Hospital orthodoxy challenged as strategies fail to free up beds

By Harley Dennett

April 23, 2015

In New South Wales, length of stay in hospitals is falling, while total admissions are rising. That’s a considerable success for NSW Health, says auditor-general Grant Hehir in his state hospital audit released today, but belies a 25% rate of unplanned readmissions related to deficiency of hospital care.

The department has flagged more research on the issue, and is reviewing its approach to incentivising fewer readmissions.

With increasing pressure on hospital admissions by older and chronically ill patients — a problem that Treasury’s Intergenerational Report says will only increase — the priority placed on reducing average length of stay is seeing results in NSW hospitals. However, there has been no corresponding reduction in unplanned readmissions as rapidly discharged patients find themselves returning for further treatment.

Length of stay is a KPI, highly documented at all levels and successfully reached the target specified in the NSW 2021 state plan. Unplanned readmissions is neither for local health districts, and has failed to achieve the state plan’s target. Both factors are costly. Each overnight stay for acute patients costs the health system on average $1400, Hehir notes:

“Reducing length of stay would create considerable savings to the health system, as each bed day freed up means additional capacity to provide care to other patients. This additional capacity allows NSW Health to meet greater demand for health services. Similarly, reducing unplanned readmissions will create efficiency gains as unnecessary admissions are avoided and bed days are freed up, creating capacity for the next patient on the waiting list.”

In Northern Sydney alone, reductions in length of stay in 2013-14 saved $92 million, which was used to treat more patients or reinvest elsewhere in health services.

There are many competing and complementary strategies in play to affect those factors, Hehir says:

“However, the impact of some local and statewide initiatives on length of stay and unplanned readmissions are not well understood and quantified due to the lack of evaluations conducted.

“Health services and programs provided out of hospital may support the reduction of length of stay and unplanned readmissions, by enabling earlier discharge and keeping patients in good health to reduce the need for future hospitalisation.

“A key enabler to the success of initiatives is good information sharing and exchange between in-hospital services and out-of-hospital services. NSW Health has introduced HealtheNet to enable the sharing of patient records between public hospitals and primary and community care providers. HealtheNet has not currently been rolled out to all Local Health Districts.”

Despite a lack of consistent documentation, Hehir found approximately 25% of unplanned readmissions were related to deficiency of hospital care. Managers at local health districts are not using the data on unplanned readmissions in the same they are using length of stay data to better manage their intake in what Hehir calls a “culture of continuous improvement” witnessed at the local health districts. Consequently, the audit office has recommended that NSW Health address the measuring of unplanned readmissions.

NSW Health has developed business intelligence portal to facilitate activity based funding. When fully rolled out, all local health districts will be able to use the portal to benchmark themselves against other state services on length of stay, unplanned readmissions and other indicators. Hehir found:

“Local Health Districts receive less funding if they exceed the state average for unplanned readmissions. However, this average is higher than the NSW 2021 target. Therefore, a Local Health District could exceed the NSW 2021 target without financial consequences, provided that it stayed below the state average. This appears to create an inconsistency between the performance required under NSW 2021 and by NSW Health.”

The readmission data is currently has it isn’t particularly useful either. Patients returning within 28 days are lumped into one category, regardless of whether their reason for return is related to the original service. Similarly, 28 days isn’t a good limited for some types of care where problems can occur months after discharge, such as a hip replacement. Readmissions to other hospitals is not captured at all.

Hehir has recommended the department coordinate statewide and local strategies to reduce unplanned readmissions by the end of the year. By mid-next year, the state should evaluate the effectiveness of HealtheNet in supporting continuity of patient services from hospital care to primary and community care.

Read more at The Mandarin: Doctor’s orders: agencies asked to ‘keep it simple’

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