Background:
Since July 2007, hospitals are required to notify hospitalized Medicare and Medicaid beneficiaries of their rights to appeal their discharge. Should a patient decide to appeal the care team’s discharge decision, federally appointed Quality Improvement Organizations review the medical record and decide either to uphold or overturn the discharge. During this time, the patient is protected from liability for hospital charges until the day after a decision is reached. The discharge appeals process is a time‐consuming process, frequently perceived as a breach of the trust inherent to the physician‐patient relationship and its effect on length of hospitalization and quality of care measures have not been reported. Similarly, the characteristics of patients that may predict engagement in the discharge appeals process are unknown.
Methods:
We conducted a retrospective case‐control analysis of Medicare/Medicaid beneficiaries admitted to the Medicine Service at New York‐Presbyterian Hospital/Weill Cornell who appealed their discharge over a 30‐month period. Data regarding patient demographics, such as gender, ethnicity, income status and language were gathered, along with potential psychosocial factors, such as place of residence, social support network, home care, alcohol and drug use and psychiatric history. The reasons behind the appeals were noted and the proposed disposition at the time of discharge were analyzed. Additionally, we hypothesized that certain medical factors, including comorbid conditions, procedural interventions, inpatient narcotic use, isolation and ICU stay, prior hospitalization and ER visits, may be important determinants. Further, we analyzed the impact of discharge appeals on added length of stay, 30‐day readmissions and follow‐up at discharge. Age‐ and discharge date‐matched controls were identified and similarly analyzed. Multivariable regression analysis was performed to identify factors that independently predict engagement in the discharge appeals process.
Results:
During a 30‐month period, 159 patients appealed their discharge and 15 considered, but canceled, the appeal. Of these, review by the QIO upheld the hospital’s decision to discharge in 94.3% of cases. The reasons behind the discharge appeal could be categorized into disagreements with the care plan (48.3%) and displeasure with the disposition at discharge, e.g. skilled nursing facility (51.7%). Analysis showed that those who appealed due to the latter were older, had been in the hospital longer, had a higher Charlson Comorbidity Index, more likely to be isolated for infectious reasons and to have undergone a change in their living situation at the time of discharge. Multivariate regression analysis was performed comparing discharge appeals cases with controls and demonstrate important psychosocial and medical factors that predict engagement in the appeals process. Finally, among patients who appealed their discharge, length of hospitalization was increased by a median of 4 days; however, there was no increase in 30‐day readmissions.
Conclusions:
The decision to appeal the discharge bears significantly on length of hospitalization, although it invariably leads to decisions in favor of the hospital. Psychosocial factors, particularly support systems, and a change in a patient’s living situation are important predictors of engagement in the discharge appeals process.