Home and Community Care Digest

Home and Community Care Digest June 2004 : 0-0

Major determinants of hospital length-of-stay and discharge destination

Abstract

Average hospital lengths-of-stay in the U.S. have been declining as the prevalence of alternate modes of care, such as nursing homes and home care, has increased. The local competitive environment and changes in Medicare and Medicaid reimbursement schemes have also had an impact on hospital discharge policies. This study uses statistical methods to determine factors that affect the timing of a patient's discharge and the choice of destination at discharge. Government policy is observed to have a significant effect: Medicaid eligibility increases transition rates to home care programs; adoption of the Prospective Payment System significantly shortens average lengths-of-stay, increasing transition rates to all destinations; and a higher proportion of nursing home expenditure covered by Medicare is associated with higher probabilities of discharge to nursing homes. These findings have important implications for Ontario as government policy evolves to expand home care programs move hospitals toward volumebased funding models.
Background: Average hospital lengths-of-stay in the U.S. have been declining as the prevalence of alternate modes of care, such as nursing homes and home care, has increased. The local competitive environment and changes in Medicare and Medicaid reimbursement schemes have also had an impact on hospital discharge policies. Length-of-stay and discharge destination can be viewed as two separate results of a single decision process, that of discharge from hospital. This study uses statistical analysis to examine the determinants of the discharge/destination decision.

Methods: Data is drawn from hospitalizations incurred by participants in the 1984, 1989, and 1994 National Long-Term Care Survey (NLTCS), linked to Medicare claims data. Analysis was restricted to four diagnoses: hip fracture, stroke, coronary heart disease, and congestive heart failure. For each hospitalization discharge, length of stay was calculated and discharge destination was classified as: home, home care, nursing home, or death. Statistical analysis was employed to estimate the probability of discharge to each of the four destinations for each day of stay in the hospital. The impact of patient health, other patient characteristics, availability of informal care (spouses and children), market characteristics, and Medicare policy on these probabilities was then estimated.

Findings: Functional limitations in activities of daily living, hip fracture, and stroke significantly decreased the probability of discharge to home. Hip fracture and stroke also decreased the likelihood of discharge to home care, and significantly increased the probability of discharge to a nursing home. Higher levels of patient income increased the likelihood of discharge to home relative to both home care and nursing homes. Medicaid eligibility had a significant positive association with transition to home care programs. Having a spouse had the expected positive influence on probability of discharge to home, while a higher number of children had a significant negative influence on the probability of transition to a nursing home. Turning to market conditions, both less competition and higher numbers of hospital beds per 1000 people in the region of hospitalization were significantly associated with lower probability of discharge to nursing homes and home care. Higher per capita income of the region negatively influenced the likelihood of discharge to home, an opposite influence to that observed for patient income. Change in Medicare policy, represented by the adoption of the Prospective Payment System, had a significant positive effect on transition rates to each of home, home care, and nursing homes, shortening average lengths-of-stay. Finally, an increase in the proportion of nursing home charges covered by Medicare was associated with increased likelihood of transition to nursing homes and to home while probability of discharge to home care decreased.

Conclusions: This study presents the results of a robust analysis of hospital discharge policies, considering both the timing and destination of the discharge. The results demonstrate some expected influences of individual characteristics: better patient health, higher patient income, and greater support at home increase the likelihood of discharge to home, while hip fracture and stroke are associated with transition to nursing homes. Government policy is observed to have a significant effect: Medicaid eligibility increases transition rates to home care programs; adoption of the Prospective Payment System significantly shortens average lengths-of-stay, increasing transition rates to all destinations, with the exception of death; and a higher proportion of nursing home expenditure covered by Medicare is associated with higher probabilities of discharge to nursing homes. These findings have important implications for Ontario as government policy evolves to expand home care programs move hospitals toward volume-based funding models.

Reference: Picone G, Wilson RM, Chou SY. "Analysis of hospital length of stay and discharge destination using hazard functions with unmeasured heterogeneity". Health Economics, December, 2003; 12 (12) 1021-1034.

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