Proton pump inhibitors (PPIs) are the third most commonly prescribed class of medication in the United States, with $13.6 billion in yearly sales.1 Despite their effectiveness in treating acid reflux2 and their mortality benefit in the treatment of patients with gastrointestinal bleeding,3 recent literature has identified a number of risks associated with PPIs, including an increased incidence of Clostridium difficile infection,4 decreased effectiveness of clopidogrel in patients with acute coronary syndrome,5 increased risk of community‐ and hospital‐acquired pneumonia, and an increased risk of hip fracture.69 Additionally, in March of 2011, the US Food and Drug Administration (FDA) issued a warning regarding the potential for PPIs to cause low magnesium levels which can, in turn, cause muscle spasms, an irregular heartbeat, and convulsions.10

Inappropriate PPI prescription practice has been demonstrated in the primary care setting,11 as well as in small studies conducted in the hospital setting.1216 We hypothesized that many hospitalized patients receive these medications without having an accepted indication, and examined 2 populations of hospitalized patients, including administrative data from 6.5 million discharges from US university hospitals, to look for appropriate diagnoses justifying their use.

METHODS

We performed a retrospective review of administrative data collected between January 1, 2008 and December 31, 2009 from 2 patient populations: (a) those discharged from Denver Health (DH), a university‐affiliated public safety net hospital in Denver, CO; and (b) patients discharged from 112 academic health centers and 256 of their affiliated hospitals that participate in the University HealthSystem Consortium (UHC). The Colorado Multiple Institution Review Board reviewed and approved the conduct of this study.

Inclusion criteria for both populations were age >18 or <90 years, and hospitalization on a Medicine service. Prisoners and women known to be pregnant were excluded. In both cohorts, if patients had more than 1 admission during the 2‐year study period, only data from the first admission were used.

We recorded demographics, admitting diagnosis, and discharge diagnoses together with information pertaining to the name, route, and duration of administration of all PPIs (ie, omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole). We created a broadly inclusive set of valid indications for PPIs by incorporating diagnoses that could be identified by International Classification of Diseases, Ninth Revision.

(ICD‐9) codes from a number of previously published sources including the National Institute of Clinical Excellence (NICE) guidelines issued by the National Health Service (NHS) of the United Kingdom in 200012, 1721 (Table 1).

To assess the accuracy of the administrative data from DH, we also reviewed the Emergency Department histories, admission histories, progress notes, electronic pharmacy records, endoscopy reports, and discharge summaries of 123 patients randomly selected (ie, a 5% sample) from the group of patients identified by administrative data to have received a PPI without a valid indication, looking for any accepted indication that might have been missed in the administrative data.

All analyses were performed using SAS Enterprise Guide 4.1 (SAS Institute, Cary, NC). A Student t test was used to compare continuous variables and a chi‐square test was used to compare categorical variables. Bonferroni corrections were used for multiple comparisons, such that P values less than 0.01 were considered to be significant for categorical variables.

RESULTS

Inclusion criteria were met by 9875 patients in the Denver Health database and 6,592,100 patients in the UHC database. The demographics and primary discharge diagnoses for these patients are summarized in Table 2.

Only 39% and 27% of the patients in the DH and UHC databases, respectively, had a valid indication for PPIs on the basis of discharge diagnoses (Table 3). In the DH data, if admission ICD‐9 codes were also inspected for valid PPI indications, 1579 (40%) of patients receiving PPIs had a valid indication (admission ICD‐9 codes were not available for patients in the UHC database). Thirty‐one percent of Denver Health patients spent time in the intensive care unit (ICU) during their hospital stay and 65% of those patients received a PPI without a valid indication, as compared to 59% of patients who remained on the General Medicine ward (Table 3).

Higher rates of concurrent C. difficile infections were observed in patients receiving PPIs in both databases; a higher rate of concurrent diagnosis of pneumonia was seen in patients receiving PPIs in the UHC population, with a nonsignificant trend towards the same finding in DH patients (Table 4).

Chart review in the DH population found valid indications for PPIs in 19% of patients who were thought not have a valid indication on the basis of the administrative data (Table 5). For 56% of those in whom no valid indication was confirmed, physicians identified prophylaxis as the justification.

DISCUSSION

The important finding of this study was that the majority of patients in 2 large groups of Medicine patients hospitalized in university‐affiliated hospitals received PPIs without having a valid indication. To our knowledge, the more than 900,000 UHC patients who received a PPI during their hospitalization represent the largest inpatient population evaluated for appropriateness of PPI prescriptions.

Our finding that 41% of the patients admitted to the DH Medicine service received a PPI during their hospital stay is similar to what has been observed by others.9, 14, 22 The rate of PPI prescription was lower in the UHC population (14%) for unclear reasons. By our definition, 61% lacked an adequate diagnosis to justify the prescription of the PPI. After performing a chart review on a randomly selected 5% of these records, we found that the DH administrative database had failed to identify 19% of patients who had a valid indication for receiving a PPI. Adjusting the administrative data accordingly still resulted in 50% of DH patients not having a valid indication for receiving a PPI. This is consistent with the 54% recorded by Batuwitage and colleagues11 in the outpatient setting by direct chart review, as well as a range of 60%‐75% for hospitalized patients in other studies.12, 13, 15, 23, 24

Stomach acidity is believed to provide an important host defense against lower gastrointestinal tract infections including Salmonella, Campylobacter, and Clostridium difficile.25 A recent study by Howell et al26 showed a doseresponse effect between PPI use and C. difficile infection, supporting a causal connection between loss of stomach acidity and development of Clostridium difficile‐associated diarrhea (CDAD). We found that C. difficile infection was more common in both populations of patients receiving PPIs (although the relative risk was much higher in the UHC database) (Table 5). The rate of CDAD in DH patients who received PPIs was 2.6 times higher than in patients who did not receive these acid suppressive agents.

The role of acid suppression in increasing risk for community‐acquired pneumonia is not entirely clear. Theories regarding the loss of an important host defense and bacterial proliferation head the list.6, 8, 27 Gastric and duodenal bacterial overgrowth is significantly more common in patients receiving PPIs than in patients receiving histamine type‐2 (H2) blockers.28 Previous studies have identified an increased rate of hospital‐acquired pneumonia and recurrent community‐acquired pneumonia27 in patients receiving any form of acid suppression therapy, but the risk appears to be greater in patients receiving PPIs than in those receiving H2 receptor antagonists (H2RAs).9 Significantly more patients in the UHC population who were taking PPIs had a concurrent diagnosis of pneumonia, consistent with previous studies alerting to this association6, 8, 9, 27 and consistent with the nonsignificant trend observed in the DH population.

Our study has a number of limitations. Our database comes from a single university‐affiliated public hospital with residents and hospitalists writing orders for all medications. The hospitals in the UHC are also teaching hospitals. Accordingly, our results might not generalize to other settings or reflect prescribing patterns in private, nonteaching hospital environments. Because our study was retrospective, we could not confirm the decision‐making process supporting the prescription of PPIs. Similarly, we could not temporarily relate the existence of the indication with the time the PPI was prescribed. Our list of appropriate indications for prescribing PPIs was developed by reviewing a number of references, and other studies have used slightly different lists (albeit the more commonly recognized indications are the same), but it may be argued that the list either includes or misses diagnoses in error.

While there is considerable debate about the use of PPIs for stress ulcer prophylaxis,29 we specifically chose not to include this as one of our valid indications for PPIs for 4 reasons. First, the American Society of Health‐System Pharmacists (ASHP) Report does not recommend prophylaxis for non‐ICU patients, and only recommends prophylaxis for those ICU patients with a coagulopathy, those requiring mechanical ventilation for more than 48 hours, those with a history of gastrointestinal ulceration or bleeding in the year prior to admission, and those with 2 or more of the following indications: sepsis, ICU stay >1 week, occult bleeding lasting 6 or more days, receiving high‐dose corticosteroids, and selected surgical situations.30 At the time the guideline was written, the authors note that there was insufficient data on PPIs to make any recommendations on their use, but no subsequent guidelines have been issued.30 Second, a review by Mohebbi and Hesch published in 2009, and a meta‐analysis by Lin and colleagues published in 2010, summarize subsequent randomized trials that suggest that PPIs and H2 blockers are, at best, similarly effective at preventing upper gastrointestinal (GI) bleeding among critically ill patients.31, 32 Third, the NICE guidelines do not include stress ulcer prophylaxis as an appropriate indication for PPIs except in the prevention and treatment of NSAID [non‐steroidal anti‐inflammatory drug]‐associated ulcers.19 Finally, H2RAs are currently the only medications with an FDA‐approved indication for stress ulcer prophylaxis. We acknowledge that PPIs may be a reasonable and acceptable choice for stress ulcer prophylaxis in patients who meet indications, but we were unable to identify such patients in either of our administrative databases.

In our Denver Health population, only 31% of our patients spent any time in the intensive care unit, and only a fraction of these would have both an accepted indication for stress ulcer prophylaxis by the ASHP guidelines and an intolerance or contraindication to an H2RA or sulcralfate. While our administrative database lacked the detail necessary to identify this small group of patients, the number of patients who might have been misclassified as not having a valid PPI indication was likely very small. Similar to the findings of previous studies,15, 18, 23, 29 prophylaxis against gastrointestinal bleeding was the stated justification for prescribing the PPI in 56% of the DH patient charts reviewed. It is impossible for us to estimate the number of patients in our administrative database for whom stress ulcer prophylaxis was justified by existing guidelines, as it would be necessary to gather a number of specific clinical details for each patient including: 1) ICU stay; 2) presence of coagulopathy; 3) duration of mechanical ventilation; 4) presence of sepsis; 5) duration of ICU stay; 6) presence of occult bleeding for >6 days; and 7) use of high‐dose corticosteroids. This level of clinical detail would likely only be available through a prospective study design, as has been suggested by other authors.33 Further research into the use, safety, and effectiveness of PPIs specifically for stress ulcer prophylaxis is warranted.

In conclusion, we found that 73% of nearly 1 million Medicine patients discharged from academic medical centers received a PPI without a valid indication during their hospitalization. The implications of our findings are broad. PPIs are more expensive31 than H2RAs and there is increasing evidence that they have significant side effects. In both databases we examined, the rate of C. difficile infection was higher in patients receiving PPIs than others. The prescribing habits of physicians in these university hospital settings appear to be far out of line with published guidelines and evidence‐based practice. Reducing inappropriate prescribing of PPIs would be an important educational and quality assurance project in most institutions.

Proton pump inhibitors (PPIs) are the third most commonly prescribed class of medication in the United States, with $13.6 billion in yearly sales.1 Despite their effectiveness in treating acid reflux2 and their mortality benefit in the treatment of patients with gastrointestinal bleeding,3 recent literature has identified a number of risks associated with PPIs, including an increased incidence of Clostridium difficile infection,4 decreased effectiveness of clopidogrel in patients with acute coronary syndrome,5 increased risk of community‐ and hospital‐acquired pneumonia, and an increased risk of hip fracture.69 Additionally, in March of 2011, the US Food and Drug Administration (FDA) issued a warning regarding the potential for PPIs to cause low magnesium levels which can, in turn, cause muscle spasms, an irregular heartbeat, and convulsions.10

Inappropriate PPI prescription practice has been demonstrated in the primary care setting,11 as well as in small studies conducted in the hospital setting.1216 We hypothesized that many hospitalized patients receive these medications without having an accepted indication, and examined 2 populations of hospitalized patients, including administrative data from 6.5 million discharges from US university hospitals, to look for appropriate diagnoses justifying their use.

METHODS

We performed a retrospective review of administrative data collected between January 1, 2008 and December 31, 2009 from 2 patient populations: (a) those discharged from Denver Health (DH), a university‐affiliated public safety net hospital in Denver, CO; and (b) patients discharged from 112 academic health centers and 256 of their affiliated hospitals that participate in the University HealthSystem Consortium (UHC). The Colorado Multiple Institution Review Board reviewed and approved the conduct of this study.

Inclusion criteria for both populations were age >18 or <90 years, and hospitalization on a Medicine service. Prisoners and women known to be pregnant were excluded. In both cohorts, if patients had more than 1 admission during the 2‐year study period, only data from the first admission were used.

We recorded demographics, admitting diagnosis, and discharge diagnoses together with information pertaining to the name, route, and duration of administration of all PPIs (ie, omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole). We created a broadly inclusive set of valid indications for PPIs by incorporating diagnoses that could be identified by International Classification of Diseases, Ninth Revision.

(ICD‐9) codes from a number of previously published sources including the National Institute of Clinical Excellence (NICE) guidelines issued by the National Health Service (NHS) of the United Kingdom in 200012, 1721 (Table 1).

To assess the accuracy of the administrative data from DH, we also reviewed the Emergency Department histories, admission histories, progress notes, electronic pharmacy records, endoscopy reports, and discharge summaries of 123 patients randomly selected (ie, a 5% sample) from the group of patients identified by administrative data to have received a PPI without a valid indication, looking for any accepted indication that might have been missed in the administrative data.

All analyses were performed using SAS Enterprise Guide 4.1 (SAS Institute, Cary, NC). A Student t test was used to compare continuous variables and a chi‐square test was used to compare categorical variables. Bonferroni corrections were used for multiple comparisons, such that P values less than 0.01 were considered to be significant for categorical variables.

RESULTS

Inclusion criteria were met by 9875 patients in the Denver Health database and 6,592,100 patients in the UHC database. The demographics and primary discharge diagnoses for these patients are summarized in Table 2.

Only 39% and 27% of the patients in the DH and UHC databases, respectively, had a valid indication for PPIs on the basis of discharge diagnoses (Table 3). In the DH data, if admission ICD‐9 codes were also inspected for valid PPI indications, 1579 (40%) of patients receiving PPIs had a valid indication (admission ICD‐9 codes were not available for patients in the UHC database). Thirty‐one percent of Denver Health patients spent time in the intensive care unit (ICU) during their hospital stay and 65% of those patients received a PPI without a valid indication, as compared to 59% of patients who remained on the General Medicine ward (Table 3).

Higher rates of concurrent C. difficile infections were observed in patients receiving PPIs in both databases; a higher rate of concurrent diagnosis of pneumonia was seen in patients receiving PPIs in the UHC population, with a nonsignificant trend towards the same finding in DH patients (Table 4).

Chart review in the DH population found valid indications for PPIs in 19% of patients who were thought not have a valid indication on the basis of the administrative data (Table 5). For 56% of those in whom no valid indication was confirmed, physicians identified prophylaxis as the justification.

DISCUSSION

The important finding of this study was that the majority of patients in 2 large groups of Medicine patients hospitalized in university‐affiliated hospitals received PPIs without having a valid indication. To our knowledge, the more than 900,000 UHC patients who received a PPI during their hospitalization represent the largest inpatient population evaluated for appropriateness of PPI prescriptions.

Our finding that 41% of the patients admitted to the DH Medicine service received a PPI during their hospital stay is similar to what has been observed by others.9, 14, 22 The rate of PPI prescription was lower in the UHC population (14%) for unclear reasons. By our definition, 61% lacked an adequate diagnosis to justify the prescription of the PPI. After performing a chart review on a randomly selected 5% of these records, we found that the DH administrative database had failed to identify 19% of patients who had a valid indication for receiving a PPI. Adjusting the administrative data accordingly still resulted in 50% of DH patients not having a valid indication for receiving a PPI. This is consistent with the 54% recorded by Batuwitage and colleagues11 in the outpatient setting by direct chart review, as well as a range of 60%‐75% for hospitalized patients in other studies.12, 13, 15, 23, 24

Stomach acidity is believed to provide an important host defense against lower gastrointestinal tract infections including Salmonella, Campylobacter, and Clostridium difficile.25 A recent study by Howell et al26 showed a doseresponse effect between PPI use and C. difficile infection, supporting a causal connection between loss of stomach acidity and development of Clostridium difficile‐associated diarrhea (CDAD). We found that C. difficile infection was more common in both populations of patients receiving PPIs (although the relative risk was much higher in the UHC database) (Table 5). The rate of CDAD in DH patients who received PPIs was 2.6 times higher than in patients who did not receive these acid suppressive agents.

The role of acid suppression in increasing risk for community‐acquired pneumonia is not entirely clear. Theories regarding the loss of an important host defense and bacterial proliferation head the list.6, 8, 27 Gastric and duodenal bacterial overgrowth is significantly more common in patients receiving PPIs than in patients receiving histamine type‐2 (H2) blockers.28 Previous studies have identified an increased rate of hospital‐acquired pneumonia and recurrent community‐acquired pneumonia27 in patients receiving any form of acid suppression therapy, but the risk appears to be greater in patients receiving PPIs than in those receiving H2 receptor antagonists (H2RAs).9 Significantly more patients in the UHC population who were taking PPIs had a concurrent diagnosis of pneumonia, consistent with previous studies alerting to this association6, 8, 9, 27 and consistent with the nonsignificant trend observed in the DH population.

Our study has a number of limitations. Our database comes from a single university‐affiliated public hospital with residents and hospitalists writing orders for all medications. The hospitals in the UHC are also teaching hospitals. Accordingly, our results might not generalize to other settings or reflect prescribing patterns in private, nonteaching hospital environments. Because our study was retrospective, we could not confirm the decision‐making process supporting the prescription of PPIs. Similarly, we could not temporarily relate the existence of the indication with the time the PPI was prescribed. Our list of appropriate indications for prescribing PPIs was developed by reviewing a number of references, and other studies have used slightly different lists (albeit the more commonly recognized indications are the same), but it may be argued that the list either includes or misses diagnoses in error.

While there is considerable debate about the use of PPIs for stress ulcer prophylaxis,29 we specifically chose not to include this as one of our valid indications for PPIs for 4 reasons. First, the American Society of Health‐System Pharmacists (ASHP) Report does not recommend prophylaxis for non‐ICU patients, and only recommends prophylaxis for those ICU patients with a coagulopathy, those requiring mechanical ventilation for more than 48 hours, those with a history of gastrointestinal ulceration or bleeding in the year prior to admission, and those with 2 or more of the following indications: sepsis, ICU stay >1 week, occult bleeding lasting 6 or more days, receiving high‐dose corticosteroids, and selected surgical situations.30 At the time the guideline was written, the authors note that there was insufficient data on PPIs to make any recommendations on their use, but no subsequent guidelines have been issued.30 Second, a review by Mohebbi and Hesch published in 2009, and a meta‐analysis by Lin and colleagues published in 2010, summarize subsequent randomized trials that suggest that PPIs and H2 blockers are, at best, similarly effective at preventing upper gastrointestinal (GI) bleeding among critically ill patients.31, 32 Third, the NICE guidelines do not include stress ulcer prophylaxis as an appropriate indication for PPIs except in the prevention and treatment of NSAID [non‐steroidal anti‐inflammatory drug]‐associated ulcers.19 Finally, H2RAs are currently the only medications with an FDA‐approved indication for stress ulcer prophylaxis. We acknowledge that PPIs may be a reasonable and acceptable choice for stress ulcer prophylaxis in patients who meet indications, but we were unable to identify such patients in either of our administrative databases.

In our Denver Health population, only 31% of our patients spent any time in the intensive care unit, and only a fraction of these would have both an accepted indication for stress ulcer prophylaxis by the ASHP guidelines and an intolerance or contraindication to an H2RA or sulcralfate. While our administrative database lacked the detail necessary to identify this small group of patients, the number of patients who might have been misclassified as not having a valid PPI indication was likely very small. Similar to the findings of previous studies,15, 18, 23, 29 prophylaxis against gastrointestinal bleeding was the stated justification for prescribing the PPI in 56% of the DH patient charts reviewed. It is impossible for us to estimate the number of patients in our administrative database for whom stress ulcer prophylaxis was justified by existing guidelines, as it would be necessary to gather a number of specific clinical details for each patient including: 1) ICU stay; 2) presence of coagulopathy; 3) duration of mechanical ventilation; 4) presence of sepsis; 5) duration of ICU stay; 6) presence of occult bleeding for >6 days; and 7) use of high‐dose corticosteroids. This level of clinical detail would likely only be available through a prospective study design, as has been suggested by other authors.33 Further research into the use, safety, and effectiveness of PPIs specifically for stress ulcer prophylaxis is warranted.

In conclusion, we found that 73% of nearly 1 million Medicine patients discharged from academic medical centers received a PPI without a valid indication during their hospitalization. The implications of our findings are broad. PPIs are more expensive31 than H2RAs and there is increasing evidence that they have significant side effects. In both databases we examined, the rate of C. difficile infection was higher in patients receiving PPIs than others. The prescribing habits of physicians in these university hospital settings appear to be far out of line with published guidelines and evidence‐based practice. Reducing inappropriate prescribing of PPIs would be an important educational and quality assurance project in most institutions.

Proton pump inhibitors (PPIs) are the third most commonly prescribed class of medication in the United States, with $13.6 billion in yearly sales.1 Despite their effectiveness in treating acid reflux2 and their mortality benefit in the treatment of patients with gastrointestinal bleeding,3 recent literature has identified a number of risks associated with PPIs, including an increased incidence of Clostridium difficile infection,4 decreased effectiveness of clopidogrel in patients with acute coronary syndrome,5 increased risk of community‐ and hospital‐acquired pneumonia, and an increased risk of hip fracture.69 Additionally, in March of 2011, the US Food and Drug Administration (FDA) issued a warning regarding the potential for PPIs to cause low magnesium levels which can, in turn, cause muscle spasms, an irregular heartbeat, and convulsions.10

Inappropriate PPI prescription practice has been demonstrated in the primary care setting,11 as well as in small studies conducted in the hospital setting.1216 We hypothesized that many hospitalized patients receive these medications without having an accepted indication, and examined 2 populations of hospitalized patients, including administrative data from 6.5 million discharges from US university hospitals, to look for appropriate diagnoses justifying their use.

METHODS

We performed a retrospective review of administrative data collected between January 1, 2008 and December 31, 2009 from 2 patient populations: (a) those discharged from Denver Health (DH), a university‐affiliated public safety net hospital in Denver, CO; and (b) patients discharged from 112 academic health centers and 256 of their affiliated hospitals that participate in the University HealthSystem Consortium (UHC). The Colorado Multiple Institution Review Board reviewed and approved the conduct of this study.

Inclusion criteria for both populations were age >18 or <90 years, and hospitalization on a Medicine service. Prisoners and women known to be pregnant were excluded. In both cohorts, if patients had more than 1 admission during the 2‐year study period, only data from the first admission were used.

We recorded demographics, admitting diagnosis, and discharge diagnoses together with information pertaining to the name, route, and duration of administration of all PPIs (ie, omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole). We created a broadly inclusive set of valid indications for PPIs by incorporating diagnoses that could be identified by International Classification of Diseases, Ninth Revision.

(ICD‐9) codes from a number of previously published sources including the National Institute of Clinical Excellence (NICE) guidelines issued by the National Health Service (NHS) of the United Kingdom in 200012, 1721 (Table 1).

To assess the accuracy of the administrative data from DH, we also reviewed the Emergency Department histories, admission histories, progress notes, electronic pharmacy records, endoscopy reports, and discharge summaries of 123 patients randomly selected (ie, a 5% sample) from the group of patients identified by administrative data to have received a PPI without a valid indication, looking for any accepted indication that might have been missed in the administrative data.

All analyses were performed using SAS Enterprise Guide 4.1 (SAS Institute, Cary, NC). A Student t test was used to compare continuous variables and a chi‐square test was used to compare categorical variables. Bonferroni corrections were used for multiple comparisons, such that P values less than 0.01 were considered to be significant for categorical variables.

RESULTS

Inclusion criteria were met by 9875 patients in the Denver Health database and 6,592,100 patients in the UHC database. The demographics and primary discharge diagnoses for these patients are summarized in Table 2.

Only 39% and 27% of the patients in the DH and UHC databases, respectively, had a valid indication for PPIs on the basis of discharge diagnoses (Table 3). In the DH data, if admission ICD‐9 codes were also inspected for valid PPI indications, 1579 (40%) of patients receiving PPIs had a valid indication (admission ICD‐9 codes were not available for patients in the UHC database). Thirty‐one percent of Denver Health patients spent time in the intensive care unit (ICU) during their hospital stay and 65% of those patients received a PPI without a valid indication, as compared to 59% of patients who remained on the General Medicine ward (Table 3).

Higher rates of concurrent C. difficile infections were observed in patients receiving PPIs in both databases; a higher rate of concurrent diagnosis of pneumonia was seen in patients receiving PPIs in the UHC population, with a nonsignificant trend towards the same finding in DH patients (Table 4).

Chart review in the DH population found valid indications for PPIs in 19% of patients who were thought not have a valid indication on the basis of the administrative data (Table 5). For 56% of those in whom no valid indication was confirmed, physicians identified prophylaxis as the justification.

DISCUSSION

The important finding of this study was that the majority of patients in 2 large groups of Medicine patients hospitalized in university‐affiliated hospitals received PPIs without having a valid indication. To our knowledge, the more than 900,000 UHC patients who received a PPI during their hospitalization represent the largest inpatient population evaluated for appropriateness of PPI prescriptions.

Our finding that 41% of the patients admitted to the DH Medicine service received a PPI during their hospital stay is similar to what has been observed by others.9, 14, 22 The rate of PPI prescription was lower in the UHC population (14%) for unclear reasons. By our definition, 61% lacked an adequate diagnosis to justify the prescription of the PPI. After performing a chart review on a randomly selected 5% of these records, we found that the DH administrative database had failed to identify 19% of patients who had a valid indication for receiving a PPI. Adjusting the administrative data accordingly still resulted in 50% of DH patients not having a valid indication for receiving a PPI. This is consistent with the 54% recorded by Batuwitage and colleagues11 in the outpatient setting by direct chart review, as well as a range of 60%‐75% for hospitalized patients in other studies.12, 13, 15, 23, 24

Stomach acidity is believed to provide an important host defense against lower gastrointestinal tract infections including Salmonella, Campylobacter, and Clostridium difficile.25 A recent study by Howell et al26 showed a doseresponse effect between PPI use and C. difficile infection, supporting a causal connection between loss of stomach acidity and development of Clostridium difficile‐associated diarrhea (CDAD). We found that C. difficile infection was more common in both populations of patients receiving PPIs (although the relative risk was much higher in the UHC database) (Table 5). The rate of CDAD in DH patients who received PPIs was 2.6 times higher than in patients who did not receive these acid suppressive agents.

The role of acid suppression in increasing risk for community‐acquired pneumonia is not entirely clear. Theories regarding the loss of an important host defense and bacterial proliferation head the list.6, 8, 27 Gastric and duodenal bacterial overgrowth is significantly more common in patients receiving PPIs than in patients receiving histamine type‐2 (H2) blockers.28 Previous studies have identified an increased rate of hospital‐acquired pneumonia and recurrent community‐acquired pneumonia27 in patients receiving any form of acid suppression therapy, but the risk appears to be greater in patients receiving PPIs than in those receiving H2 receptor antagonists (H2RAs).9 Significantly more patients in the UHC population who were taking PPIs had a concurrent diagnosis of pneumonia, consistent with previous studies alerting to this association6, 8, 9, 27 and consistent with the nonsignificant trend observed in the DH population.

Our study has a number of limitations. Our database comes from a single university‐affiliated public hospital with residents and hospitalists writing orders for all medications. The hospitals in the UHC are also teaching hospitals. Accordingly, our results might not generalize to other settings or reflect prescribing patterns in private, nonteaching hospital environments. Because our study was retrospective, we could not confirm the decision‐making process supporting the prescription of PPIs. Similarly, we could not temporarily relate the existence of the indication with the time the PPI was prescribed. Our list of appropriate indications for prescribing PPIs was developed by reviewing a number of references, and other studies have used slightly different lists (albeit the more commonly recognized indications are the same), but it may be argued that the list either includes or misses diagnoses in error.

While there is considerable debate about the use of PPIs for stress ulcer prophylaxis,29 we specifically chose not to include this as one of our valid indications for PPIs for 4 reasons. First, the American Society of Health‐System Pharmacists (ASHP) Report does not recommend prophylaxis for non‐ICU patients, and only recommends prophylaxis for those ICU patients with a coagulopathy, those requiring mechanical ventilation for more than 48 hours, those with a history of gastrointestinal ulceration or bleeding in the year prior to admission, and those with 2 or more of the following indications: sepsis, ICU stay >1 week, occult bleeding lasting 6 or more days, receiving high‐dose corticosteroids, and selected surgical situations.30 At the time the guideline was written, the authors note that there was insufficient data on PPIs to make any recommendations on their use, but no subsequent guidelines have been issued.30 Second, a review by Mohebbi and Hesch published in 2009, and a meta‐analysis by Lin and colleagues published in 2010, summarize subsequent randomized trials that suggest that PPIs and H2 blockers are, at best, similarly effective at preventing upper gastrointestinal (GI) bleeding among critically ill patients.31, 32 Third, the NICE guidelines do not include stress ulcer prophylaxis as an appropriate indication for PPIs except in the prevention and treatment of NSAID [non‐steroidal anti‐inflammatory drug]‐associated ulcers.19 Finally, H2RAs are currently the only medications with an FDA‐approved indication for stress ulcer prophylaxis. We acknowledge that PPIs may be a reasonable and acceptable choice for stress ulcer prophylaxis in patients who meet indications, but we were unable to identify such patients in either of our administrative databases.

In our Denver Health population, only 31% of our patients spent any time in the intensive care unit, and only a fraction of these would have both an accepted indication for stress ulcer prophylaxis by the ASHP guidelines and an intolerance or contraindication to an H2RA or sulcralfate. While our administrative database lacked the detail necessary to identify this small group of patients, the number of patients who might have been misclassified as not having a valid PPI indication was likely very small. Similar to the findings of previous studies,15, 18, 23, 29 prophylaxis against gastrointestinal bleeding was the stated justification for prescribing the PPI in 56% of the DH patient charts reviewed. It is impossible for us to estimate the number of patients in our administrative database for whom stress ulcer prophylaxis was justified by existing guidelines, as it would be necessary to gather a number of specific clinical details for each patient including: 1) ICU stay; 2) presence of coagulopathy; 3) duration of mechanical ventilation; 4) presence of sepsis; 5) duration of ICU stay; 6) presence of occult bleeding for >6 days; and 7) use of high‐dose corticosteroids. This level of clinical detail would likely only be available through a prospective study design, as has been suggested by other authors.33 Further research into the use, safety, and effectiveness of PPIs specifically for stress ulcer prophylaxis is warranted.

In conclusion, we found that 73% of nearly 1 million Medicine patients discharged from academic medical centers received a PPI without a valid indication during their hospitalization. The implications of our findings are broad. PPIs are more expensive31 than H2RAs and there is increasing evidence that they have significant side effects. In both databases we examined, the rate of C. difficile infection was higher in patients receiving PPIs than others. The prescribing habits of physicians in these university hospital settings appear to be far out of line with published guidelines and evidence‐based practice. Reducing inappropriate prescribing of PPIs would be an important educational and quality assurance project in most institutions.

In recent years, much attention has been paid to concerns regarding length of stay (LOS) and safety of hospital discharges.13 Yet studies conducted in a variety of populations suggest that long stays do not wholly reflect acute medical necessity, but may also be driven by nonmedical factors.46 In a study of frail elderly patients, nonmedical factors accounted for over half of patients' hospital stay days.5 Nonmedical factors may include the availability of community and outpatient resources, inadequate patient social support, disagreement with family and/or patient decision‐making, and post‐hospital placement and care needs.7

Homebound patients are at particular risk for long stays because they are typically frail, elderly, and medically complex.8 The United States homebound population numbers at least 2 million and is expected to increase to at least 3 million by the year 2020.9 This group is medically underserved, often only receiving care for medical emergencies, and represents a costly group of health care beneficiaries.10 Although homebound primary care (HBPC) programs are structured to provide coordinated medical and supportive care in the home, the clinical complexity of patients often requires hospitalization during times of acute illness.11

Navigating the discharge process for homebound patients can prove time‐consuming for inpatient physicians whose clinical obligations encompass ensuring safe care transitions between hospital and home.12 The lack of literature on the discharge needs of the homebound population provides little guidance for physicians and health systems seeking to safely transition homebound patients from the hospital to the home in a timely and efficient manner. We performed a pilot study of an urban homebound population cared for by a single academic homebound program to identify and describe nonmedical factors associated with prolonged hospitalization.

METHODS

This retrospective descriptive study included homebound patients cared for by The Mount Sinai Visiting Doctors Program (MSVD), a primary care program affiliated with The Mount Sinai Hospital. MSVD is the largest academic homebound primary care program in the United States. The structure and patient population of MSVD patients have been described previously.13 Briefly, the program employs 8 physicians, 2 nurse practitioners, and support personnel including 2 registered nurses, 4 social workers, and 4 clerical staff members to serve over 1000 homebound patients annually. To be enrolled in the program, patients must meet the Medicare definition of homebound (ie, they must be able to leave home only with great difficulty and for infrequent or short absences). Patients are referred from a variety of sources including emergency rooms, inpatient units, and local nursing and social service agencies. Physicians visit patients on average once every 2 months, but can make more frequent home visits when a clinical need arises. Thirty‐six percent of patients in the program are hospitalized at least once per year while they are under the MSVD's care.14 Patients in the MSVD are referred by their primary care physician to outpatient social work as needed for finite interventions, though not for ongoing case management; approximately one‐third of all MSVD patients have been seen by an MSVD social worker over a 1‐year period.14

All patients enrolled in MSVD discharged from The Mount Sinai Hospital in New York from January 1, 2007, to December 31, 2007, were evaluated for inclusion in this study. The MSVD clinical database was cross‐referenced with The Mount Sinai Hospital data system to maximize reliability of recorded admission and discharge dates. Discrepancies in dates were investigated and corrected by the authors. As the study focused on admissions rather than individual patients, repeat hospitalizations and factors contributing to long stays were included and considered separately. In the event of repeat hospitalizations, factors contributing to LOS were also assessed separately.

Using the University HealthSystems Consortium (UHC) Database, the selected discharges were analyzed for LOS data. The UHC Database contains data from The Mount Sinai Hospital and 106 other academic medical centers and 233 other affiliated hospitals, representing approximately 90% of the United States' nonprofit academic medical centers. UHC members submit clinical, financial, and administrative information for the purpose of facilitating comparative data analysis among institutions.15 The model assigns an expected LOS for each patient based on a 4‐step risk adjustment methodology that adjusts for variations in patient characteristics. The regression models consider a range of independent variables including patient age, sex, race, socioeconomic status, admission source, and comorbid conditions. The expected LOS value is used to produce an LOS ratio, which is the ratio of a patient's observed LOS to expected LOS. We compared LOS ratios for all patient discharges during the study period and determined the mean LOS ratio for the group. Long‐stay patients were defined using the UHC definition of an LOS ratio greater than 2 standard deviations above the mean. These patients were selected for analysis to examine factors contributing to their long stays.

The primary author conducted a chart review for the long‐stay patients. The date of medical readiness for discharge was defined as the date when no acute hospital care needs or pending procedures (eg, intravenous medication, transfusion, invasive and noninvasive testing, surgery) were documented by the attending physician, house officer, nurse practitioner, or physician assistant in the chart. Patients with a discharge immediately following determination of medical readiness were characterized as having a medical stay (eg, patient admitted for pneumonia and discharged home after 3 days once fever, leukocytosis, and symptoms improved with a prescription for remaining antibiotic course). Patients who were classified as medically ready for discharge yet remained additional days in the hospital were categorized as having a nonmedical component to their hospitalization and comprised the nonmedical stay group (eg, patient admitted for pneumonia with improved vital signs and symptoms after 3 days, but discharged home after 10 days awaiting approval of increased home health aide hours). The primary author reviewed cases (<5%) with coauthors when categorization of patient data was unclear from physician documentation in the patient's chart. Similar methodology and terminology have been used in previous studies examining the contribution of nonmedical factors to LOS.5, 7

While literature in other fields, such as social work, often characterize similar factors as social or social care factors, we use the term nonmedical to draw the distinction between factors that acutely reflect a patient's state of health and necessitate days spent in the hospital (eg, surgery, infection), in contrast to factors that are not direct contributors to the patient's current medical status (eg, post‐hospital placement). Factors contributing to nonmedical days were determined based on previous studies and categorized as follows: nursing facility bed availability, nursing facility rejection of the patient, complications with insurance coverage, lack of patient/family agreement with discharge plan, home care service delays, and other. The category other was included to identify and explore any unexpected or unique reasons for prolongation of hospitalization in this population. When multiple nonmedical factors were identified for a given hospitalization, all contributing factors were recorded.

Demographic, clinical, and discharge characteristics were extracted from the MSVD clinical database to qualitatively describe and compare the long‐stay hospitalizations to the remainder of the sample.

RESULTS

There were a total of 479 discharges of 267 unique MSVD patients from The Mount Sinai Hospital occurring from January 1, 2007, to December 31, 2007. During this 12‐month period, the average observed LOS for all admissions was 7.84 days, with a mean UHC LOS ratio of 1.23 (SD = 3.43). Seventeen admissions were identified as long‐stays, representing 3.5% of discharges. The 17 admissions represent 17 unique patients.

As shown in Table 1, the long‐stay group (n = 17) was slightly younger, more likely to be male, and had less dementia than the nonlong‐stay group (n = 462). There was a marked difference in the location of patient discharge; long‐stay patients were more than twice as likely to be discharged to a facility and less likely to be discharged home. There were no in‐hospital deaths in the long‐stay patient group during the time period studied.

Of the 17 long‐stay patients, 8 (47%) remained in the hospital past the date they were determined to be medically ready for discharge and were defined as having a nonmedical component for the extension of their hospitalizations. The number of nonmedical days ranged from 6 to 34 days (mean, 17 days). Out of 428 total long‐stay patient days, 136 were nonmedical. This represented 31.8% of all long‐stay patient days, and 53% of the nonmedical group's total hospital days. The mean LOS ratio for the nonmedical cases was 6.04 (Table 2).

Nine patients were defined as medical stay cases (ie, no nonmedical component contributing to the long hospitalization). The mean observed LOS was 19.2 days, and the mean LOS ratio for this group was 5.07 (Table 2). There were no significant differences between primary diagnosis‐related groups (DRGs) seen in the medical and nonmedical stay groups.

The most common reason for a nonmedical stay was nursing facility placement delays (Table 3), specifically related to lack of bed availability and facility rejection of the patient leading to prolonged time waiting for long‐term placement (n = 6). Other nonmedical factors contributing to LOS were lack of patient and/or family agreement with discharge plans (eg, disagreement among family members regarding caregiving responsibilities, goals of care, or patient refusal to be discharged on a particular day) (n = 4); complications with insurance coverage for facility placement or for home care (n = 3); and home care service delays, such as patient need for increased home care hours after discharge (n = 2). Of note, 5 of the 8 nonmedical stay cases had multiple factors contributing to patients' long stays. All delays were assigned to one of the a priori defined categories. There were no other or unexpected reasons identified.

Of the nonmedical cases, all but 1 patient had been seen by an MSVD social worker prior to hospital admission, though the social work referral may have been years prior to or unrelated to the current admission.

DISCUSSION

Almost half of long‐stay patients identified in this homebound population remained hospitalized in an urban academic medical center due to at least one, and often multiple, nonmedical factors. Nonmedical factors identified in this group are similar to those described in previous studies, particularly family and patient decision‐making and post‐hospital placement and care needs.5, 7 Although this pilot study was limited to a single‐site population, it is to our knowledge the first study to describe these factors in a homebound population, and may be able to guide future research and discussion on this topic.

This study used a risk‐adjusted LOS measure to determine long stay cases. Using the UHC Database allowed for a more accurate understanding of the contribution of nonmedical factors to LOS by accounting for hospitalizations that were numerically lengthy but medically appropriate for their respective DRG. The use of the LOS ratio also allows for standardized application of these data across academic health centers. In our sample, 50% of the patients classified as LOS outliers by the UHC Database (cases with LOS in the top percentile for their respective DRG) had nonmedical stays. Conventional strategies often dismiss outliers in analyses of patient LOS data. However, in doing so there is a missed opportunity to identify underlying reasons for their disproportionately long hospitalizations that may also be impacting the broader set of patients with similar nonmedical factors affecting LOS.

The 8 nonmedical stay patients spent a combined 136 days longer in the hospital than medically necessary due to a variety of nonmedical factors, and represented over half of the nonmedical stay group's total hospital days. Using a conservative estimate for cost per hospital day of $1770,16 the nonmedical days cost the hospital almost a quarter of a million dollars ($240,720). Because this figure only accounts for long‐stay patients, the actual costs attributable to nonmedical days for the homebound population in general may be higher.

The longest patient stays, whether attributable to medical or nonmedical factors, were more likely to result in discharge to a facility than the rest of the sample hospitalizations. Facility placement was the most common nonmedical factor contributing to long stays in this sample. In contrast, home carerelated factors contributed the least to nonmedical days. This finding highlights the need for hospital‐based physicians and other inpatient staff members to be aware that despite patient enrollment in an HBPC, the possibility for homebound patients to be discharged to a nursing facility remains significant. A decreasing number of skilled nursing beds across the United States may magnify this factor in long‐stay cases.17 Increased awareness of this possibility among inpatient staff can allow the team to address facility placement considerations early in the hospital stay, potentially decreasing nonmedical days.18

Seven of the 8 nonmedical stay patients had been referred to and seen by MSVD social workers before hospitalization, a high percentage relative to the general MSVD population, of which fewer than half are seen by a social worker during their enrollment in MSVD. This finding may suggest that this group of patients already exhibited difficult social circumstances before their hospital admission, yet the current referral‐based social work model at MSVD did not mitigate their high LOS. This finding further suggests that patient enrollment in an HBPC does not mitigate the risk of high LOS and prolonged nonmedical stays, and that involvement of inpatient practitioners remains a critical part of advanced discharge planning.

This pilot study found that 32% of all long‐stay hospital days were due to nonmedical factors, suggesting that these factors play a greater role in the homebound population than for general medical patients. A recent study at an academic medical center examined 3574 patient‐days on a general medicine service, and noted that 11% of all days were felt to be medically unnecessary by the treating hospitalists.19 Hospitalists are well situated to participate in and lead improvement efforts given their expertise in managing complex dispositions and advancing collaborative strategies for care of patients with high overall acuity.20 These efforts will be needed to target those patients at highest risk for prolonged LOS with the greatest social care needs. Because this study did not pilot strategies to reduce LOS, we cannot offer evidence‐based suggestions for an enhanced multidisciplinary approach or other avenues for improvement. However, we believe that the study findings provide the basis for future research to test strategies to reduce excess LOS by focusing on nonmedical factors and a multidisciplinary approach. This will become especially relevant as health care systems bear increasing financial responsibility for inefficient and/or unnecessary hospitalizations and readmissions.

The involvement of social work before hospitalization for most of the homebound population with prolonged hospitalization suggests a need for greater team‐based efforts across venues. Though hospital interdisciplinary rounds aim to increase collaboration and reduce LOS, costs, and readmissions, these rounds do not typically include outpatient care providers.21 Improved communication and collaboration between social work with both inpatient and outpatient care teams to address nonmedical issues contributing to long stays are likely to improve care and transitions, though rigorous studies examining specific communication models across venues are lacking. This study found that delay in nursing facility placement was the most common reason for prolonged hospitalization for long‐stay cases. This finding emphasizes the need for communication between inpatient and outpatient staff to convey prior conversations or preparations for placement, identify patients who need post‐discharge facility placement early in hospitalization, and prompt timely discussions with patients and families.

The finding that prolonged hospitalization for the homebound population was due to nonmedical factors for almost one‐half of patients with long hospital stays has important implications for policymakers and other key stakeholders. For example, accountable care organizations are being developed to align members of the health care sector to provide higher quality care in a more efficient manner. These study data suggest that this alignment should include hospitals, nursing homes, and home health care agencies to ensure that discharge delays are minimized and unnecessary societal costs are avoided. Future research will need to confirm and build upon these findings of nonmedical reasons for excessive LOS to further inform the process of implementation of health care reform measures. Recent plans to cut Medicaid funding to nursing homes may further limit bed availability, increasing the risk of prolonged LOS and related costs to the health care system. This potential concern highlights the importance of care coordination and communication between inpatient and outpatient care providers to proactively address nursing home placement needs before hospitalization occurs, and/or to identify alternative safe discharge plans if a previously homebound patient is hospitalized.

There are several limitations to this descriptive study. Admissions included in this analysis were only captured for those admitted to The Mount Sinai Hospital. While MSVD providers report that more than 90% of hospitalizations for MSVD patients occur at The Mount Sinai Hospital, patients may also be admitted to one of many New York City metropolitan area hospitals closer to the patient's residence. It is possible that additional factors contributing to high LOS might be revealed if these admissions were included in the analysis. The urban homebound population served by MSVD may have more access to supplementary home care services (e.g. home attendants, meal services) than populations in more rural and less service‐intensive areas. Thus, it may be difficult to generalize these findings to programs serving less urban constituencies or with more restrictive policies regarding home care services. Additionally, as New York registers one of the highest nursing facility occupancy rates (in 2008, 92.2% versus the national average of 82.9%), patients in other markets may face a shorter wait time for a bed, decreasing the number of nonmedical days attributable to nursing home bed supply.17 The small total number of long‐stay patients also prevented statistical analysis comparing those patients with the rest of the sample. This pilot study may inform the design of future studies that may be able to include multiple HBPC programs or study homebound patients over a longer period to increase sample size.

Identifying the significant contribution of nonmedical days to patient stay is an important initial step to avoiding costly and medically unnecessary days for the patient and the hospital. As has been demonstrated in other interdisciplinary efforts, increased collaboration among physicians, social workers, discharge planners, and other disciplines may help address current gaps in patient care with regard to LOS.20, 21 Future studies should determine which homebound patients are at highest risk for prolonged hospitalization due to nonmedical factors to help design focused strategies and interventions for this vulnerable population.

In recent years, much attention has been paid to concerns regarding length of stay (LOS) and safety of hospital discharges.13 Yet studies conducted in a variety of populations suggest that long stays do not wholly reflect acute medical necessity, but may also be driven by nonmedical factors.46 In a study of frail elderly patients, nonmedical factors accounted for over half of patients' hospital stay days.5 Nonmedical factors may include the availability of community and outpatient resources, inadequate patient social support, disagreement with family and/or patient decision‐making, and post‐hospital placement and care needs.7

Homebound patients are at particular risk for long stays because they are typically frail, elderly, and medically complex.8 The United States homebound population numbers at least 2 million and is expected to increase to at least 3 million by the year 2020.9 This group is medically underserved, often only receiving care for medical emergencies, and represents a costly group of health care beneficiaries.10 Although homebound primary care (HBPC) programs are structured to provide coordinated medical and supportive care in the home, the clinical complexity of patients often requires hospitalization during times of acute illness.11

Navigating the discharge process for homebound patients can prove time‐consuming for inpatient physicians whose clinical obligations encompass ensuring safe care transitions between hospital and home.12 The lack of literature on the discharge needs of the homebound population provides little guidance for physicians and health systems seeking to safely transition homebound patients from the hospital to the home in a timely and efficient manner. We performed a pilot study of an urban homebound population cared for by a single academic homebound program to identify and describe nonmedical factors associated with prolonged hospitalization.

METHODS

This retrospective descriptive study included homebound patients cared for by The Mount Sinai Visiting Doctors Program (MSVD), a primary care program affiliated with The Mount Sinai Hospital. MSVD is the largest academic homebound primary care program in the United States. The structure and patient population of MSVD patients have been described previously.13 Briefly, the program employs 8 physicians, 2 nurse practitioners, and support personnel including 2 registered nurses, 4 social workers, and 4 clerical staff members to serve over 1000 homebound patients annually. To be enrolled in the program, patients must meet the Medicare definition of homebound (ie, they must be able to leave home only with great difficulty and for infrequent or short absences). Patients are referred from a variety of sources including emergency rooms, inpatient units, and local nursing and social service agencies. Physicians visit patients on average once every 2 months, but can make more frequent home visits when a clinical need arises. Thirty‐six percent of patients in the program are hospitalized at least once per year while they are under the MSVD's care.14 Patients in the MSVD are referred by their primary care physician to outpatient social work as needed for finite interventions, though not for ongoing case management; approximately one‐third of all MSVD patients have been seen by an MSVD social worker over a 1‐year period.14

All patients enrolled in MSVD discharged from The Mount Sinai Hospital in New York from January 1, 2007, to December 31, 2007, were evaluated for inclusion in this study. The MSVD clinical database was cross‐referenced with The Mount Sinai Hospital data system to maximize reliability of recorded admission and discharge dates. Discrepancies in dates were investigated and corrected by the authors. As the study focused on admissions rather than individual patients, repeat hospitalizations and factors contributing to long stays were included and considered separately. In the event of repeat hospitalizations, factors contributing to LOS were also assessed separately.

Using the University HealthSystems Consortium (UHC) Database, the selected discharges were analyzed for LOS data. The UHC Database contains data from The Mount Sinai Hospital and 106 other academic medical centers and 233 other affiliated hospitals, representing approximately 90% of the United States' nonprofit academic medical centers. UHC members submit clinical, financial, and administrative information for the purpose of facilitating comparative data analysis among institutions.15 The model assigns an expected LOS for each patient based on a 4‐step risk adjustment methodology that adjusts for variations in patient characteristics. The regression models consider a range of independent variables including patient age, sex, race, socioeconomic status, admission source, and comorbid conditions. The expected LOS value is used to produce an LOS ratio, which is the ratio of a patient's observed LOS to expected LOS. We compared LOS ratios for all patient discharges during the study period and determined the mean LOS ratio for the group. Long‐stay patients were defined using the UHC definition of an LOS ratio greater than 2 standard deviations above the mean. These patients were selected for analysis to examine factors contributing to their long stays.

The primary author conducted a chart review for the long‐stay patients. The date of medical readiness for discharge was defined as the date when no acute hospital care needs or pending procedures (eg, intravenous medication, transfusion, invasive and noninvasive testing, surgery) were documented by the attending physician, house officer, nurse practitioner, or physician assistant in the chart. Patients with a discharge immediately following determination of medical readiness were characterized as having a medical stay (eg, patient admitted for pneumonia and discharged home after 3 days once fever, leukocytosis, and symptoms improved with a prescription for remaining antibiotic course). Patients who were classified as medically ready for discharge yet remained additional days in the hospital were categorized as having a nonmedical component to their hospitalization and comprised the nonmedical stay group (eg, patient admitted for pneumonia with improved vital signs and symptoms after 3 days, but discharged home after 10 days awaiting approval of increased home health aide hours). The primary author reviewed cases (<5%) with coauthors when categorization of patient data was unclear from physician documentation in the patient's chart. Similar methodology and terminology have been used in previous studies examining the contribution of nonmedical factors to LOS.5, 7

While literature in other fields, such as social work, often characterize similar factors as social or social care factors, we use the term nonmedical to draw the distinction between factors that acutely reflect a patient's state of health and necessitate days spent in the hospital (eg, surgery, infection), in contrast to factors that are not direct contributors to the patient's current medical status (eg, post‐hospital placement). Factors contributing to nonmedical days were determined based on previous studies and categorized as follows: nursing facility bed availability, nursing facility rejection of the patient, complications with insurance coverage, lack of patient/family agreement with discharge plan, home care service delays, and other. The category other was included to identify and explore any unexpected or unique reasons for prolongation of hospitalization in this population. When multiple nonmedical factors were identified for a given hospitalization, all contributing factors were recorded.

Demographic, clinical, and discharge characteristics were extracted from the MSVD clinical database to qualitatively describe and compare the long‐stay hospitalizations to the remainder of the sample.

RESULTS

There were a total of 479 discharges of 267 unique MSVD patients from The Mount Sinai Hospital occurring from January 1, 2007, to December 31, 2007. During this 12‐month period, the average observed LOS for all admissions was 7.84 days, with a mean UHC LOS ratio of 1.23 (SD = 3.43). Seventeen admissions were identified as long‐stays, representing 3.5% of discharges. The 17 admissions represent 17 unique patients.

As shown in Table 1, the long‐stay group (n = 17) was slightly younger, more likely to be male, and had less dementia than the nonlong‐stay group (n = 462). There was a marked difference in the location of patient discharge; long‐stay patients were more than twice as likely to be discharged to a facility and less likely to be discharged home. There were no in‐hospital deaths in the long‐stay patient group during the time period studied.

Of the 17 long‐stay patients, 8 (47%) remained in the hospital past the date they were determined to be medically ready for discharge and were defined as having a nonmedical component for the extension of their hospitalizations. The number of nonmedical days ranged from 6 to 34 days (mean, 17 days). Out of 428 total long‐stay patient days, 136 were nonmedical. This represented 31.8% of all long‐stay patient days, and 53% of the nonmedical group's total hospital days. The mean LOS ratio for the nonmedical cases was 6.04 (Table 2).

Nine patients were defined as medical stay cases (ie, no nonmedical component contributing to the long hospitalization). The mean observed LOS was 19.2 days, and the mean LOS ratio for this group was 5.07 (Table 2). There were no significant differences between primary diagnosis‐related groups (DRGs) seen in the medical and nonmedical stay groups.

The most common reason for a nonmedical stay was nursing facility placement delays (Table 3), specifically related to lack of bed availability and facility rejection of the patient leading to prolonged time waiting for long‐term placement (n = 6). Other nonmedical factors contributing to LOS were lack of patient and/or family agreement with discharge plans (eg, disagreement among family members regarding caregiving responsibilities, goals of care, or patient refusal to be discharged on a particular day) (n = 4); complications with insurance coverage for facility placement or for home care (n = 3); and home care service delays, such as patient need for increased home care hours after discharge (n = 2). Of note, 5 of the 8 nonmedical stay cases had multiple factors contributing to patients' long stays. All delays were assigned to one of the a priori defined categories. There were no other or unexpected reasons identified.

Of the nonmedical cases, all but 1 patient had been seen by an MSVD social worker prior to hospital admission, though the social work referral may have been years prior to or unrelated to the current admission.

DISCUSSION

Almost half of long‐stay patients identified in this homebound population remained hospitalized in an urban academic medical center due to at least one, and often multiple, nonmedical factors. Nonmedical factors identified in this group are similar to those described in previous studies, particularly family and patient decision‐making and post‐hospital placement and care needs.5, 7 Although this pilot study was limited to a single‐site population, it is to our knowledge the first study to describe these factors in a homebound population, and may be able to guide future research and discussion on this topic.

This study used a risk‐adjusted LOS measure to determine long stay cases. Using the UHC Database allowed for a more accurate understanding of the contribution of nonmedical factors to LOS by accounting for hospitalizations that were numerically lengthy but medically appropriate for their respective DRG. The use of the LOS ratio also allows for standardized application of these data across academic health centers. In our sample, 50% of the patients classified as LOS outliers by the UHC Database (cases with LOS in the top percentile for their respective DRG) had nonmedical stays. Conventional strategies often dismiss outliers in analyses of patient LOS data. However, in doing so there is a missed opportunity to identify underlying reasons for their disproportionately long hospitalizations that may also be impacting the broader set of patients with similar nonmedical factors affecting LOS.

The 8 nonmedical stay patients spent a combined 136 days longer in the hospital than medically necessary due to a variety of nonmedical factors, and represented over half of the nonmedical stay group's total hospital days. Using a conservative estimate for cost per hospital day of $1770,16 the nonmedical days cost the hospital almost a quarter of a million dollars ($240,720). Because this figure only accounts for long‐stay patients, the actual costs attributable to nonmedical days for the homebound population in general may be higher.

The longest patient stays, whether attributable to medical or nonmedical factors, were more likely to result in discharge to a facility than the rest of the sample hospitalizations. Facility placement was the most common nonmedical factor contributing to long stays in this sample. In contrast, home carerelated factors contributed the least to nonmedical days. This finding highlights the need for hospital‐based physicians and other inpatient staff members to be aware that despite patient enrollment in an HBPC, the possibility for homebound patients to be discharged to a nursing facility remains significant. A decreasing number of skilled nursing beds across the United States may magnify this factor in long‐stay cases.17 Increased awareness of this possibility among inpatient staff can allow the team to address facility placement considerations early in the hospital stay, potentially decreasing nonmedical days.18

Seven of the 8 nonmedical stay patients had been referred to and seen by MSVD social workers before hospitalization, a high percentage relative to the general MSVD population, of which fewer than half are seen by a social worker during their enrollment in MSVD. This finding may suggest that this group of patients already exhibited difficult social circumstances before their hospital admission, yet the current referral‐based social work model at MSVD did not mitigate their high LOS. This finding further suggests that patient enrollment in an HBPC does not mitigate the risk of high LOS and prolonged nonmedical stays, and that involvement of inpatient practitioners remains a critical part of advanced discharge planning.

This pilot study found that 32% of all long‐stay hospital days were due to nonmedical factors, suggesting that these factors play a greater role in the homebound population than for general medical patients. A recent study at an academic medical center examined 3574 patient‐days on a general medicine service, and noted that 11% of all days were felt to be medically unnecessary by the treating hospitalists.19 Hospitalists are well situated to participate in and lead improvement efforts given their expertise in managing complex dispositions and advancing collaborative strategies for care of patients with high overall acuity.20 These efforts will be needed to target those patients at highest risk for prolonged LOS with the greatest social care needs. Because this study did not pilot strategies to reduce LOS, we cannot offer evidence‐based suggestions for an enhanced multidisciplinary approach or other avenues for improvement. However, we believe that the study findings provide the basis for future research to test strategies to reduce excess LOS by focusing on nonmedical factors and a multidisciplinary approach. This will become especially relevant as health care systems bear increasing financial responsibility for inefficient and/or unnecessary hospitalizations and readmissions.

The involvement of social work before hospitalization for most of the homebound population with prolonged hospitalization suggests a need for greater team‐based efforts across venues. Though hospital interdisciplinary rounds aim to increase collaboration and reduce LOS, costs, and readmissions, these rounds do not typically include outpatient care providers.21 Improved communication and collaboration between social work with both inpatient and outpatient care teams to address nonmedical issues contributing to long stays are likely to improve care and transitions, though rigorous studies examining specific communication models across venues are lacking. This study found that delay in nursing facility placement was the most common reason for prolonged hospitalization for long‐stay cases. This finding emphasizes the need for communication between inpatient and outpatient staff to convey prior conversations or preparations for placement, identify patients who need post‐discharge facility placement early in hospitalization, and prompt timely discussions with patients and families.

The finding that prolonged hospitalization for the homebound population was due to nonmedical factors for almost one‐half of patients with long hospital stays has important implications for policymakers and other key stakeholders. For example, accountable care organizations are being developed to align members of the health care sector to provide higher quality care in a more efficient manner. These study data suggest that this alignment should include hospitals, nursing homes, and home health care agencies to ensure that discharge delays are minimized and unnecessary societal costs are avoided. Future research will need to confirm and build upon these findings of nonmedical reasons for excessive LOS to further inform the process of implementation of health care reform measures. Recent plans to cut Medicaid funding to nursing homes may further limit bed availability, increasing the risk of prolonged LOS and related costs to the health care system. This potential concern highlights the importance of care coordination and communication between inpatient and outpatient care providers to proactively address nursing home placement needs before hospitalization occurs, and/or to identify alternative safe discharge plans if a previously homebound patient is hospitalized.

There are several limitations to this descriptive study. Admissions included in this analysis were only captured for those admitted to The Mount Sinai Hospital. While MSVD providers report that more than 90% of hospitalizations for MSVD patients occur at The Mount Sinai Hospital, patients may also be admitted to one of many New York City metropolitan area hospitals closer to the patient's residence. It is possible that additional factors contributing to high LOS might be revealed if these admissions were included in the analysis. The urban homebound population served by MSVD may have more access to supplementary home care services (e.g. home attendants, meal services) than populations in more rural and less service‐intensive areas. Thus, it may be difficult to generalize these findings to programs serving less urban constituencies or with more restrictive policies regarding home care services. Additionally, as New York registers one of the highest nursing facility occupancy rates (in 2008, 92.2% versus the national average of 82.9%), patients in other markets may face a shorter wait time for a bed, decreasing the number of nonmedical days attributable to nursing home bed supply.17 The small total number of long‐stay patients also prevented statistical analysis comparing those patients with the rest of the sample. This pilot study may inform the design of future studies that may be able to include multiple HBPC programs or study homebound patients over a longer period to increase sample size.

Identifying the significant contribution of nonmedical days to patient stay is an important initial step to avoiding costly and medically unnecessary days for the patient and the hospital. As has been demonstrated in other interdisciplinary efforts, increased collaboration among physicians, social workers, discharge planners, and other disciplines may help address current gaps in patient care with regard to LOS.20, 21 Future studies should determine which homebound patients are at highest risk for prolonged hospitalization due to nonmedical factors to help design focused strategies and interventions for this vulnerable population.

In recent years, much attention has been paid to concerns regarding length of stay (LOS) and safety of hospital discharges.13 Yet studies conducted in a variety of populations suggest that long stays do not wholly reflect acute medical necessity, but may also be driven by nonmedical factors.46 In a study of frail elderly patients, nonmedical factors accounted for over half of patients' hospital stay days.5 Nonmedical factors may include the availability of community and outpatient resources, inadequate patient social support, disagreement with family and/or patient decision‐making, and post‐hospital placement and care needs.7

Homebound patients are at particular risk for long stays because they are typically frail, elderly, and medically complex.8 The United States homebound population numbers at least 2 million and is expected to increase to at least 3 million by the year 2020.9 This group is medically underserved, often only receiving care for medical emergencies, and represents a costly group of health care beneficiaries.10 Although homebound primary care (HBPC) programs are structured to provide coordinated medical and supportive care in the home, the clinical complexity of patients often requires hospitalization during times of acute illness.11

Navigating the discharge process for homebound patients can prove time‐consuming for inpatient physicians whose clinical obligations encompass ensuring safe care transitions between hospital and home.12 The lack of literature on the discharge needs of the homebound population provides little guidance for physicians and health systems seeking to safely transition homebound patients from the hospital to the home in a timely and efficient manner. We performed a pilot study of an urban homebound population cared for by a single academic homebound program to identify and describe nonmedical factors associated with prolonged hospitalization.

METHODS

This retrospective descriptive study included homebound patients cared for by The Mount Sinai Visiting Doctors Program (MSVD), a primary care program affiliated with The Mount Sinai Hospital. MSVD is the largest academic homebound primary care program in the United States. The structure and patient population of MSVD patients have been described previously.13 Briefly, the program employs 8 physicians, 2 nurse practitioners, and support personnel including 2 registered nurses, 4 social workers, and 4 clerical staff members to serve over 1000 homebound patients annually. To be enrolled in the program, patients must meet the Medicare definition of homebound (ie, they must be able to leave home only with great difficulty and for infrequent or short absences). Patients are referred from a variety of sources including emergency rooms, inpatient units, and local nursing and social service agencies. Physicians visit patients on average once every 2 months, but can make more frequent home visits when a clinical need arises. Thirty‐six percent of patients in the program are hospitalized at least once per year while they are under the MSVD's care.14 Patients in the MSVD are referred by their primary care physician to outpatient social work as needed for finite interventions, though not for ongoing case management; approximately one‐third of all MSVD patients have been seen by an MSVD social worker over a 1‐year period.14

All patients enrolled in MSVD discharged from The Mount Sinai Hospital in New York from January 1, 2007, to December 31, 2007, were evaluated for inclusion in this study. The MSVD clinical database was cross‐referenced with The Mount Sinai Hospital data system to maximize reliability of recorded admission and discharge dates. Discrepancies in dates were investigated and corrected by the authors. As the study focused on admissions rather than individual patients, repeat hospitalizations and factors contributing to long stays were included and considered separately. In the event of repeat hospitalizations, factors contributing to LOS were also assessed separately.

Using the University HealthSystems Consortium (UHC) Database, the selected discharges were analyzed for LOS data. The UHC Database contains data from The Mount Sinai Hospital and 106 other academic medical centers and 233 other affiliated hospitals, representing approximately 90% of the United States' nonprofit academic medical centers. UHC members submit clinical, financial, and administrative information for the purpose of facilitating comparative data analysis among institutions.15 The model assigns an expected LOS for each patient based on a 4‐step risk adjustment methodology that adjusts for variations in patient characteristics. The regression models consider a range of independent variables including patient age, sex, race, socioeconomic status, admission source, and comorbid conditions. The expected LOS value is used to produce an LOS ratio, which is the ratio of a patient's observed LOS to expected LOS. We compared LOS ratios for all patient discharges during the study period and determined the mean LOS ratio for the group. Long‐stay patients were defined using the UHC definition of an LOS ratio greater than 2 standard deviations above the mean. These patients were selected for analysis to examine factors contributing to their long stays.

The primary author conducted a chart review for the long‐stay patients. The date of medical readiness for discharge was defined as the date when no acute hospital care needs or pending procedures (eg, intravenous medication, transfusion, invasive and noninvasive testing, surgery) were documented by the attending physician, house officer, nurse practitioner, or physician assistant in the chart. Patients with a discharge immediately following determination of medical readiness were characterized as having a medical stay (eg, patient admitted for pneumonia and discharged home after 3 days once fever, leukocytosis, and symptoms improved with a prescription for remaining antibiotic course). Patients who were classified as medically ready for discharge yet remained additional days in the hospital were categorized as having a nonmedical component to their hospitalization and comprised the nonmedical stay group (eg, patient admitted for pneumonia with improved vital signs and symptoms after 3 days, but discharged home after 10 days awaiting approval of increased home health aide hours). The primary author reviewed cases (<5%) with coauthors when categorization of patient data was unclear from physician documentation in the patient's chart. Similar methodology and terminology have been used in previous studies examining the contribution of nonmedical factors to LOS.5, 7

While literature in other fields, such as social work, often characterize similar factors as social or social care factors, we use the term nonmedical to draw the distinction between factors that acutely reflect a patient's state of health and necessitate days spent in the hospital (eg, surgery, infection), in contrast to factors that are not direct contributors to the patient's current medical status (eg, post‐hospital placement). Factors contributing to nonmedical days were determined based on previous studies and categorized as follows: nursing facility bed availability, nursing facility rejection of the patient, complications with insurance coverage, lack of patient/family agreement with discharge plan, home care service delays, and other. The category other was included to identify and explore any unexpected or unique reasons for prolongation of hospitalization in this population. When multiple nonmedical factors were identified for a given hospitalization, all contributing factors were recorded.

Demographic, clinical, and discharge characteristics were extracted from the MSVD clinical database to qualitatively describe and compare the long‐stay hospitalizations to the remainder of the sample.

RESULTS

There were a total of 479 discharges of 267 unique MSVD patients from The Mount Sinai Hospital occurring from January 1, 2007, to December 31, 2007. During this 12‐month period, the average observed LOS for all admissions was 7.84 days, with a mean UHC LOS ratio of 1.23 (SD = 3.43). Seventeen admissions were identified as long‐stays, representing 3.5% of discharges. The 17 admissions represent 17 unique patients.

As shown in Table 1, the long‐stay group (n = 17) was slightly younger, more likely to be male, and had less dementia than the nonlong‐stay group (n = 462). There was a marked difference in the location of patient discharge; long‐stay patients were more than twice as likely to be discharged to a facility and less likely to be discharged home. There were no in‐hospital deaths in the long‐stay patient group during the time period studied.

Of the 17 long‐stay patients, 8 (47%) remained in the hospital past the date they were determined to be medically ready for discharge and were defined as having a nonmedical component for the extension of their hospitalizations. The number of nonmedical days ranged from 6 to 34 days (mean, 17 days). Out of 428 total long‐stay patient days, 136 were nonmedical. This represented 31.8% of all long‐stay patient days, and 53% of the nonmedical group's total hospital days. The mean LOS ratio for the nonmedical cases was 6.04 (Table 2).

Nine patients were defined as medical stay cases (ie, no nonmedical component contributing to the long hospitalization). The mean observed LOS was 19.2 days, and the mean LOS ratio for this group was 5.07 (Table 2). There were no significant differences between primary diagnosis‐related groups (DRGs) seen in the medical and nonmedical stay groups.

The most common reason for a nonmedical stay was nursing facility placement delays (Table 3), specifically related to lack of bed availability and facility rejection of the patient leading to prolonged time waiting for long‐term placement (n = 6). Other nonmedical factors contributing to LOS were lack of patient and/or family agreement with discharge plans (eg, disagreement among family members regarding caregiving responsibilities, goals of care, or patient refusal to be discharged on a particular day) (n = 4); complications with insurance coverage for facility placement or for home care (n = 3); and home care service delays, such as patient need for increased home care hours after discharge (n = 2). Of note, 5 of the 8 nonmedical stay cases had multiple factors contributing to patients' long stays. All delays were assigned to one of the a priori defined categories. There were no other or unexpected reasons identified.

Of the nonmedical cases, all but 1 patient had been seen by an MSVD social worker prior to hospital admission, though the social work referral may have been years prior to or unrelated to the current admission.

DISCUSSION

Almost half of long‐stay patients identified in this homebound population remained hospitalized in an urban academic medical center due to at least one, and often multiple, nonmedical factors. Nonmedical factors identified in this group are similar to those described in previous studies, particularly family and patient decision‐making and post‐hospital placement and care needs.5, 7 Although this pilot study was limited to a single‐site population, it is to our knowledge the first study to describe these factors in a homebound population, and may be able to guide future research and discussion on this topic.

This study used a risk‐adjusted LOS measure to determine long stay cases. Using the UHC Database allowed for a more accurate understanding of the contribution of nonmedical factors to LOS by accounting for hospitalizations that were numerically lengthy but medically appropriate for their respective DRG. The use of the LOS ratio also allows for standardized application of these data across academic health centers. In our sample, 50% of the patients classified as LOS outliers by the UHC Database (cases with LOS in the top percentile for their respective DRG) had nonmedical stays. Conventional strategies often dismiss outliers in analyses of patient LOS data. However, in doing so there is a missed opportunity to identify underlying reasons for their disproportionately long hospitalizations that may also be impacting the broader set of patients with similar nonmedical factors affecting LOS.

The 8 nonmedical stay patients spent a combined 136 days longer in the hospital than medically necessary due to a variety of nonmedical factors, and represented over half of the nonmedical stay group's total hospital days. Using a conservative estimate for cost per hospital day of $1770,16 the nonmedical days cost the hospital almost a quarter of a million dollars ($240,720). Because this figure only accounts for long‐stay patients, the actual costs attributable to nonmedical days for the homebound population in general may be higher.

The longest patient stays, whether attributable to medical or nonmedical factors, were more likely to result in discharge to a facility than the rest of the sample hospitalizations. Facility placement was the most common nonmedical factor contributing to long stays in this sample. In contrast, home carerelated factors contributed the least to nonmedical days. This finding highlights the need for hospital‐based physicians and other inpatient staff members to be aware that despite patient enrollment in an HBPC, the possibility for homebound patients to be discharged to a nursing facility remains significant. A decreasing number of skilled nursing beds across the United States may magnify this factor in long‐stay cases.17 Increased awareness of this possibility among inpatient staff can allow the team to address facility placement considerations early in the hospital stay, potentially decreasing nonmedical days.18

Seven of the 8 nonmedical stay patients had been referred to and seen by MSVD social workers before hospitalization, a high percentage relative to the general MSVD population, of which fewer than half are seen by a social worker during their enrollment in MSVD. This finding may suggest that this group of patients already exhibited difficult social circumstances before their hospital admission, yet the current referral‐based social work model at MSVD did not mitigate their high LOS. This finding further suggests that patient enrollment in an HBPC does not mitigate the risk of high LOS and prolonged nonmedical stays, and that involvement of inpatient practitioners remains a critical part of advanced discharge planning.

This pilot study found that 32% of all long‐stay hospital days were due to nonmedical factors, suggesting that these factors play a greater role in the homebound population than for general medical patients. A recent study at an academic medical center examined 3574 patient‐days on a general medicine service, and noted that 11% of all days were felt to be medically unnecessary by the treating hospitalists.19 Hospitalists are well situated to participate in and lead improvement efforts given their expertise in managing complex dispositions and advancing collaborative strategies for care of patients with high overall acuity.20 These efforts will be needed to target those patients at highest risk for prolonged LOS with the greatest social care needs. Because this study did not pilot strategies to reduce LOS, we cannot offer evidence‐based suggestions for an enhanced multidisciplinary approach or other avenues for improvement. However, we believe that the study findings provide the basis for future research to test strategies to reduce excess LOS by focusing on nonmedical factors and a multidisciplinary approach. This will become especially relevant as health care systems bear increasing financial responsibility for inefficient and/or unnecessary hospitalizations and readmissions.

The involvement of social work before hospitalization for most of the homebound population with prolonged hospitalization suggests a need for greater team‐based efforts across venues. Though hospital interdisciplinary rounds aim to increase collaboration and reduce LOS, costs, and readmissions, these rounds do not typically include outpatient care providers.21 Improved communication and collaboration between social work with both inpatient and outpatient care teams to address nonmedical issues contributing to long stays are likely to improve care and transitions, though rigorous studies examining specific communication models across venues are lacking. This study found that delay in nursing facility placement was the most common reason for prolonged hospitalization for long‐stay cases. This finding emphasizes the need for communication between inpatient and outpatient staff to convey prior conversations or preparations for placement, identify patients who need post‐discharge facility placement early in hospitalization, and prompt timely discussions with patients and families.

The finding that prolonged hospitalization for the homebound population was due to nonmedical factors for almost one‐half of patients with long hospital stays has important implications for policymakers and other key stakeholders. For example, accountable care organizations are being developed to align members of the health care sector to provide higher quality care in a more efficient manner. These study data suggest that this alignment should include hospitals, nursing homes, and home health care agencies to ensure that discharge delays are minimized and unnecessary societal costs are avoided. Future research will need to confirm and build upon these findings of nonmedical reasons for excessive LOS to further inform the process of implementation of health care reform measures. Recent plans to cut Medicaid funding to nursing homes may further limit bed availability, increasing the risk of prolonged LOS and related costs to the health care system. This potential concern highlights the importance of care coordination and communication between inpatient and outpatient care providers to proactively address nursing home placement needs before hospitalization occurs, and/or to identify alternative safe discharge plans if a previously homebound patient is hospitalized.

There are several limitations to this descriptive study. Admissions included in this analysis were only captured for those admitted to The Mount Sinai Hospital. While MSVD providers report that more than 90% of hospitalizations for MSVD patients occur at The Mount Sinai Hospital, patients may also be admitted to one of many New York City metropolitan area hospitals closer to the patient's residence. It is possible that additional factors contributing to high LOS might be revealed if these admissions were included in the analysis. The urban homebound population served by MSVD may have more access to supplementary home care services (e.g. home attendants, meal services) than populations in more rural and less service‐intensive areas. Thus, it may be difficult to generalize these findings to programs serving less urban constituencies or with more restrictive policies regarding home care services. Additionally, as New York registers one of the highest nursing facility occupancy rates (in 2008, 92.2% versus the national average of 82.9%), patients in other markets may face a shorter wait time for a bed, decreasing the number of nonmedical days attributable to nursing home bed supply.17 The small total number of long‐stay patients also prevented statistical analysis comparing those patients with the rest of the sample. This pilot study may inform the design of future studies that may be able to include multiple HBPC programs or study homebound patients over a longer period to increase sample size.

Identifying the significant contribution of nonmedical days to patient stay is an important initial step to avoiding costly and medically unnecessary days for the patient and the hospital. As has been demonstrated in other interdisciplinary efforts, increased collaboration among physicians, social workers, discharge planners, and other disciplines may help address current gaps in patient care with regard to LOS.20, 21 Future studies should determine which homebound patients are at highest risk for prolonged hospitalization due to nonmedical factors to help design focused strategies and interventions for this vulnerable population.