Lack of patients? – a hypothesis for understanding discrepancies between hospital resources and productivity

Purpose of the study

The purpose of the study was to analyse patient volume figures in relation to available resources as a measure of productivity, in view of possible changes in case mix and simple quality criteria in a large general hospital. Since most of the activity in a hospital (both patient care and resource expenditure) is generated on the micro-level where the patient meets the doctor, complete analysis of different departments and health care professions were considered important.

Study period

Norwegian hospitals have traditionally been owned and operated by 19 different county councils. Most of the funding was provided by the national government in the form of block grants based on the size of the population as well as demographic and social characteristics. Since1997, the block funding has been gradually replaced by a matching grant depending on the number and composition of treatments (DRG-based), from 30% of gross budget in 1997 to 60% in 2001. Outpatient activities are reimbursed based on activity (number of consultations). Furthermore, because of the problems within the Norwegian National Health Service, a reform was passed where the central government took over the operation of all hospitals organised through five regional hospital enterprises, active from January 2002. The analysis of St. Olavs University Hospital was therefore focused on the years from 1995 to 2001 leading up to this reform.

Data acquisition and analysis

Data on departmental health care personnel, economic resources, patient admissions and outpatient consultations were obtained from the yearly hospital statistical reports as well as the monthly reports submitted by the hospital to the National Patient Registry. Data on admissions and in-hospital-mortality of high risk patients groups (DRG 14 (stroke), DRG 89–90 (Pneumonia in patients > 17 years) DRG 121–122 (Myocardial infarction), DRG 127 (heart failure and shock), DRG 210–211 (Hip fracture in patients > 17 years) and DRG 236 (Hip and pelvic fracture)) were obtained from the National Patient Registry and analysed and compared by a year-to-year comparison as well as for the whole study period.

Data were analysed both for emergency and elective admissions as well as outpatient visits specified into new referrals and follow-up consultations. A new referral was defined as a patient having his first consultation after referral for a specific (new) problem. A follow-up consultation was defined as a consultation for a problem for which the patient had been seen before during the last 12 months. These two patient groups are accounted separately and therefore specified in all reports. It was postulated that such analyses of a case report from departments at a single institution could identify developmental trends not observed in the national data, and thereby generate new hypotheses for the explanation of the seemingly discrepancy between resource allocation and productivity.

Total hospital resource expenditure

Patient volume

As also shown in Table 1, during the same time period there has also been an increase in admitted patients and consultations at the outpatient clinics, but to a considerably lesser extent. Hospital admissions increased by only 10.0% mainly related to an increase in elective admissions. Emergency admissions increased by only 6.4% and emergency admissions as a percentage of total admissions were reduced by 4.8%. In comparison, the catchment population increased by 3.2% during the study period. Furthermore, the average length of stay decreased by 16.4% resulting in a decrease in in-hospital days by 2.4%. Outpatient consultations (including day patients) increased by 15%. However, this was entirely caused by a 31.8% increase in follow-up consultations, while new referrals were actually reduced by 6.6%. During the time period 1995–2001 also he number of operations increased by 8.3% and the number of intensive care patients (excluding neonatology) increased by 15.4%.

Relative patient load for different professions and activities

Interdepartmental variations in FTEs

As can be seen from Table 3, the increase FTEs was not evenly distributed between the different departments. The increase in doctors and nurses was mainly seen in the medical departments, with an increase in doctors from 20% to 86.1% (average increase 62.2%) and nurses from 8.8% to 67.2% (average increase of 45.4%). In comparison, the increase in FTEs in the surgical departments, were on average 23.2% for doctors and 14.2% for nurses. During the study period the weekly basic working hours were 38 hours for physicians in call systems and 40 hours for physicians with day work only. Average scheduled extended working hours for physicians were approximately 8 hours pr. week with no major changes during the study period. Nurses working shifts had a 35.5 hour week, others 38 hours per week.

Interdepartmental variations in patient load and activities

As shown in Table 4 and Table 5 there were also significant differences in the development of patient related activities during the study period, both between different departments but particularly between medical and surgical departments. In most of the medical departments there was an increase in admitted patients, particularly in elective admissions, as well as in total outpatient consultations, both in new referrals and follow-up consultations. The exception is in paediatrics. Some departments also showed significant year to year variations. The increase in new referrals in oncology from 1999–2001 was probably related to a significant increase in radiation capacity. The increase in admissions and reduction in outpatient consultations at the department of dermatology starting in 1997, was related both to a shift in treatment policy and increased capacity. The increase in elective neurologic admissions from 1999 to 2001 was a result of an effort to reduce waiting time that were among the longest in the hospital (average waiting time for elective admission > 1 year).

In most of the surgical departments, however, the increase in admitted patients was more modest, particularly in emergency admissions, and some departments had a significant reduction in emergency admission (ophthalmology, gynaecology and neurosurgery). Also in general surgery and orthopaedic surgery the increase in admitted patients were below the hospital average. In otorhinolaryngology and gynaecology there was no increase or even a reduction in total admissions.

Outpatient consultations in the surgical departments also showed a different pattern than in the medical departments. The increase in the total number of consultations was more modest, and there was a significant decrease in the number of new referrals in many of the departments, in general surgery by 21.2%, in orthopaedic surgery by 14.8%, in gynaecology by 27.1% and in ophthalmology by 33.2%. In several of these departments (and in paediatrics, Table 4), the increase in the total outpatient consultations can completely be explained by a compensatory increase in follow-up consultations, which in some departments was very high, such as general surgery 71.7%, gynaecology 61.3% and paediatrics 52.0%. Furthermore, even in departments with an increase also in new referrals, the number of follow-up consultations increased even more.

Patient complexity and quality considerations

Increased focus on quality

Hospital performance and expenditure is not only related to patient volume but also to quality and intensity of treatment, as well as case-mix [10, 11]. It might therefore be argued that the increase in resource allocation could be related to improvement in treatment quality or changes in case-mix. Thus, during the study period there was an increased focus on quality, particularly in documentation of patient records and reports. This can partly explain the increase in office and administrative staff. On the other hand, admissions of high risk patient groups did not change, neither did in-hospital mortality for these patients, indicating that the severity of sickness or volume of these patients had not changed during the study period [11]. Furthermore, the volume of diagnostic patient work-up, such as laboratory tests and imaging procedures were not increased during the study period, also indicating that complexity and case-mix of admitted patients had not been significantly changed. Thus, data related to treatment quality did not indicate significant changes in case-mix or treatment quality during the study period.

Bottlenecks and technological developments

Low productivity in hospitals has often been explained by bottlenecks, particularly in the medical service professions such as radiology and anaesthesiology [13, 14]. Since a reduction in these activities was seen both in volume/physician (laboratory services, radiology and anaesthesiology) and volume/patient (laboratory services, radiology) it is unlikely that these services were true bottlenecks in the treatment lines.

Also, during the study period no major technological developments or new diseases were introduced, although an increase in the use of cardiovascular stents and laparoscopic surgery was seen. The average patient treated in 2001 was therefore probably not more complicated to treat than in 1995.

Imbalance between hospital beds and medical resources

Another explanation that might be considered is related to the steady demand by hospital owners for increased effectiveness, reflected in a significant reduction in in-hospital days and average length of stay for each patient. It might be speculated that this trend actually creates more work with each patient by creating a need to see the patient again (in the department or at the outpatient clinic), because the work-up or treatment could not be fully completed during the short hospital stay. This hypothesis is also supported by national data showing that during the period from 1996 to 2003 the number of patients readmitted as an emergency case within 30 days after discharge increased from 8% to 9,6% of all emergency admissions [15]. Furthermore, the number of patient with a single admission during a year was reduced from 57 to 55 per cent of the total number of admission [15]. In a recent European study it was found that 24% of patients admitted to a department of internal medicine were readmitted within 6 months from discharge, with major impact on resource utilisation [16]. One might therefore speculate if the reduction in the number of hospital beds as a measure to increase effectiveness (by reducing the length of stay), has actually resulted in an imbalance between staffing resources and available beds. It can therefore be hypothesised that if the hospital to some extent also had increased the number of beds in relation to the increase in manpower, instead of reducing them by 2% (Table 1), the productivity per employee might also have been increased in stead of being reduced.

Lack of professional continuity in patient care

There might also be organisational reasons for this development. With the increase in the number of doctors and interrupted working plans, it is difficult to organise the service so the physician who will be seeing the patient at the follow-up consultation at the outpatient clinic is the same who treated the patient while in the department. In the eye of the new doctor, the patient will also be new. This situation is likely to result in the schedule of another follow-up visit before the patient is referred back to the general practitioner. The (new) doctor might feel that this is necessary, but by medical criteria it might not be indicated. Private practitioners in Norway have thus complained that the hospitals keep referred patients too long with too many follow-up visits [4]. This emphasises the need to have clinical guidelines (departmental or national) structuring necessary follow-up, particularly for major patient categories. This is an issue of such impact on hospital productivity and effectiveness that it should not be up to the individual doctor (often in-training) to decide.

Do hospitals lack patients?

The most striking finding in this study is the data concerning the outpatient population. The significant increase in the number of follow-up consultations, while new referral consultations actually went down must also raise the hypothesis that the slow increase in patient-related activities at the hospital, in spite of a significant increase in resource allocation, can be explained by a relative lack of patients. It might also be speculated if the relatively slow increase in the number of patients who are admitted might be explained in the same way. Data from the Norwegian Patient Registry show that from 1999 to 2000 the number of individuals admitted to Norwegian hospitals increased by 0,3%, while the number of admissions increased by 1,8% [4]. The increased number of admissions is therefore to a large extent caused by re-admittance of patients recently discharged, and not by new patients taken in. It can be speculated that this reflects that the market (patient volume) might not be big enough in relation to the investments in increased production capacity (equipment and manpower) at hospitals. In this context the patient population might actually be a limited reserve. In agreement with this speculation, more hospitals and departments in Norway now advertise their services to patients in other health regions, possibly in order to recruit patients to keep up their activity. This is particularly evident in relation to surgery.

Hospital owners and politicians have for many years asked hospitals to increase their admissions and out-patient consultations to meet the seemingly unlimited demand for treatment. It might therefore be speculated that if patient population (volume) might be limited, the only possible answer to increase volume is to recycle the patients you already have. The modest increase in admitted patients and operations at the surgical departments, but significant increases in follow-up patient at the surgical outpatient clinics, might therefore reflect that it is easier to recycle a successfully operated patient for an extra consultation at the outpatient clinic than to readmit him. Most medical departments also show relatively similar developments in admitted patients and outpatients consultations. It can thus be speculated if the long waiting lists at St. Olavs University Hospital as well as at other Norwegian hospitals, are mainly caused by a tendency to readmit recently treated patients and once again see follow-up patients, instead of scheduling new patients from the waiting lists [17].

Finally, the fact that the patient population over time might be limited can also be related to general social-demographic trends. Although the general picture seems to be an increased demand for new treatments for new diseases or malfunctions, the other trend is an increasingly healthier population, partly because of increased focus on physical exercise, healthier food habits and less smoking. Focus on external hazards, such as traffic accidents have in spite of a significant increase in the number of automobiles resulted in a reduction in fatal accidents by 10% during the last ten years, while injuries have not increased more than the population size [18]. Furthermore, the technological developments, which have made a major impact on hospital treatment, have also made it possible for patients to take care of and monitor their treatment in their own home and reduce the need for hospital visits [4]. This developmental trend will probably continue.