The Outliers’ Conundrum

Alvin Gore, MD

Issues of utilization management stand at the top of daily functioning of every US hospital. However, the formal studies that deal with these topics are not common. Therefore, it was especially nice to see the publication in the online journal BMC Health Services Research by a group of authors that investigated the increasing impact of LOS “outliers” in the academic hospital, which was co-authored by the immediate past President of the ACPA, Dr. Charles Locke1. Prior to this publication two of the authors — Drs. Hughes and Locke — presented the findings of this study at the Grand Rounds at my hospital, so I was able to see the ‘early preview’.

The topic of outliers is certainly not new to anyone who is reading this newsletter. While various institutions define outlier patients differently, the main issue remains unchanged: the impact of the outlier population on the LOS metric (whether or not one agrees with the use of this metric) is profoundly significant. Despite their relatively small numbers (about 1.5% of total discharges in the study, and about 3% in my institution), these patients impact another metric in a major way — that is of a combined ‘outlier patient-days product’ (outlier patient volume X average outlier LOS). For instance, at my UM Committee we now provide regular updates to the ‘outlier patient-days’ metric – when it is presented as a percentage of the entire hospital’s patient-days number, the impact could be quite significant. This issue is not limited only to major academic centers, but is just as relevant to traditional community hospitals as well.

We can certainly debate the reasons for the increasing impact of this patient subgroup. As was shown in this study, both the number of cases and their LOS have increased from 2014 to 2019. The reasons could be varied — some related to the society in general, such as an aging population, numerous socioeconomic factors particularly affecting more vulnerable patients, homelessness, the unwavering substance abuse epidemic, etc. Others relate to structural issues within the healthcare delivery system itself, such as the decreasing numbers of PCPs leading to reduced access for primary care follow-up after a hospital stay, flat numbers of skilled nursing facilities that frequently struggle to keep their doors open, access to long-term care beds and so on.

Despite the incredible technological advances in healthcare, at the end of the hospital stay it frequently comes down to very basic needs that cannot be met, leading to these patients remaining in the acute care setting.

I certainly hope that more studies like this one will come out from our midst in the future highlighting this crucial but underappreciated issue.

¹ The increasing impact of length of stay “outliers” on length of stay at an urban academic hospital | BMC Health Services Research | Full Text (biomedcentral.com) 

Dr. Alvin Gore is Physician Advisor and Director of Utilization Management at St. Joseph Health in Sonoma County, California.