Untangling the Effects of Hospital Distance on Stays for COPD

Patients with chronic obstructive pulmonary disease (COPD) who live close to hospitals may spend more days in the hospital than those who live further away, according to a new Australian study published in the Internal Medicine Journal.

In 2016, COPD resulted in 3 million deaths globally, making it the third-leading cause of death. COPD was the underlying cause of death of 7889 Australians in 2018 and was the fifth-leading cause of death in Australia. Although COPD is progressive and noncurable, appropriate treatment and condition management can alleviate symptoms, reduce mortality rates, and improve patient quality of life.

“Understanding the factors responsible for variations in COPD related hospital length of stay due to distance will critically assist policymakers and health practitioners to improve COPD related health outcomes and reduce avoidable demand for hospital care, especially for emergency department presentations,” said investigators, who noted that existing research lacks consensus on the intersection of geographic distance, hospital or ED admissions, and the length of stay.

The current study explored the null hypothesis that distance does not affect health care utilization through the use of ED services or hospital admissions. Researchers looked at data from late 2016 to late 2018 on hospital admission after emergency department (ED) presentation and length of stay for 4914 patients with COPD as a primary medical diagnosis at 3 hospitals in Queensland, Australia. In the Australian hospital system, patients are assessed according to a triage systems from 1 to 5, with 1 being life threatening and 5 meaning the patient’s treatment has a 2-hour window.

The distance to the hospital was divided into 3 categories: 0-15 kilometers (short); 15-50 kilometers (intermediate); and more than 50 kilometers (long).

The mean length of stay for patients who travelled a short or intermediate distance was identical. However, the hospital stays for patients traveling a long distance was less than half that of patients who lived closer.

A large majority of long distanced patients were discharged from the hospital in less than 2 days compared with only half of short and intermediate distanced patients.

Results showed that 1 in every 2 patients, across all distances, who presented to ED were assessed as triage category 3, with a majority of more than 85% of patients being triage category 2 or 3. Over 10% of patients who travelled a long distance were triaged as category 1, compared with 4% who travelled an intermediate distance and 6% who travelled a short distance (P <.05).

“These results confirm that distance plays an important role in determining duration of hospital stay among COPD patients, with clear evidence of the distance decay phenomenon. The distance decay effect states that the interaction between two locales declines as the distance between them increases,” said investigators.

Investigators cited several reasons for why people living more distant from the hospital typically had shorter lengths of stay compared with those who lived closer. Patients with COPD who live in rural areas may have a better health status than their counterparts who live in urban areas or that patients with more severe COPD may live closer to allow for quicker hospital access if necessary.

Additionally, patients who come from further away that do not need to be admitted to a hospital for medical reasons may be kept in hospital anyway for logistical, practical, or social reasons; whereas patients who live closer and do not need hospital admittance would likely be discharged.

About 1 in 10 patients were discharged without hospital admission among those who arrived from a short or intermediate distance, compared with 1 in 20 patients who lived further away.

Limitations for the study included not having access to key patient characteristics such as gender, income level, or existence of comorbidities. Investigators also had to use postal codes to estimate the distance that each patient lived from the hospital because specific addresses of patients were unavailable. In addition, the authors did not take into account the quality of hospital care, which can influence a patient’s choice of hospital.

“If [patients with COPD] are critically ill due to inappropriate disease management and/or other comorbidities, it would be highly appropriate for them to travel considerable distances to access treatment,” said investigators.

Reference

Rana R, Gow J, Moloney C, et al. Does distance to hospital affect emergency department presentations and hospital length of stay among COPD patients? Intern. Med. J. Published online August 12 2020. doi: 10.1111/imj.15014