Evaluating Hospital Inpatient Discharges at the Regional Level

Historically, the evaluation of hospital utilization in the United States has been addressed by providers and health planning agencies. This study evaluated resident inpatient hospital discharges for adult medicine and adult surgery in the Central New York Health Service Area, an eleven county region of upstate New York. It focused on small local hospitals and larger referral center hospitals in the region. The study demonstrated that numbers of adult medicine resident discharges from small local hospitals declined by 17.3 percent in most counties of the region between 2012 and 2017. This reduction resulted, in part, from the implementation of medical observation programs that shifted many patients with low severity of illness to outpatient status. The study also demonstrated that numbers of adult surgery resident inpatient discharges from small local hospitals declined by 15.8 percent. This resulted from the inmigration of many surgical patients from these providers to larger hospitals in the region. The study suggested that there may not be sufficient inpatient adult surgery and medicine volumes to support the current number of hospitals in the region.


Introduction
In recent years, interest in improving efficiency and outcomes in the health care system of the United States has increased. This interest has been supported by an expanding amount of resources consumed by this sector of the economy [1] [2] [3].
The relationships between health care utilization and demographics emphasize the connections between this sector and regional and community popula-tions. Health care is a community based service related to the needs of populations [4] [5] [6].
A major driver of health care at the community level is the utilization of inpatient hospitals. These providers focus on the delivery of inpatient acute care, although they also deliver emergency, outpatient, and other services. This care can include inpatient adult medicine, adult surgery, pediatrics, obstetrics, and mental health.
One of the most important indicators of the use of health care utilization is inpatient hospital discharges. Discharges are important because they identify use of acute care. They are also important because they are the basis of hospital reimbursement for health care payers [7].
Historically, health planning initiatives have focused on hospital discharges at regional and community levels. These include the Health Systems Agencies developed through federal legislation during the twentieth century as well as State government efforts to evaluate and regulate health care providers [8].
In the United States, most inpatient hospital payments are determined by utilization, especially inpatient discharges. Because of the relationship between hospital discharges and reimbursement, efforts to maintain financial viability are frequently linked to inpatient discharge volumes [9].

Population
This study focused on hospital utilization in the Central New York Health Ser-

Method
This study evaluated resident hospital inpatient utilization by county in the Within these definitions, the study focused on hospital discharges for adult medicine and adult surgery. These services included all hospital inpatients except those aged 17 years and younger and those identified as obstetrics, psychiatry, and substance abuse treatment according to the All Patients Refined Diagnosis related Groups Defined by 3M™ Health Information Systems. These services accounted for approximately 80 percent of all hospital inpatient discharges in the region.
By identifying resident hospital discharges for adult medicine and adult surgery between 2012 and 2017, the study was able to evaluate the extent of this utilization during this period. It was also able to evaluate the impact of developments including the implementation of medical observation regulations for Medicare and other payors in 2013 and the movement of some surgical patients between hospitals.
The study data for 2012 and 2017 were obtained from the New York State Planning and Research Cooperative System (SPARCS) maintained by the New York State Department of Health. They included hospital inpatient discharges for the most recent year period available.
The study data for adult medicine and adult surgery were analyzed in tables for each of the two inpatient services. Each table included total numbers of resident hospital discharges for adult medicine and adult surgery for each of the eleven counties in the region for 2012 and 2017. This utilization was identified by the hospitals where the discharges occurred. They included local hospitals located within each county, in the combined Syracuse hospitals, and in other hospitals located outside the resident counties and the Syracuse hospitals.
Analysis of the data for adult medicine and adult surgery focused on comparison of resident discharges among the resident counties in the region for 2017. These data included local hospitals, the Syracuse hospitals, and other hospitals. The analysis also focused on identification of changes in resident discharges for each of these categories and the individual counties between 2012 and 2017.

Results
The initial component of the study focused on resident hospital discharges by county in the Central New York Health Service Area for adult medicine. Relevant data are summarized in Table 1.
This information demonstrated that the largest numbers of resident hospital discharges from local hospitals for adult medicine patients occurred in Ononda-

Discussion
In the United States, the utilization of inpatient hospitals is related to populations at the regional and community levels. Historically, the evaluation of regional hospital utilization has been developed by health planning agencies and groups of providers. This process has supported the monitoring and planning of the use of hospital services at the regional and community levels.
Evaluation of inpatient hospital utilization at the regional level is useful because it is based on wide utilization patterns, rather than fragmented approaches involving small numbers of providers. Regional utilization usually includes sufficient numbers of discharges to identify consistent developments in the provision of care over time. surgery discharges for these hospitals. As a result of these reductions, by 2017, the percentage of total resident adult surgery discharges performed at hospitals in the smaller counties was 27 percent or less. This reduction resulted, in part, from the increased migration of adult surgery patients to hospitals in Syracuse. The percentage of adult medicine resident discharges from local hospitals also declined. This resulted, in part, from the implementation of medical observation programs that shifted many of these individuals to outpatient status.
Another issue concerned counties with larger inpatient adult medicine and surgery volumes that were not part of the regional center such as Oneida, Tompkins, and Jefferson Counties. The study data suggested that discharge volumes in these areas declined, but not enough to challenge their viability.
The study data suggested that, in the Central New York Health Service Area, there may not be sufficient inpatient discharge volumes to support the continued viability of hospitals in most of the smaller counties. This could reduce the number of hospitals in the region to those in Syracuse and those in counties such as Oneida, Tompkins, and Jefferson. Additional research concerning inpatient utilization should be carried out to determine whether similar developments have occurred in other regions.