More hospitals will get dangerously overcrowded, researchers project

If your local hospital isn't already packed with patients, there's a good chance it will be in a few years. That's the conclusion of a research letter published in JAMA Network Open that projects overall national hospital occupancy will reach an unsafe level by 2032.

The paper provokes important questions that journalists can strive to answer:

• Are your local hospitals operating at unsafe capacities? If so, how are patients being affected?
• How have hospital closures affected access to care?
• What strategies are local, state and federal policymakers considering to meet growing inpatient demand?

Reversing historic oversupply

Bed supply wasn't always tight. After a construction boom, government and private payers tried to contain ballooning inpatient costs in the 1980s by reducing lengths of stay and shifting care to less expensive outpatient venues. Occupancy fell, leading to a decades-long trend of consolidations and closures.

To examine where capacity is heading now, researchers at David Geffen School of Medicine at UCLA, Los Angeles, tapped a federal dashboard of weekly hospital occupancy reports created as part of a COVID-19 pandemic data tracking effort. (As of May 1, 2024, hospitals were no longer required to report their occupancy data to the federal government. However, the American Hospital Association collects similar data.)

The pandemic appears to be a tipping point where contraction of the bed supply may have gone too far. The researchers reported that the national occupancy rate spiked to 75% after the pandemic, compared with an average of about 64% in the decade before the public health emergency.

They wrote that the U.S. "has achieved a new post-pandemic hospital occupancy steady state 11 percentage points higher than it was pre-pandemic." They added that appeared to be driven by a 16% reduction in the number of staffed hospital beds rather than more hospitalizations.

That's a bad sign for patient safety. The states of Rhode Island, Massachusetts and Washington (see chart) have already exceeded a key threshold of 85%, the maximum at which an individual hospital can be expected to handle demand surges from seasonal spikes or unexpected emergencies safely.

Note that some evidence suggests adverse events from overcrowding - such as medication errors and delayed care-occur well below that 85% benchmark, especially for small and rural hospitals.

A crowded future

The researchers projected that the nation's hospitals will get more crowded in the coming decade.

Absent changes in the hospitalization rate or staffed bed supply, annual hospitalizations will climb from 36 million this year to 40 million in 2035 due to an aging population, they found. In that case, the national occupancy rate will reach 85% by 2032 for adult beds and 3035 for adult and pediatric beds combined.

That's alarming because studies in developed countries link overcrowding and understaffing to increased inpatient mortality. In some areas, overcrowding has already created risky situations such as older patients staying overnight in the emergency department.

"If the U.S. were to sustain a national hospital occupancy of 85% or greater, it is likely that we would see tens to hundreds of thousands of excess American deaths each year," lead investigator Richard Leuchter, M.D., an internist and assistant professor of medicine at UCLA, said in a news release.

In their analysis, the researchers did not account for factors such as recent growth in the average length of stay, unexpected medical breakthroughs or changes in population health that could affect utilization, or the ability to shift resources within the health care system.

The research team noted that trends in national hospital utilization may not hold for individual states, counties or hospitals.

Stories to follow

Reporters can expose how shortages of staffed inpatient beds affect patient care and what if anything hospital planners and government policymakers are doing to address current and future shortages.

Many ideas are floating about.

The UCLA researchers cited measures to shore up capacity: preventing more hospital closures and bankruptcies by revamping reimbursement schemes and regulating private equity involvement in health care; relieving clinician burnout; expanding the pipeline of health care professionals; and innovating care delivery.

In an accompanying editorial, two emergency medicine physicians argued for a regulatory course correction that enables rapid expansion of hospital capacity.

During the pandemic, a 1,000-bed hospital was reportedly built in China in just 10 days, they noted, while the U.S. financing system has "perversely" restricted the development of inpatient beds to help the sickest patients.