Patient Care

Small Bowel Block in Elderly Merits Full Hospitalization


NEW YORK (Reuters Health) - The "vast majority" of elderly patients admitted with small bowel obstruction (SBO) are hospitalized for more than two days, and the diagnosis alone should allow appropriate Medicare coverage, according to a new study.

In a paper online July 1 in Annals of Surgery, Dr. Zara Cooper, of Brigham and Women's Hospital, Boston, and colleagues noted that their study was prompted by the Two-Midnight Rule established by the Centers for Medicare & Medicaid Services (CMS) in 2013.

The authors explained that if a physician expects a patient to need a hospital stay that crosses two midnights and thus admits the patient, related costs may be covered. However, shorter stays are deemed as observational and can raise the possibility of non-reimbursement for hospitals.

For example, if someone is admitted as an inpatient, but discharged in less than two days, payment will be made only if it can be documented that a longer stay was reasonably expected and unforeseen circumstances led to the shorter stay. Hospital stays that are incorrectly classified or have improperly documented changes in admission status will not be paid.

However, Dr. Cooper told Reuters Health by email, "Older patients with SBO, a very common diagnosis, should be presumed to be admitted for more than two midnights and hospitals should not get penalized."

She and her colleagues pointed out that SBO accounts for about 15% of surgical admissions to U.S. hospitals and more than $1 billion in annual hospital charges. However, diagnosis requires surgeons to observe patients to determine if surgery is warranted.

Thus, the authors wrote, "It is critically important for surgeons to correctly assign admission status for patients with SBO to ensure that hospitals are reimbursed appropriately, and patients are not unduly burdened."

The investigators examined data on 855 older patients admitted with SBO from 2006 and 2013. Of these, 816 (95%) stayed for two midnights or longer. This was true of all patients aged 85 years or older (n=108, approximately 13%).

The only significant difference in clinical characteristics was the presence of inflammatory bowel disease. Of five such patients, only one stayed for less than two midnights.

"Based on our study and others," the investigators wrote, "we propose that hospital admission for SBO in elderly patients is sufficient justification for the reasonable expectation" of the required length of stay for reimbursement.

This also may be true of other conditions. Dr. Cooper concluded, "More studies like this are needed in surgical patients to better understand the impact of CMS admission guidelines. The rule may not make sense in certain populations, leading to heavy and unfair penalties for hospitals."

The authors reported no disclosures.

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