Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7426.1257 (Published 27 November 2003) Cite this as: BMJ 2003;327:1257
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There is plenty wrong with UK health and social services. Maybe we do
have something to learn from Kaiser. But I was not wholly convinced by the
analysis of Ham et al.
1. If mean length of stay for stroke and hip fracture, really was 4-5
days under Kaiser, one of 2 things must be happening. Either the care was
grossly deficient, or, more likely, patients were being transferred to
'intermediate care' or nursing home beds when in the UK they would have
been rehabilitated in hospital. But a UK nursing home would not be
recognisable to the a Californian facilities performing this function.
They are often large facilities with have their own therapy and medical
staff. What in the UK we would call a 'hospital'. This is simply a matter
of definitions and organisation, not philosophy. One reason we could not
emulate the US is that we struggle to find adequate medical, nursing and
therapy staff for these patients, and dispersing them would bring dis-
economies of scale that we could not afford.
2. The reason that patients wait in NHS beds is not because we do not
know how to plan discharges. The first problem is the ongoing problems
with arranging community home care support packages and institutional care
for those who need them. Over the 8 years I have been a consultant I have
seen social workers withdrawn from multi-disciplinary meetings on both
acute and rehabilitation wards, and a 48h notice period for home care
swell into a fortnight to get an allocated social worker and a further
fortnight to assemble the required package.
3. A further problem is with the assumption that most people want to
go home. They do, but perhaps 10-20% do not. My rehabilitation philosophy
is that we try to maximise abilities to give people choices (about
returning home) that they would not otherwise have. However, a significant
minority, or their families, have little desire to try. The assumption
that institutional care will necessarily be arranged from hospital in
these cases (and there are scant alternatives)is very wasteful of hospital
beds. Some families are also very tardy in looking for institutional care
places when requested to find them. In neither case do NHS staff have any
authority or sanction to speed the process up.
4. We know that in-patient stroke unit care (and to an extent
specialist hip fracture rehabilitation) is highly effective in improving
outcomes. Intermediate care models (often without specialist medical
support) have not been tested in the same way. We evaluated the Nottingham
Early Discharge and Rehabiltiation service by randomised controlled trial
(Age and Ageing, in press). It was highly successful. But despite us
having a stake in developing the service, as well as trying to recruit for
the trial, we found that only a few per cent of elderly patients were
suitable. We have also evaluated residential home rehabilitation -
outcomes were similar but length of stay was greatly increased in the
residential home participants. Do we believe in evidence-based policy or
not?
Ham et als analysis looks rather naive. Were they unaware of the
differences of definition, or effect of 'politically driven' secular
expectations? What did the 35 clinicians and managers who were sent to
look at Kaiser have to say? Their views are not systematically reported.
To an extent the NHS has evolved to adapt to some of the peculiar
pressures placed upon it (not least staffing and funding constraints).
There may be quick wins to be had in sorting out Social Services
responsiveness, but we won't shift the public's expectation of a hospital
bed on demand too quickly. I worry that someone as senior and
authoritative as Chris Ham may assume that structural change along the
lines of Kaiser will solve the NHSs problems. It wouldn't, it would make
things even worse.
Competing interests:
None declared
Competing interests: No competing interests
I am only able to comment on the validity of this article in
relationship to hip fracture patients. The article implies that
improvements in NHS care to these patients would occur it their length of
stay was similar to the mean of 5 days for those in the Kaiser scheme in
comparison to the 27 days in a NHS hospital for hip fracture patients. The
low length of stay for the Kaiser patients is achieved by transferring
almost all hip fracture patients to step down facilities, which are not
classified as ‘hospital stay’. The contrasts with the majority of the NHS
patients being discharged directly home.
Dose these utilisations of step down facilities improve the outcome
for hip fracture patients or reduce costs? There is very little published
material on the topic.
Fitzgerald, Moore and Dittus 1988, reported a mean hospital stay of 10
days in the USA, with 49% of hip fracture patients being transferred to
step down facilities and 39% of these patients still being there six
months later. Comparison on costs for hip fracture care is even more
difficult to achieve. A cost of hip fracture care of 17,500 US dollars was
quoted in 1997 (Brinsky et al 1997). This compares with our estimate of
around 5000 UK pounds in 1993.
These figures are only rough estimates and until more carefully
conducted studies are undertaken regarding the outcomes and costs for hip
fracture care between the different health systems or models of care, it
is inappropriate to suggest that shorter hospital stays are the better way
to manage hip fracture patients.
References
Brainsky A, Glick H, Lydick E, Epstein R, Fox KM, Hawkes W et al. The
economic cost of hip fractures in community-dwelling older adults: a
prospective study. J Am Ger Soc 1997;45:281-287.
Fitzgerald JF, Moore PS, Dittus RS. The care of elderly patients with
hip fracture: changes since implementation of the prospective payment
system. N Engl J Med 1988;319:1392-1397.
Hollingworth W, Todd C, Parker MJ, Roberts JA, Williams R. Cost
analysis of early discharge after hip fracture. Br Med J 1993;307:903-6.
Competing interests:
None declared
Competing interests: No competing interests
Ham and colleagues are to be congratulated on triggering healthy
debate on utilisatrion of beds in the NHS. Whilst the data is lacking in
quality comparators, it is clear that Kaiser Permanente manage their
acute hospital beds more efficiently. So why do we seem reluctant to
learn from others who may be doing better? Should the response not be –
how can we do better? Are some of the inefficiencies and waste we see in
our current system merely a reflection of how we are electing to practice
– clinicians and managers working within artificial organisational and
professional boundaries whilst patients are “packaged and posted” between
different parts of a system which fails to allow vital information to flow
seamlessly with the individual.
Pursuing Perfection is a programme being led by the Institute of
Health Care Improvement (IHI) in Boston, USA. 4 UK sites are currently
working with the NHS Modernisation Agency and the IHI to challenge our
current thinking by setting ambitious goals for services extending across
organisations and providing real time objective measurement of
improvement. Lambeth and Southwark represent one health and social care
community which has committed itself to this pursuit of perfection. 1 year
down the line we are already starting to see significant improvements
locally:
- reduction in LOS for elective knee replacement from 11 days to 5
days (the ambition is day case joint replacement)
- reduction in LOS for all COPD patients from 14.4 days to 6 days
- improvement in quality of prescribing for older people using a
national audit tool from 81% to 98% on a composite measure of 5 quality
prescribing indicators
- reduction in A&E attendance and hospital admission for older
people who are actively case managed in primary care
- reduction in readmission rates for older people
- active involvement of patients in the management of their own
disease and in the redesign of local services
Much of the success to date has been through providing clinical teams
with time and space to improve their own services and arming them with
tried and tested improvement techniques to help achieve goals that are
jointly set by patients and clinicians. Teams are actively encouraged to
learn from others nationally and internationally and create local context
to information gathered. Timely access to data displayed in an easily
digestible format has proved invaluable.
Gone are the days for us when we invest time and energy defending
mediocre services. So much can be achieved by learning from others who are
doing better. Why shouldn’t we strive to deliver the best care for our
patients.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Chris Ham et al state both in their abstract and the body of their
paper that the NHS can learn from Kaiser Permanente's methods. This
implies that these methods are transferable to the NHS with benefit. They
provide no evidence for this assertion, nor was it one of the study's
objectives.
Should the BMJ be more careful about 'spin', especially in papers
with roots in the Department of Health?
Yours faithfully,
Michael Lewis
GP Principal
Competing interests: none.
Reference.
1.Ham C, York N, Shaw R, Sutch S. Hospital bed utilisation in the
NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine
data.
BMJ 2003; 327:1257-60.
Competing interests:
None declared
Competing interests: No competing interests
Ham et al(1) have replicated data suggesting that bed day use is
three times longer in the NHS than in the Californian health maintenance
organisation Kaiser Permanente, for a variety of medical conditions in
over 65s. However, they have not apparently controlled for great old age
or psychiatric co-morbidity (particularly dementia), which are both major
causes of delayed discharge in older people(2). This may undermine their
broad conclusion that the NHS could learn from Kaiser Permanente, for two
reasons. Firstly, patients with dementia are likely to be excluded by
health maintenance organisations. Secondly, Ham et al have not specified
the age profile of the over 65s; dementia is an age sensitive condition,
rare at age 65, doubling in prevalence every 5 years thereafter.
If there were more very elderly people with co-morbidity admitted to
hospital in the NHS than in California, the populations are not strictly
comparable.
There is an obvious problem with delayed discharge of elderly people
in the NHS. The solution may lie not in Californian methods of health
care, but in improving hospital and community dementia care in the UK.
Yours sincerely
JERRY SEYMOUR
CONSULTANT IN OLD AGE PSYCHIATRY
(1) Ham, C., York, N., Sutch, S., Shaw, R. Hospital
bed utilisation in the NHS, Kaiser
Permanente, and the US Medicare programme :
analysis of routine data.
BMJ 2003; 327 : 1257-60.
(2) Holmes, J., Butley, K., Cameron, I. Between two
stools : Psychiatric services
for older people in General Hospitals.
Report of a UK Survey. University of Leeds, 2002
Competing interests:
None declared
Competing interests: No competing interests
How are we to reconcile two recent BMJ articles? The first examined
bed stay in the state of California - one of the most affluent economies
in the world (1). The second looked at guidelines for deprived patients in
the UK (2). Smith stated in an editorial that there were four different
methods to fund health care (3). One extreme was in the UK where one
provider covers the whole population with state sponsored care. The
opposite was found in the USA, which has non-compulsory health care
insurance with many providers, where the poor may not be covered. The UK
provides health care, irrespective of affluence, but deprived patients
need special consideration. Any model of health care must include these
patients if it is to be relevant to the UK. We must start with a bottom-up
approach for planning and analysis of service. Universal figures for
whole or selected populations are misleading as they examine neither
social implications nor allow subgroup analysis where variations of
practice occur.
Deprivation can be measured. It is possible to determine the
suitability of each patient and family for reduced post-operative stay.
Guidelines such as those of the College of Surgeons of England for day
case surgery include consideration of social conditions (5). Using a
patient-centred approach, we built a model for extending day case surgery
to children undergoing tonsillectomy (6). Over 95% of patients in the
most affluent quintile were suitable for day case care, whereas only 55%
of the least deprived were. Various factors were built into the model.
The risks of postoperative complications were modeled from audit and
literature review. The general health of the patient was measured by the
American Society of Anesthetists (ASA) grade. The demographics of the
population included the distance from the hospital, car ownership and
number of adults resident. When the model is applied to aging adults, the
proportion found to be medically unsuitable will be higher than in normal
children (2%).
Orthopaedic surgeons at the Royal Orthopaedic Hospital in Birmingham
use a similar approach. They have developed a community service for
adults following major joint replacement. Patients who are grade ASA I or
II, and have appropriate social conditions for community care have a stay
of only four days (70% of adults, personal communication). This is similar
to that seen in California. The remainder require longer hospital stay.
Practice varies within the UK and members of medical teams should take
their social and medical responsibilities seriously to provide safe
patient-centred care.
I note that there were no additional funds for the California project
and this sounds remarkably like a politician’s comment!
1. Ham C, York N, Sutch S, Shaw R. Hospital bed utilization in the
HNS, Kaiser Permanente, and the US Medicare programme: analysis of routine
data. BMJ. 2003; 327: 1257- 1260
2. Aldrich R, Kemp L, Stewart J et al. Using socioeconomic evidence in
clinical guidelines. BMJ. 2003; 327: 1283-1285
3. Smith R. The future of health care systems. 1997; 314: 1495-1496
4. Anon. Guidelines for Day Surgery. Royal College of Surgeons of
England. 1992.
5. Drake-Lee A, Harris S. Social conditions and paediatric day case
tonsillectomy. Journal of Health Service Research and Policy. 1999; 4:
101- 105
Competing interests:
None declared
Competing interests: No competing interests
The comparison of the bed utilization in the NHS vs. Kaiser
Permanente(1) suggests the NHS could improve drastically its management of
beds. However the analysis leaves open the possibility that it could be
expensive for the NHS in effort and money to reach the levels of
efficiency at Kaiser. But we already have a body of direct evidence from
other statistics within the NHS that suggest very large improvements are
possible and likely to be cheap to implement. These statistics are
reinforced by the early results of some modelling exercises we are
currently conducting that focus on the impact of key practices in how
hospitals manage beds.
We know, for example, that length of stay (LOS) varies a great deal
in different hospitals (and for reasons not readily explained by
demographics or differences in specialisations). We also know that within
most hospitals the expected length of stay varies by around one day
depending on which day you arrive(2) (a pattern with no conceivable
clinical justification).
Our models (which build a picture of hourly bed utilization given
known patterns of emergency arrivals - which are somewhat random, elective
arrivals - which are at least in principle subject to management control,
and discharges - which are definitely under management control) suggest
that the observed variations are largely due to the widespread practice of
not discharging many patients at weekends. Given a hospital with a length
of stay of about 7 days (about average), the consequence of not
discharging patients on Saturday and Sunday is to waste at least 30% of
the effective bed capacity.
Active management of discharges and planned arrivals is key to making
gains in bed management, but the evidence we have suggests that few
hospitals make any attempt to manage either: in many trusts elective
“planned” arrivals are more variable than (and uncoordinated with)
emergency arrivals. Discharge during weekends requires either consultants
to run discharge rounds or to set criteria for nurse-led discharges.
Neither of these is an expensive change.
We know that large improvements are possible and not just theoretical, as
some hospitals have achieved them by applying active management to the
arrival and discharge processes. The converse is also true: with no active
management, adding more beds often reduces performance (throughput goes
down, LOS goes up).
We know how to improve bed management in the NHS and it is not
expensive. The biggest barrier is not a lack of resources but a deep-
rooted unwillingness to change working practices for the benefit of
patients.
1. Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the
NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine
data. Br Med J 2003;327:1257-1260.
2. Audit Commission. Acute hospital portfolio: bed management -
review of national findings. London: Audit Commission; 2003.
Competing interests:
None declared
Competing interests: No competing interests
Editor,
NHS has declared loud and clear that it is a learning organisation
and would work more proactively with partners to become a consistent, high
commitment, learning organisation (1). In a recent statement (2) the
Secretary of State for Health warned the critics who are opposed to
learning from a different health care system and emphasised that
preparedness to learn and improve is a sign of strength, not of weakness.
He also listed the five lessons that the NHS could learn from Kaiser
Permanente, USA, and the most relevant lesson being integration of health
care provision.
We have a tendency to dismiss totally or view with great scepticism
any issues being championed by senior NHS managers or politicians assuming
that the hidden agenda is to cut costs. In our enthusiasm to safeguard
patient care, we should not rush to veto initiatives from other health
care systems. One of the criticisms (3) of the paper by Ham et al (BMJ Nov
29) is that no evidence has been presented for the conclusion “that Kaiser
has accomplished its better acute bed utilisation “through integration of
care, active management of patients, the use of intermediate care, self
care and medical leadership”.
Ham et al do state in their methods that to understand the reasons
for difference in bed days, one of the authors interviewed senior clinical
and managerial staff including visits to Kaiser medical facilities. This
type of qualitative data is hard to summarise and present in a
quantitative manner. However, there is empirical evidence to show that
Kaiser’s Chronic Care Programme Management targeting diabetes,
hyperlipidemia, asthma and congestive heart failure has reduced emergency
department visits. From 1996 to 2000, the emergency department visit rate
for Kaiser patients declined from 10 per 100 persistent asthmatics to four
(4). In a randomised controlled trail in Kaiser Health Plan’s facility in
Pleasanton, California (5) a multidisciplinary outpatient diabetes care
management delivered by a diabetes nurse educator, a psychologist, a
nutritionist, and a pharmacist in cluster visit settings of 10-18 patients
per month for 6 months reduced both inpatient and outpatient utilization.
Kaiser is also the market leader in providing and implementing self-
management support for patients (6).
In the 21st century NHS, we should be open to new ideas and
innovations from anywhere including market economies and in the case of
Kaiser we should not throw the baby out with the bath water. In our
efforts to reject the principles of market economy from the US health care
system, we should not refuse to learn the good practices from across the
Atlantic, which will ultimately benefit our patients. To quote the
Secretary of State “To refuse to learn at all is to commit an institution
to steady decline. The NHS is a strong powerful social force in British
society. It has the capacity and the strength to learn from the market
just as it has the capacity and strength not to copy it".
I would like to point out here that Political and Managerial
Champions are as important as Clinical Champions to deliver the best
possible service to the communities we serve. If we stand by and ignore
the opportunities to learn from other systems, then health care historians
will blame us for not bringing the best to our clients.
References
1.‘Working Together – Learning Together’. A Framework for Life Long
Learning in the NHS. http://www.doh.gov.uk/lifelonglearning/ accessed on
6th December 2003.
2.THE NHS MUST LEARN FROM OTHER HEALTHCARE SYSTEMS – REID. DOH press
release, Tuesday 4th November 2003.
http://www.info.doh.gov.uk/doh/intpress.nsf/page/2003-0423?OpenDocument.
accessed on 6th December 2003.
3. Evans DA. Debate about Kaiser needs transparency and hard
evidence. BMJ rapid response, 3rd December.
http://bmj.bmjjournals.com/cgi/eletters/327/7426/1257#42194 accessed on
6th December.
4. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for
patients with chronic illness. JAMA. 2002;288:1775-9.
5. Sadur CN, Moline N, Costa M, et al. Diabetes management in a
health maintenance organization. Efficacy of care management using cluster
visits. Diabetes Care. 1999;22:2011-7. Full text free access
http://care.diabetesjournals.org/cgi/reprint/22/12/2011.pdf
6. Glasgow RE, Davis CL, Funnell MM, Beck A. Implementing practical
interventions to support chronic illness self-management. Jt Comm J Qual
Saf. 2003;29:563-74.
(The views expressed here are that of the author only and not of his
employer or other associated organisations/institutions)
Competing interests:
The author is a keen believer in some of the principles and methods of health care delivery by Kaiser and has approached the Unit headed by Professor Chris Ham for a letter of support to spend a month in a Kaiser organisation to learn from observation and interaction.
Competing interests: No competing interests
Ham and colleagues report that bed-days used for a range of common
diagnoses among people aged 65 years and over are substantially higher in
the NHS than in United States managed care programmes.[1] They conclude
that the NHS can learn from Kaiser Permanente Medical Care Programme’s
integrated model.
Stroke admissions contribute most to the extra bed-days in the NHS
and also show the largest relative differences from the USA comparators
used in the analysis. Since admissions for stroke are driven by the
incidence of stroke, one would expect countries with a high incidence of
stroke to have high admission rates. Comparable incidence rates are not
available, but mortality, which serves as a reasonable proxy for
incidence, shows that the USA has much lower rates of stroke than the UK;
age-adjusted stroke mortality rates in the USA are about 35% and 49% lower
at ages 35-74 and 75-84 years respectively.[2]
The analysis presented here shows that despite the lower risk of
stroke, admission rates for Medicare in California and USA are about 45%
higher than the NHS rates, and Kaiser’s rates are broadly similar. It
seems likely that the higher Medicare stroke admission rates in the face
of lower incidence is due to a higher proportion of re-admissions among US
stroke patients that among NHS patients. A considerable proportion of the
longer average stay for NHS patients must simply represent the fact that
more British patients are admitted only once, rather than repeatedly.
Furthermore, the NHS bed-days include days spent in intermediate care
beds, but these post-acute bed-days are not included for the US data.
Randomised controlled trials of stroke units demonstrate clear
benefits in terms of long-term disability and mortality, with none of the
trials in a Cochrane systematic review reporting median lengths of stay of
less than 13 days.[3] It seems implausible that high quality stroke care
is consistent with US managed care stays of only 4 to 6 days. It is
perfectly possible to discharge elderly people with strokes (and other
conditions) from acute hospitals very rapidly, but if the consequences are
a failure to apply effective clinical interventions and rapid re-
admissions this hardly constitutes successful management. Ham et al
suggest that patients should be “co-providers” of their care. The vision
of stroke patients admitted, then readmitted to hospital would be a
perfect satire on the “cost is all” view of “saving” the NHS, if it were
not clear that this message would be greeted enthusiastically by
government.
1. Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the
NHS, Kaiser Permanente,and the US Medicare programme: analysis of routine
data. BMJ 2003;327:
2. Sarti C, Rastenyte D, Cepaitis Z, Tuomilehto J. International
trends in mortality from stroke, 1968 to 1994. Stroke 2000;31:1588-1601
3. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke
unit) care for stroke (Cochrane Review). In: The Cochrane Library, Issue
3, 2003. Oxford: Update Software
Competing interests:
None declared
Competing interests: No competing interests
Incidence / Prevalence OUGHT to affect bed use
Ham et al, in a detailed and thorough effort to
compare like-with-like and avoid bias, have certainly caused me to see what I
can learn from Kaiser ! I happen to
believe that NHS doctors feel that they 'share' a stake in the NHS, but
their efforts are more 'compartmented' than integrated.. Already considerable incentives to keep
people out of hospital (eg: NO BEDS ! , GP quality payments, etc. ) would be
further enhanced by local PCT empowerment of 'GP purchasing' , using a
neo-fundholding model, under a system
of NHS Tariffs ( an idea I proposed to Chris Ham 10 years ago ! ). It is not that primary and secondary
care have to be 'integrated' (some hope
! ) , but rather that one 'purchasing' power overseeing the whole
patient-pathway provides the efficiency Kaiser seems to have.
In the paper, I noticed that the sum total of bed-days used for all 4 heart conditions
(Coronary bypass, MI, heart failure, Angina)
is much the same per 100,000 population under both systems, although
under Kaiser it appears that this usage comprises more frequent admission, for
shorter stays. Acknowledging that
unseen bed-usage differences ( beds 'outside' each system , eg. private or
intermediate-care) might bias, Ham shows, at least for 'within-system'
bed-usage, that average bed-days usedper 100,000 population, for
each of 11 'health-needs', is very much less under Kaiser, than under the NHS.
Professor Shah Ebrahim , in his 'Rapid Response ' , said
"Since admissions for stroke are driven by the incidence of stroke,
one would expect countries with a high incidence of stroke to have high
admission rates. Comparable incidence rates are not available, but mortality,
which serves as a reasonable proxy for incidence, shows that the USA has much
lower rates of stroke than the UK; age-adjusted stroke mortality rates in the
USA are about 35% and 49% lower at ages 35-74 and 75-84 years respectively.[2]
". This set me thinking that
significant 'incidence' and 'prevalence' differences between the two healthcare
systems might introduce bias which fundamentally undermines the paper's
conclusion..
Incidence
Bias :- What if there
are only half as many strokes in the Kaiser population, in the period ? The comparison between each system's bed-usage-per-stroke could show a reversed position.
Prevalence
Bias :- What
if the number of over-65's with
ischaemic heart disease is twice as high in the NHS as it is in Kaiser ?
This could mean that bed usageper ischaemic person in the NHS would be half that of Kaiser.
Is it possible to incorporate Incidence / Prevalence
comparisons into a re-analysis ?
Yours sincerely,
Dr L S Lewis
Surgery
Newport
Pembrokeshire
Competing interests:
I work for the NHS
Competing interests: No competing interests