LAUSR

In this issue of Medical Care, Doctoroff and Mukamal use data from the Vizient Clinical Database to examine longitudinal trends in hospital length of stay (LOS) in United States (US) academic medical centers (AMCs) between 2007 and 2016.1 Using rich all-payer data from ~90% of US AMCs, the investigators found that declines in hospital LOS recently plateaued and may even be increasing. The apparent nadir in LOS has occurred even as AMCs continue the long-term trend of reducing the proportion of admissions with LOS of <1 day, but this now is offset by an apparent expansion in the proportion of patients with LOS > 10 days occurring between 2010 and 2016. Several aspects of the current study warrant consideration. First, an arguably metaphysical consideration: should hospital LOS matter and, if yes, to whom and why? If viewed through the eyes of patients and families, a short hospital LOS is seldom a top priority.2,3 LOS does not feature prominently in most satisfaction measures for hospitalized patients.4 Patients and families rightly prioritize hard outcomes (eg, mortality) and softer outcomes of patient-reported outcome and experience measures (PROMs and PREMs). Physicians and other front-line clinicians probably would not highly prioritize LOS without encouragement from payers and hospital administration. While clinicians commonly warn patients that remaining in hospital puts patients at risk for illdefined hospital-acquired conditions and iatrogenesis (bad things will happen if you remain in hospital),5 empirical data showing that prolonged hospitalization causes adverse outcomes are weak, with significant confounding because patients with longer LOS are sicker in both measured (and most likely unmeasured) ways; I am reminded that causality and directionality are complex.6,7 In my clinical practice, I find myself increasingly uncomfortable using the risk of iatrogenesis mediated by prolonged LOS as a strategy to encourage (coerce?) reluctant patients to agree to discharge. If viewed from the perspective of society, payers, or health systems, a focus on LOS as part of a balanced scorecard is more perspicuous. From a societal standpoint, AMCs are increasingly filled to capacity, resulting in packed emergency departments and harried administrators. AMCs have embarked on aggressive expansion with recent estimates of costs of $500 million to $1 billion for hospital expansions of 400–600 beds8; these costs are ultimately passed on to payers, taxpayers, and patients. Are there other options to consider besides construction? Improving “throughput” and reducing LOS are easy suggestions, but other strategies might help too. Could AMCs and their physicians be more judicious in which patients require hospitalization and what would be the impact on LOS? It seems obvious that patients who can safely be treated without hospitalization should not be admitted.9 Yet, empirical data suggest that 10%–20% of hospital admissions could be managed safely as outpatients10; potentially avoidable admissions tend to be patients destined for a shorter LOS because of less acuity, fewer comorbid conditions, and better social support.11 In an effort to reduce