Hancock oversimplifies one-day hospital stays

March 01, 2010

Jay Hancock's column "Md. hospital stays: the one-day wonder" (Feb. 28), regarding "one day" hospital admissions, fails to address the multi-dimensional nature of the issue. One would conclude from the article that patients admitted to the acute care setting for only one day did not need to be admitted at all and that one-day admissions reflect unnecessary and/or over-utilization of medical resources.

While Maryland's unique payment system has indeed given hospitals an incentive to admit patients (as hospitals are reimbursed by this methodology), all hospitals through their utilization processes are bound to use rigorous criteria to screen patients for placement in the appropriate level of care. Patients are admitted to the hospital based on presenting symptoms and the physician's "complex medical judgment," which takes into account the "patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients ... and the relative appropriateness of treatment in each setting," according to the Medicare definition of an inpatient. It is easy in hindsight, following the diagnostic work up and evaluation, to say that the chest pain patient who was "ruled out" for a heart attack didn't need to be admitted. At the same time we are caring for the patient exactly as the one who does have the heart attack, with all of the diagnostics, monitoring and required treatment. The patient who presents to the emergency department with chest pain may be appropriate for an outpatient "observation" status but only if the physician determines that the patient is at low risk and can be monitored safely in an ambulatory setting.

As hospitals strive to become more efficient, overall length of stay has decreased, and in many cases, the one-day stay today, was a two- or three-day stay several years ago. With improved technology and efficiency in rapid diagnostic testing and therapeutic intervention, more patients may be evaluated, diagnosed, treated and transitioned to a lower level of care within 24 hours. Procedures such as minimally invasive hip replacements or radical prostatectomies have evolved to allow for rapid recovery but in no means obviate the need for appropriate admission to the hospital. An acutely ill patient with pneumonia may be diagnosed, treated and monitored, and depending on the patient's response, could be rapidly discharged from the hospital with home care nursing and intravenous antibiotics. Patients are no longer able to fully recover in the hospital, as the acute care mode is one of "stabilization and transition." As it is, patients feel they are pushed out of the hospital long before they feel prepared to leave.

It is inappropriate for public and private payers to conclude that one-day hospital admissions are avoidable and thus should not be reimbursed. Hospitals and physicians that are efficiently managing their patients should not be penalized. Acutely ill one-day stay patients cost the hospital the same or more per day as the patient who is admitted for greater than 24 hours. Hospitals and physician providers are keenly aware that the hospital is the most costly place to treat the patient and strive to avoid hospitalization when alternative approaches are viable. There is no "crystal ball" to tell the physician that their 85-year-old patient with a history of heart disease and diabetes who arrives at the emergency room door with severe chest pain is only having "indigestion." Only after an evidence-based risk assessment, diagnostic evaluation and treatment, can it be determined that the patient is safe to go home -- after a one day stay.

Amy Deutschendorf, Baltimore

The writer is senior director of utilization/clinical resource management at Johns Hopkins Hospital.

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