Background: Over 6-months after the end of the Covid-19 Public Health Emergency, U.S. hospitals are still experiencing unprecedented levels of sustained stress with national hospital occupancy remaining 10 percentage points higher than before the pandemic. The demand for hospitalization is likely to increase over the next decade as the U.S. population ages, which will place further strain on hospitals. In order to inform policies to avert a potential hospital bed shortage, it is crucial to understand if and when the U.S. will experience a critical hospital bed occupancy.
Methods: In this observational population-based study, we projected the number of annual non-critical care U.S. hospitalizations between 2024-2034 for five age bands (0-17, 18-44, 45-64, 65-79, 80+) by multiplying official U.S. Census Bureau population projections by the National Inpatient Sample 2019 (pre-pandemic) hospitalization rate for that age band. We then projected aging-adjusted average hospital occupancy for each year from 2024-2034 by multiplying the projected hospitalizations for that year by the ratio of how 2023 hospital occupancy (through November 18, 2023) corresponded to 2023 (post-pandemic) hospitalizations. We obtained 2019 in-hospital mortality rates and average length of stay for adults ≥65 years from the 100% Medicare file, and estimated excess mortality associated with a hospital bed shortage using previously published assumptions that an 85% national hospital occupancy results in an increase in the odds of in-hospital mortality of 2% per day hospitalized.In a sensitivity analysis designed to assess the validity of our method to project the number of hospitalizations, we used it to retrospectively calculate hospitalizations from 2002-2019 and compared the estimates to observed hospitalizations through a Pearson correlation.
Results: National hospital occupancy ranged from 63-67% between 2002-2019, peaked at 79% in January 2022, and remained at an average of over 75% throughout 2023 (Figure 1). In the aging-adjusted projections, total hospitalizations were projected to increase by 11% from 38,085,000 in 2024 to 42,316,000 in 2034 (Figure 2), which corresponds to a national hospital occupancy of 85% being reached by 2031 for adult beds and by 2034 for adult and pediatric beds combined (Figure 1). Among adults 65 years and older, an 85% hospital occupancy in 2031 would be associated with more than 40,000 excess deaths annually.Retrospectively estimated hospitalizations from 2002-2019 correlated well with observed hospitalizations during these years (R2=0.95), suggesting the method used here to project the number of hospitalizations was reliable.
Conclusions: The projections presented here suggest that the persistently elevated post-pandemic hospital occupancy, superimposed on an aging U.S. population, may lead to an unprecedented hospital bed shortage and over 40,000 excess deaths annually between 2031-2034 unless urgent action is taken to avert this alarming trend. Policymakers and health system leaders should focus on 1) reducing hospital utilization through preventive medicine and new care models that can better treat acute illness in the outpatient setting, and 2) increasing hospital capacity by stopping rural hospital closures or ameliorating staffing shortages.
