip codes in which hospitalized patients live.

Main results: The number of internal medicine admissions increased from 1991 (117/month) to 2004 (455/month); p < 0.0001. Mean length of stay for the index admission decreased from 8.7 to 4.9 days; p < 0.001. The percentage of patients readmitted within 12 months of the discharge date of the index admission increased from 42.3% to 49.5%; p = 0.045. Mean cumulative length of stay over 12 months, including readmissions, decreased significantly (15.8 to 12.5 days; p = 0.031). Compared to all US hospitals, our hospital had a greater increase in admissions and a greater decrease in length of stay. During this time period, in surrounding zip codes, there were decreases in total population and total number of persons living in poverty, but also multiple closures of area hospitals that served poor patients.

Conclusion: During the 13-year study period, despite increased readmission rates, the overall number of hospitalized days per year on the internal medicine inpatient service decreased. As local hospitals serving this inner city low income area have closed, our hospital had atypically high increases in numbers of admissions and decreases in length of stay. This raises questions about current adequacy of hospital care in inner city areas of poverty.

Figure 1

Hospital discharges, lengths of stay, and hospital readmission data for patients hospitalized on an internal medicine service during 2-month time periods in 1991, 1998, and 2004. Error bars display standard errors of the mean.