Prolonged hospitalization in Brazil: clinical need or systemic failure?

Area of Science:

• Healthcare Management
• Health Services Research
• Hospital Operations

Background:

• Prolonged hospitalization poses risks for adverse events and resource overuse.
• Brazil's dual public-private healthcare system presents unique challenges in understanding hospital length of stay (LOS).
• Distinguishing clinical necessity from systemic delays in LOS is crucial for healthcare efficiency.

Purpose of the Study:

• To quantify clinical and non-clinical factors contributing to medical inpatient LOS.
• To compare LOS patterns between public (Unified Health System [SUS]) and privately insured patients in Brazil.

Main Methods:

• Prospective multicenter cohort study of 5,423 adult internal medicine patients across three Brazilian hospitals (2009-2022).
• Daily physician assessment of hospitalization necessity versus delays (diagnostic, specialist, administrative, social).
• Multivariate statistical models adjusted for comorbidities and frailty.

Main Results:

• Mean LOS was 11.8 days; only 38% (4.5 days) were clinically justified.
• Non-clinical delays accounted for the majority of LOS, primarily from diagnostics (2.9 days) and specialist input (1.9 days).
• Unified Health System (SUS) patients experienced longer LOS (13.2 days) than privately insured patients (10.1 days), with higher odds of extended stays and significant delays in tests and specialist evaluations, even after adjustments.

Conclusions:

• The majority of hospital days are not driven by clinical necessity but by systemic delays.
• Diagnostic and specialist delays are major contributors to prolonged LOS, particularly within the public healthcare system.
• Findings highlight structural inefficiencies and the urgent need for healthcare system reforms in Brazil.