Impact of shortened length of stay for delivery on the required bed capacity in maternity services: results from forecast analysis on administrative data

Research article Open Access Open Peer Review Published: 05 September 2019 Impact of shortened length of stay for delivery on the required bed capacity in maternity services: results from forecast analysis on administrative data Mélanie Lefèvre1, Koen Van den Heede1, Cécile Camberlin1, Nicolas Bouckaert1, Claire Beguin1, Carl Devos1 & Carine Van de Voorde1  BMC Health Services Research volume 19, Article number: 637 (2019) | Download Citation Article metrics 130 Accesses Abstract Background We examine the implications of reducing the average length of stay (ALOS) for a delivery on the required capacity in terms of service volume and maternity beds in Belgium, using administrative data covering all inpatient stays in Belgian general hospitals over the period 2003–2014. Methods A projection model generates forecasts of all inpatient and day-care services with a time horizon of 2025. It adjusts the observed hospital use in 2014 to the combined effect of three evolutions: the change in population size and composition, the time trend evolution of ALOS, and the time trend evolution of the admission rates. In addition, we develop an alternative scenario to evaluate the impact of an accelerated reduction of ALOS. Results Between 2014 and 2025, we expect the number of deliveries to increase by 4.41%, and the number of stays in maternity services by 3.38%. At the same time, a reduction in ALOS is projected for all types of deliveries. The required capacity for maternity beds will decrease by 17%. In case of an accelerated reduction of the ALOS to reach international standards, this required capacity for maternity beds will decrease by more than 30%. Conclusions Despite an expected increase in the number of deliveries, future hospital capacity in terms of maternity beds can be considerably reduced in Belgium, due to the continuing reduction of ALOS. Open Peer Review reports Background Reductions in the length of postpartum hospital stay are observed in almost all industrial countries. In the United States, for instance, the standard length of postpartum stay was 8 to 14 days in the 1950s but declined to less than 2 days in the mid-1990s and levelled off at 2 days ever since [1, 2]. Also in Europe the average length of stay (ALOS) for a normal delivery dropped from 5 days in 2000 to 3.2 days in 2014 [3]. Belgium, the country that is analysed in the current study, follows this international evolution with a reduction in the average length of stay for a normal delivery of almost 25% since 2000 (from 4.9 days in 2000 to 3.7 days in 2014) [1]. Aside from evolutions in clinical practice, reducing the average length of stay is perceived as a way to achieve efficiency [3, 4]. Indeed, a shorter stay reduces the cost per patient as it shifts care from inpatient to less expensive post-acute settings. While controversy remains [5], early postpartum discharge appears to be safe in controlled studies with a post-hospital follow-up program [6]. Typically, reducing the length of time patients stay in hospital could release capacity in the hospital system. Due to this reduction in length of stay, several countries, such as France [7] and England [8], have reduced their bed capacity in maternity services. However, this process is often the result of negotiation and is based on very rough data. To avoid under- and overcapacity, it is necessary to provide policy makers with a more objective and detailed assessment of the required capacity. Belgium is a relevant case for at least two reasons. First, the country is currently undergoing a major reform of the hospital landscape and payment system in which maternity services are an important component [9]. In the context of this reform, several pilot projects focusing on deliveries with shortened stays have been launched [10]. There is indeed room for such a shortening as the ALOS is situated 20% above the European average and well above the 2 days threshold after which further reductions appear hard to achieve [1]. Second, almost all deliveries (99%) take place in the hospital [11]. We examine the possible implications of reducing the ALOS on the required capacity in terms of service volume and maternity beds in Belgium. We first shortly describe the currently available capacity of maternity services. Then, we generate forecasts for the required capacity with a time horizon of 2025. Methods Although the focus of this study is on maternity services, the forecast analysis is part of a larger exercise exploring the global required hospital bed capacity [12]. In order to support decision makers in anticipating future hospital capacity need (in terms of stays, days and beds), a projection model was built that generates forecasts of all inpatient and day-care services in general hospitals in Belgium with a time horizon of 2025. However, the future required capacity for maternity services was examined more into detail and is the focus of this article. The starting point of the projection model is hospital use in 2014. This is subsequently adjusted by the combined effect of three evolutions to generate forecasts for future hospital capacity: the future evolution in population size and composition, the time trend evolution of ALOS, and the time trend evolution of the admission rates (more details below). The effect of the three evolutions can be separately identified. The outcome of the projection model can be interpreted as a ‘no policy change scenario’. Nevertheless, policy actions that were taken in the past, are reflected in the estimated time trends and their continued effect is projected into the future. In addition, we develop an alternative scenario in which the impact of an accelerated reduction of ALOS for deliveries is evaluated. DataPopulation data Past demographics are necessary to analyse hospital service use by sociodemographic group over time. The observed population size by age and sex over the period 2003 to 2016 is provided by Statistics Belgium based on the place of residence and aggregated at the level of the three Belgian regions: Flanders, Wallonia and Brussels. For the future evolution of the population residing in Belgium we use the projections that were released by the Federal Planning Bureau and Statistics Belgium in March 2017, providing annual projections of the population size up to 2061, subdivided by age, sex and region [13]. These population projections take into account international migration, domestic relocation, and the future evolution in fertility and mortality. Hospital data and APR-DRG classification system All Belgian general hospitals are required to submit twice a year a large set of data on all inpatient and day-care stays and emergency room contacts. Hospital data were available for 2003–2014 for all inpatient stays. Each inpatient stay is assigned an APR-DRG (All Patient Refined-Diagnosis Related Group) code using information on principal diagnosis, secondary diagno (...truncated)