Discharge destination and length of stay: differences between US and English hospitals for people aged 65 and over
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7440.605 (Published 11 March 2004) Cite this as: BMJ 2004;328:605All rapid responses
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The article regarding length of stay in UK vs US hospitals is not
really that revelationary as it does not explain or investigate both the
differences in care, sort of facilities available and the total deaths per
year for each diagnosis.
The UK does not have a lot of "intermediate care" facilties hence it
is unlikely to discharge there. The patients discharged home, like NZ,
will have followup at home and in followup clinics. Does this happen in
the US ?
To compare deaths in hospital when it seems that the US discharge even
quicker than NZ facilities is unfair and maybe deaths in US in
intermediate and hospital care may be better. Also time spent in
intermediate care may be beneficial to compare like with like.
The UK would dearly like to be able to discharge to lower intensity
and cost care facilities but is hampered due to there being a lot of
nursing homes full of long term stayers - hence the comparison of
socialised medicine with that funded by insurance, personal pocket or
medicare (for those lucky enough) in USA is unfair.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR- How sad to see the re-emergence of the perjorative term
"bedblocker" in your journal (1).
Jarman et al present an analysis of bed utilisation for over 65's in
the UK compared to the US.
The paper contrasts shorter hospital length of stay, greater use of
intermediate care, decreased discharge directly home, and decreased in-
hospital death rates in the US, with the UK in over 65's.
The paper appears to suggest that all these ends are desirable in
themselves. No data on quality of care, patient satisfaction or longer
term outcome are however presented.
Intermediate care remains largely unevaluated; and the data on in-
hospital mortality seem to be refuted by another paper in the same issue
showing far wider variation in US hospitals (2).
More worryingly, such patients are described as "bedblockers" in the
introduction to the paper. This unhelpful term suggests that such
(elderly) patients are merely unwelcome interlopers in acute care. As a
previous paper in this journal demonstrated, such patients are usually
detained not solely by social factors, but more commonly by treatable
medical problems (3).
Such patients require not a label, but appropriate multidisciplinary
assessment, followed by appropriate inputs be they medical,
rehabilitative, or social; not merely knee-jerk transfer to an
intermediate care facility.
Although the NSF for elderly people heavily flags up intermediate
care, it also leads with rooting out age discrimination (4). The term
"bedblocker" when applied in the context of elderly people risks
compromising that laudable objective.
1 Dr Foster's casenotes.
BMJ 2004;328:605
2 Wennberg JE, Thomson PY , Fisher ES, Stukel TA, Skinner JS, Sharp
SM, Bronner KK
Use of hospitals, physician visits, and hospice care during last six
months of life among cohorts loyal to highly respected hospitals in the
United States
BMJ 2004;328:607-10
3 Maguire PA, Taylor IC, Stout RW
Elderly patients in acute medical wards: factors predicting length of stay
in hospital
BMJ 1986;292:1251-1253
4 Department of Health
National service framework for older people
2001
Competing interests:
None declared
Competing interests: No competing interests
Our Acute Geriatric Care Unit takes care of medical and surgical
inpatients older than 65 in our hospital. We would like to present data on
our elderly surgical inpatient for the 1999-2001 period. Surgical
inpatients older than 65 are assessed by our Multidisciplinary Inpatient
Geriatric Assessment Team. All patients > 74 years are systematically
followed-up in collaboration with the surgical team. Patients 65 to 74
years are followed-up by our team only if: cognitive, functional or social
impairment and/or serious co-morbidity.
5915 were admitted on surgical wards. 83% were assessed by our team in the
first 24 hours and 61% were actively followed-up. Mean age: 74.5 years,
52% were men. Mean length of stay was 7 days. There was a 1.9% inpatient
mortality. 92.7% were discharged at home and the rest to intermediate
care.
The aim of our team is to select and assess surgical inpatients at the
earliest and medically support them to prevent any inpatient complication.
Patients who do not benefit from our geriatric care are discharged to
intermediate care soon.
Our Inpatient Surgical Geriatric Assessment Team has similar results in
mean length of stay (days)as the USA hospitals (this shorter hospital
stay allow us to have a short elective surgery waiting list)and to the UK
hospital in destination after discharge from hospital.
Competing interests:
None declared
Competing interests: No competing interests
This article attempts to put a very simple spin on what is
undoubtedly a very complex subject. Possible differences of co-morbidity
and age distribution are not discussed and the number of available beds
per head of population should at least be mentioned if people are to have
sufficient information to see what is being compared on the two sides of
the Atlantic.
I have serious misgivings about the entire basis of the article when many
of the percentage differences being discussed as highly important are less
than or of the same order as the difference in admission rates of over 20%
which the authors descibe as similar in the two groups.
Competing interests:
None declared
Competing interests: No competing interests
Dr Foster's Case Notes and political correctness
The first two case notes from Dr Foster have politically correct
messages that do not follow from their data. The hospitals with acute
stroke units or prompt access to CT scanning may have admitted patients
with a better prognosis than patients in hospitals without these
facilities. The case-mix, rather than the process of care, may have
determined the outcomes. The notes imply that process is all. The notes on
discharge destination and length of stay of elderly people conclude that
questions are raised about the appropriate use of hospital beds in the UK.
They did not present the equally valid conclusion that elderly people may
be excluded in the USA from hospital care that they need. Organisations
such as Dr Foster have a valuable role in providing medical information to
the general public and to politicians. Scientific journals like the BMJ
need to subject such organisations to continued surveillance to ensure
that their conclusions are robust.
Competing interests:
None declared
Competing interests: No competing interests