The Burden of Guardianship: A Matched Cohort Study
BACKGROUND: In cases where patients are unable to provide informed consent and have no surrogate decision-maker, a hospital must seek guardian appointment as a legally recognized surrogate decision-maker.
OBJECTIVE: The aim of this study was to examine the magnitudes of length of stay (LOS) beyond medical clearance and healthcare costs among patients referred for guardianship.
DESIGN, SETTING AND PATIENTS: This was a retrospective cohort study of all 61 adult inpatients in a single tertiary care hospital requiring guardianship between October 1, 2014, and September 30, 2015, matched with up to 3 controls from the same discharging services and hospitalized for at least as long as the date of clearance for referred patients.
MEASUREMENTS: The following parameters were measured using generalized estimating equations: total LOS, LOS beyond medical clearance (excess LOS), medical complications, and total charges among referred patients, and the LOS and costs were compared with those of matched controls.
RESULTS: Mean LOS for patients requiring guardianship was 31 ± 2 days, and the total charges averaged $179,243 ± 22,950. We documented 12 hospital-acquired complications in 10 (16%; 95% confidence interval [CI], 8%–28%) unique patients. Accounting for potential confounders, the process of obtaining guardianship was associated with a 37% longer total LOS (95% CI [12%-67%]; P = .002), 58% higher excess LOS (95% CI [2%-145%]; P = .04), and 23% higher total charges (95% CI [4%-46%]; P = .02).
CONCLUSION: In this single-center cohort study, the guardianship process was associated with prolonged hospital stay and higher total hospital charges even when compared with matched controls. Furthermore, one in six patients suffered from a hospital-associated complication after medical clearance.
© 2018 Society of Hospital Medicine
Implications
At a time where medical systems are searching for opportunities to reduce the length of stay, prevent unnecessary hospitalization, and improve the quality of care, reevaluating the guardianship process is ripe with opportunity. In this single academic center, the process of guardianship was associated with 58% excess length of stay and 23% higher total hospital charges. Furthermore, one in six patients requiring guardianship suffered from hospital-associated complications.
This matched cohort study adds quantitative data demonstrating substantial burdens to the healthcare system as a result of the guardianship process and can be used as an impetus for hospital administration and legal systems to expedite the process. Potential improvements include increasing HCP form completions (which would eliminate the need to pursue guardianship for most of such patients), identifying patients who lack a legally recognized surrogate decision-maker earlier in their hospital stay (ideally upon admission), and providing resources to assist clinical teams in the completion of affidavits necessary to support the appointment of a guardian, so that paperwork can be filed with courts sooner. Further research that provides more generalizable prospective data could potentially improve the guardianship process and reduce its burden on hospitals and patients even further.
Acknowledgments
The authors express their tremendous thanks to Gail Piatkowski for her invaluable assistance in collecting administrative and billing data.
Disclosures
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article
