Segment Description: Christian Sandrock, MD, MPH, FCCP, reviews the factors that contribute to a hospital’s system-wide or episode-of-care costs for the treatment of acute bacterial skin and skin structure infections.
Christian Sandrock, MD, MPH, FCCP: At our hospital here in California, generally, our reimbursement is DRG, so we’re actually paid per disease state. Some hospitals here in California and elsewhere in the country, they’re critical access hospitals (CAHs), so they may be paid actually in full. So, if someone stays for 3 days, they get 3 days. If they stay for 6 days, they get 6 days. We just get a flat rate, or a DRG based on that disease state. For example, a skin and soft tissue infection, or a skin and soft tissue infection with what we call SIRS—or systemic infection—slightly varies by about 0.2 or 0.3 days, as far as an average length of stay and the amount of money we have. That allows us from a financial perspective to say, “OK, how long does the patient have to stay for us to break even on them?” I’m not involved a lot in the finances, but, as far as antimicrobial stewardship, we do look at this. We do know, for example, that at about 2.8 to 3 days is where our DRG, or our flat money comes in; about where we break even for a skin and soft tissue infection.
However, when we look at our patients, we know on average they stay almost 6 days. And when we look at the factors that go into their length of stay, it’s actually really very complicated. We initially thought there are staying 6 days because they have bad disease; maybe their wound is large, and it needs a lot of local wound care. The surgeon takes them to the operating room, and we actually found that that’s not the case.
Likewise, we also found that comorbidities, such as uncontrolled diabetes, heart disease, other things, really don’t play a big role in the long length of stay of our skin and soft tissue patients. What often did, were mostly social factors. So, again, these patients often come from difficult backgrounds. They don’t have a home to go to, they don’t have access to healthcare. Even though we obviously know with the Affordable Care Act, many of these patients can get insurance. They don’t have a fixed address, they don’t have a home. Many of them have to use the county-based system here, which means if we write them a prescription for an antibiotic, they have to go to the county. They often wait 2 to 3 days to get the antibiotic filled, which means they’re certainly not going to wait that long, and then their non-compliance rate goes up.
Then lastly, we see a large amount of drug use, and actual psychiatric disease associated with it. So, they may be actively using drugs, they come in for their skin and soft tissue infection and then they go through a period of withdrawal; whether it’s alcohol, methamphetamines, even narcotics and heroin. That then allows them to have a period of instability where we just can’t send them home after 3 days, particularly with methamphetamines, which is very common; they’ll skin pop. We see a lot of abscesses with methamphetamines. They actually will have a psychotic break and then, because they’re psychologically unstable, we can’t discharge them. And it’s not unusual, we just do not have psychiatric facilities here, so we have to wait until that period of time clears for them to become stable. Very often, unfortunately, they leave against medical advice usually by day 7 or 8.
When we looked at it, it was often social factors, psychiatric factors, drug use, that factored in to that length of stay, and allows us to really focus on these patients, both from a social perspective— getting social planning, discharge planning involved. But then at the same time, if we can defer an admission in some of these patients, it actually becomes beneficial both for the patient and the hospital financially, and socially, and from a healthcare perspective.