Social inequalities, length of hospital stay for chronic conditions and the mediating role of comorbidity and discharge destination: A multilevel analysis of hospital administrative data linked to the population census in Switzerland

Abstract

Social factors are recognized determinants of morbidity and mortality and also have an impact on use of medical services. The objective of this study was to assess the associations of educational attainment, social and financial resources, and migration factors with length of hospital stays for chronic conditions. In addition, the study investigated the role of comorbidity and discharge destination in mediating these associations. The study made use of nationwide inpatient data that was linked with Swiss census data. The study sample included n = 141,307 records of n = 92,623 inpatients aged 25 to 84 years, hospitalized between 2010 and 2016 for a chronic condition. Cross-classified multilevel models and mediation analysis were performed. Patients with upper secondary and compulsory education stayed longer in hospital compared to those with tertiary education (β 0.24 days, 95% CI 0.14–0.33; β 0.37, 95% CI 0.27–0.47, respectively) when taking into account demographic factors, main diagnosis and clustering on patient and hospital level. However, these effects were almost fully mediated by burden of comorbidity. The effect of living alone on length of stay (β 0.60 days, 95% CI 0.50–0.70) was partially mediated by both burden of comorbidities (33%) and discharge destination (30.4%). (Semi-) private insurance was associated with prolonged stays, but an inverse effect was observed for colon and breast cancer. Allophone patients had also prolonged hospital stays (β 0.34, 95% CI 0.13–0.55). Hospital stays could be a window of opportunity to discern patients who need additional time and support to better cope with everyday life after discharge, reducing the risks of future hospital stays. However, inpatient care in Switzerland seems to take into account rather obvious individual needs due to lack of immediate support at home, but not necessarily more hidden needs of patients with low health literacy and less resources to assert their interests within the health system.

Social disparities in unplanned 30-day readmission rates after hospital discharge in patients with chronic health conditions: A retrospective cohort study using patient level hospital administrative data linked to the population census in Switzerland

“…Our analyses further show a high comorbidity burden of socially disadvantaged patients at hospital admission ( Fig 3 ). This confirms previous study findings that, in many countries, people with low educational attainment have higher comorbidity at hospital admission [ 64 ], higher proportions of ACS conditions [ 65 ] and poorer overall health [ 36 ] than people with high educational attainment. We assume that the presence of comorbidities further complicates discharge coordination, outpatient management and also self-management of the disease, thereby exacerbating social inequalities in readmission risks.…”

“…However, as the comparison of the statistical models shows, the significant effect of living alone ( Table 4 , model B) only disappeared when length of hospital stay was also taken into account (model C). In our previous analysis on length of hospital stay with the same data, living alone predicted a significantly longer length of hospital stay, independent of health status, social or demographic factors [ 64 ]. We therefore assume that the effect of living alone on readmission rates is partially mediated by length of stay.…”

“…A longer length of hospital stay also offers more time for instructions or training which may lead to a better prevention of 30-day readmission. We did not see the same pattern in patients with low levels of education; educational attainment did not predict length of hospital stay in the fully adjusted model [ 64 ].…”

Hospital length of stay and 30-day readmissions in older people: their association in a 20-year cohort study in Italy

“…In our study, the marked reduction of the mean and variability of LOS over time indicates that the decreasing trend concerned mainly the longest hospitalizations. However, the patients more likely to deserve a prolonged hospital stay are generally those with greater clinical vulnerability and/or poorer social assistance [31][32][33]. In these cases, reducing LOS with no concurrent improvements in the social and health services supporting the management of older adults after discharge could have unexpected and detrimental consequences.…”