In the United States, the health care system has been a major part of society for more than fifty years. The need for health care has been closely connected to the quality of life of populations. The system has also been one of the largest businesses in the nation  .
The Coronavirus epidemic has probably strengthened the connection between health care and the quality of life. The utilization of hospitals, physicians, and other providers of care has increased. The awareness of symptoms and the use of preventive measures such as masks have become widespread. The consciousness of the importance of the health care system has been reflected in daily media reports  .
Amid this level of interest, attention to health care costs and efficiency has been somewhat lacking. Large amounts of money have been justifiably spent on Coronavirus vaccines. Billions of dollars have been devoted to the provision of care in hospitals and other providers, without a large amount of attention to the efficiency of these expenditures   .
It appears that epidemics and other clinical conditions will continue to challenge health care systems. At the same time, providers will need to improve efficiency and manage the resources needed to address these circumstances. This study included examples of programs that have been employed to meet these challenges at the community level  .
This study reviewed programs that have focused on improving the utilization of health care programs in the metropolitan area of Syracuse, New York. This area includes three large acute care facilities, Crouse Hospital (17,204 inpatient discharges excluding well newborns, 2020), St. Joseph’s Hospital Health Center (21,328 discharges, 2020), and Upstate University Hospital (30,988 discharges, 2020) .
These hospitals provide a full range of care to an immediate service area with a population of approximately 600,000. They also provide tertiary services to the eleven county Central New York Health Service Area with a population of approximately 1,400,000. The Syracuse hospitals have worked through the Hospital Executive Council to improve the efficiency of care in their service area.
This study reviewed three different programs developed to improve the efficiency of care in the service area of the Syracuse hospitals. Information concerning utilization of these services was available. They were implemented at the community level.
Each of the programs was employed by the management of provider services to expedite the utilization of care. These programs were developed prior to the Coronavirus epidemic, however, they have been useful in helping area providers address this challenge.
The initial program has been the use of ambulance diversion to improve access to care by moving incoming patients from hospitals that are at or near inpatient capacity to those where additional capacity is available. This has been accomplished though coordination with ambulance dispatchers. Through this approach, ambulances have been diverted prior to arrival at hospital emergency departments. This approach has influenced inpatient admissions and reduces the need for inpatient transfers between hospitals.
Ambulance diversion has been used by the Syracuse hospitals since the 1980s. They have employed the EMSystem to provide ambulance dispatchers and hospital with continuous information concerning the status of the system. It is operated by the Hospital Exfecutive Council.
The second efficiency program has been the use of length of stay reduction for adult medicine and adult surgery within a number of the individual Syracuse hospitals. This effort has included a variety of approaches to limiting stays by expediting the movement of patients home and to appropriate community services. They have focused on reduction of acute care stays, especially for patients who have needed extended inpatient therapy. Data for the program have been developed and distributed by the Hospital Executive Council.
The third program has been the increased use of ambulatory care services in the community for hospital patients with low severity of illness. These services have been used by hospitals and community physicians, especially orthopedists and other surgeons.
The initial program in the study involved the development of efficiency in admitting hospital inpatients by diverting incoming ambulances from hospitals where little or no additional capacity was available to hospitals where additional capacity existed. Relevant data are summarized in Table 1.
During the period between December 2020 and May 2021, the Syracuse hospitals experienced difficulties in locating unoccupied adult medicine and adult surgery beds. This resulted from increased occupancy produced by patients with
Table 1. Emergency department utilization, hours on ambulance diversion, Syracuse hospitals, December 2020-May 2021.
Source: Hospital Executive Council data.
the Coronavirus as well as the need to accommodate patients from previous time periods during the epidemic.
The data in Table 1 indicated that numbers of hours on ambulance diversion per month ranged from 69 to 345 in Hospital C, compared with 5 - 62 hours per month in Hospital B and 19 - 104 hours per month in Hospital A between December 2020 and May 2021. These data reflected the much larger numbers of hours when the emergency department in Hospital C was at or near capacity, compared with those in Hospital A and Hospital B. The data demonstrated that Hospitals A and B also generated hours on ambulance diversion, but at much lower levels than Hospital C.
As a result of the use of ambulance diversion, the Syracuse hospitals also experienced differences in numbers of ambulances received during the period of the study. In Hospital C that was at or near capacity, the monthly number of ambulances received ranged from 1198 to 1414. In Hospital B, the monthly volume ranged from 1807 to 2006 and in Hospital A, the monthly volume ranged from 1315 to 1569. The higher numbers of ambulances received at Hospitals B and A reflected the diversion of patients from Hospital C.
These data demonstrated how the use of ambulance diversion improved the system wide efficiency of the Syracuse hospitals with respect to incoming ambulances. Incoming patients were diverted from a provider where care was less available to hospitals where additional capacity existed. These data also made it possible for Hospital C, which had the largest Coronavirus population, to devote more resources to this population. Some of the additional capacity to serve this group was produced by the use of resources at the other hospitals.
The second efficiency program involved the use of length of stay reduction to improve efficiency by developing additional inpatient adult medicine capacity in the Syracuse hospitals. Relevant data are summarized in Table 2.
This information identified adult medicine lengths of stay in each of the Syracuse hospitals compared with severity adjusted national average for October 2019-March 2021. For each hospital, the data included the actual stays, differences between the hospital stays and the national average stays in patient days, and the differences in the average daily censuses.
The lengths of stay and related data suggested the impact of length of stay reduction among the Syracuse hospitals during the three month period. Compared with the severity adjusted national averages in Hospital A, the differences in stays generated reductions of 24.68 - 305.65 days per month for the six month period. In Hospital B, the stays produced savings of 448.15 - 1314.87 days per month. In Hospital C, the differences in patient days saved were 204.60 - 583.95 days per month.
The data demonstrated that substantial numbers of patient days were saved through length of stay reduction at two of the hospitals. These patient days saved amounted to reductions in the need for hospital resources such as nursing staff time, pharmaceuticals, and testing. These savings resulted in the need for 23.45
Table 2. Inpatient adult medicine mean lengths of stay and patient days difference from severity adjusted national average, Syracuse hospitals, October 2020-March 2021.
Source: Hospital Executive Council.
fewer inpatient beds at Hospital B and 12.74 fewer beds at Hospital C. The additional beds available at Hospital B amounted to a full nursing unit.
The third component of the study focused on the development of efficiency in the Syracuse hospitals through the substitution of ambulatory surgery for inpatient orthopedic surgery in the Syracuse hospitals. Relevant data are summarized in Table 3.
This information identified numbers of hip and knee joint replacements between July 2018-March 2019 and July 2020-March 21 in the combined hospitals. The data were categorized by severity of illness. During this period, additional ambulatory surgery capacity was developed in the community.
The data demonstrated that the number of inpatient hip replacements declined by 569, or 38.4 percent and the number of inpatient knee replacements declined by 908, or 61.5 percent, during the three nine month periods. Almost all of the reductions in inpatient joint replacements involved patients at Minor or Moderate severity of illness.
The study data suggested that the changes in the location of joint procedures during the three year period involved movement from inpatient to outpatient care. This development improved the efficiency of the health care system in Syracuse by reducing the need for inpatient resources and making beds available for other patients.
Table 3. Inpatient hospital discharges, hip & knee joint replacement (APR DRGs 301, 302), by severity of illness, Syracuse hospitals, July 2018-March 2021.
Source: Hospital Executive Council.
Since the middle of the twentieth century, health care providers and payors in the United States have worked to provide effective care at reasonable costs. This has frequently been a challenge, as demonstrated by rising expenses for health care and the limited success of federal health planning and private approaches such as managed care.
Addressing the COVID epidemic has added to this challenge. It has generated large expenditures to provide care accompanied by limited efforts to constrain costs. This study reviewed a few efforts to improve the efficiency of health care in this context. It focused on efforts at the community level where most health care is delivered.
Based on the experiences of providers in Syracuse, New York, the study suggested realistic approaches are necessary to improve health care efficiency. It described three different programs that have improved utilization at the community level. They have included the diversion of ambulances that has directed patients to emergency departments where care has been most available. They have also involved length of stay reduction to make additional inpatient care available. They have also included the use of ambulatory surgery for low severity of illness patients to limit the need for inpatient care.
The programs described in the study have demonstrated that the development of efficiency involves extensive efforts for the participating providers. Ambulance diversion has involved extensive communication and planning by ambulance dispatchers and emergency medical service staffs. Length of stay reduction has required large amounts of planning by hospital case managers, medical staffs, and long term care providers. The development of ambulatory surgery has included major expansion of this level of care.
The data from these programs demonstrated that efforts to improve efficiency of care can have an important impact on health care utilization and outcomes. Ambulance diversion and length of stay reduction in one of the hospitals made a large amount of capacity available to treat COVID patients in another. Length of stay reduction produced the largest impact by reducing the need for large amounts of inpatient hospital resources. At one of the hospitals, it made a nursing unit and related expenses available for other care needs. These developments occurred at a time when nursing staff were in short supply.
The results generated by the efficiency programs in the health care system of Syracuse suggest that, at a time when health care is involved with much larger issues, saving expenses is well worth the considerable efforts that it requires. The experiences of these programs demonstrate that fewer resources can be a more important objective than more of them.
 Auerbach, D.L. and Kellermann, A.L. (2011) A Decade of Health Care Cost Growth Has Wiped Out Real Income Gains for an Average U.S. Family. Health Affairs, 30, 1630-1636.
 Keehan, S.P., Cuckler. G.A., Sisko, A.M., Madison, A.J., Smith, S.D., Stone, D.A., Poisal, J.A., Wolfe, C.J. and Lizonitz, J.M. (2015) National Health Expenditure Projections, 2014-2024: Spending Growth Faster than Recent Trends. Health Affairs, 34, 1407-1417.
 Lagoe, R., Pasinski, T., Kronenberg, P., Quinn, T. and Schaengold, P. (2006) Linking Health Services at the Community Level. Canada Health Care Quarterly, 9, 60-65.