long-term hospitals, nursing homes or similar facilities. The identification of ... Inappropriate utilization could be due to organizational deficiencies of die hospital, to ..... which to develop specific actions to avoid inappropriate admissions or ...
Inappropriate hospitalization Reasons and determinants DAVID OTERINO DE LA FUENTE, SALVADOR PEIR6, CATALINA MARCHAN, EDUARD PORTELLA •
Key words: utilization review, inappropriate utilization
I
identification and reduction of inappropriate hospital utilization is one of the most interesting possibilities for simultaneously improving die quality and efficiency of hospital care.1"* Included widiin die concept of inappropriate hospital utilization, also known as unnecessary or non-acute use, are die hospital stays of patients which, from die strictly clinical point of view, could have been avoided if die same care had been given at more suitable levels of care: ambulatory care, day centre care, home care, long-term hospitals, nursing homes or similar facilities. The identification of unnecessary hospital use by means of objective instruments applied to die retrospective review of medical records (MRs) is usual in utilization review programmes in die United States and dieir estimation, despite being very variable depending on die hospitals and review mediodologies, is found to be approximately one diird of all hospital stays.^ In Europe die figures are similar,10"13 although publications are more scarce and usually deal with researches which do not form part of intervention programmes oriented towards die reduction of unnecessary use. Inappropriate utilization could be due to organizational deficiencies of die hospital, to inefficiencies in die medical management of die patients, to die patient's own problems (social and family) or to problems of die care network, such as die lack of alternative treatment set* O. Oterlno de la Fuente'. S. Pelro1. C Marchan', E. Portella' 1 Research Unit Hospital Olnko-Unlvenitarlo, Valencia. Spain 2 Health Sconces Research Unit Vatendan Institute for Studies in Public Health. Valencia, Spain Correspondence Salvador Pelro. Health Services Research Unit Valendan Institute for Studies In Public Hearth, Juan de Garay 21,46017 Valencia. Spain. Ml. +34 6 3S693S9, fax +34 6 3869370
tings. In studies carried out in die USA, cases attributable to hospital inefficiency or to die doctors who work in diem, amount to three-quarters of die total number, die remaining quarter being attributable to socio-family problems and to deficiencies in die care network.2'6'1* This last figure is lower in our setting which, despite probably having more family support, does not appear to have a greater supply of alternative care. l5 ' 16 The lack of reporting of socio-healdi data in MRs could, however, hinder - from die retrospective review of medical archives - die identification of die causes of inappropriate use originating from die patient's background or from die external care system of die hospital, giving way to biased results and perhaps being a source of the differences with United States' studies. A review of MRs while the patients are still hospitalized, would avoid diis restriction by allowing access to information from the patients or rheir families, die doctor, nursing staff and social services. On the odier hand, early identification of patient characteristics or of die hospitalization episode associated widi unnecessary use, would allow die development of selective strategies for its reduction, as well as activities at die beginning of hospitaliiation in those cases widi a greater probability of inappropriate use. The aims of this study are die identification of die reasons for inappropriate hospital use and the identification of the characteristics of the patients or of die hospitalization episodes associated widi unnecessary hospital utilization. MATERIAL AND METHODS Study population and scope A cross-sectional study was conducted reviewing 611 hospital stays of patients admitted for at least 2 days in a
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The aims of this study are the identification of the reasons for inappropriate hospital utilization In a Spanish university hospital and the identification of the characteristics of the patients or of the hospitalization episodes associated with Inappropriate hospital use. A concurrent review of 6 1 1 hospital stays was conducted, weighted by the proportion of beds in each group of hospital departments (n=334), by means of the appropriateness evaluation protocol (AEP), identifying the dinical need of each stay and assigning, in each case, reasons for unnecessary use. A descriptive analysis and logistic regression are presented to identify the determinants of unnecessary utilization. Of the hospital stays 43.9% were assessed as unnecessary. Almost 90% of unnecessary stays were attributed to the responsibility of the hospital, the department or the doctor, 2% to the sodo-family background of the patient and 7.5% to lack of alternative hospital resources. Lack of family support, the assessment as unnecessary of the day of admission and the hospital department were significantly associated with inappropriate utilization, although the first factor has scarce practical relevance due to its low frequency. The results show the importance of unnecessary hospital utilization and the possibilities of designing specific measures for improving hospital efficiency.
lnappropriau hospitahzaaon
third-level hospital run by the Valencian Health Service. Stays of patients under 7 years old and admissions to paediatrics, obstetrics, psychiatry and toxicology wards and intensive care units were excluded. Although the sample - designed to show differences between departments which are presented elsewhere1* — was calculated separately for each of the 4 hospital departments (involving populations of between 4,000 and 10,000 stays according to departments, an estimated proportion of inappropriate stays of 40%, a random error of 8% and a confidence interval of 95%) in diis study the sample has been weighted (n-334) assigning a weight to each department proportional to its number of hospital beds, so that the results represent those patients hospitalized in a 1 day cross-sectional cut-off point. Table 1 presents the characteristics of diis sample.
The AEP evaluates the need for admission by means of 16 criteria relating to die medical status of die patients and die intensity of die care diey receive. The need for each stay is evaluated by means of 27 criteria relating to the medical status of die patient and die medical and nursing care diey receive. In bodi cases, die presence of only 1 of die criteria is sufficient to consider die admission or stay as appropriate. If none of die criteria are fulfilled die stay is considered inappropriate. Judgement about die
Review process The mediodology and review instruments were explained to die hospital management and die doctors and nursing staff responsible before initiation of die field work, which was carried out between May and June 1993. The reviewers were 1 doctor and 1 nurse previously trained in die use of die AEP until dieir degree of concordance widi an experienced reviewer, measured by overall agreement, 22 surpassed 90%. The reviewers, following a strategy which simulated a cross-sectional cut-off point of 1 day's hospitalization, reviewed die MRs of each of die patient days selected, and evaluated die need for diat stay as well as diat of die day of admission. If diey were considered unnecessary a reason was given. Later die patient or die family was interviewed to obtain data which did not appear in die medical records and to re-evaluate die reason given. If doubts persisted about die assignation of die reason for unnecessary use die doctor in charge of die patient, die nursing supervisor or bodi were interviewed. An average of 15 reviews were carried out per day. The lengdi of stay (LOS) was obtained after patients' discharge.
Table 1 Characteristics of hospital departments and distribution of reviewed stays
Deparment characteristics Number of bedi Percentage occupation Average length of stay Rotation (month) Sample characteristics Reviewed stays Weight Weighted tample
Gynaecology'
Trauma tologv Orthopaedics
32 67.1 7.0 2.9
40 98.1 11.4 2.6
138 0.2319 32
152 0.3158
48
Surgical1 99
87J 10.9 2.6 158 0.6266 99
Medical 163 92.8 10.5 2.7 163 0.9509 155
Department! included' * Gynaecology b: Tnumatdogy, Orthopaedics, Maxillo-facial plastic surgery c: Genera) surgery, Neurosurgery, Cardiovascular ortalmology, ENT (ear, nose and throat), Urology d: Internal medicine, Cardiology, Digestive, Endocrinology, Neumology, Nephrology, Oncology, Haemaiology. Infecrioui, Dermatology The characteristics of the departments refer to 1993 for all patients admitted
Analysis A descriptive analysis was conducted from die weighted sample which represents a cross-section of 1 day of hospitalization and an unadjusted logistic regression analysis to estimate die odds ratio for each of die explanatory variables. A multiple logistic regression analysis was also conducted (with die unweighted sample since it is adjusted for die variable hospital department) to estimate die likelihood diat die stay reviewed was inappropriate according to
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Review instruments For the identification of inappropriate utilization the Spanish version1^ of the appropriateness evaluation protocol (AEP) l *' 17 (available on application to the authors) was employed, consisting of 2 sets of criteria, objective and independent of die diagnosis, destined for the identification of admissions and inappropriate stays respectively in adult patients (neither psychiatric or obstetric). The validity and reliability of die AEP has been evaluated by its authors in the United States 17 and by independent evaluators in the USA, 18 Israel,19 and Spain,20-21 in each case showing satisfactory results.
need for admission is based on die information available in medical records until die end of die day of admission and die day of stay is assessed according to die information available up to die day of review. The AEP includes a list of reasons for inappropriate use grouped into 4 blocks: • patients who required admission to hospital but not on die day of die review (e.g. a patient admitted on Monday for elective surgery on Wednesday), • attributable to hospital organization problems or to die doctor, • attributable to die patients and dieir families and • attributable to die setting (e.g.: non-existence of resources odier dian die hospital). The last 3 groups include patients who no longer need to remain hospitalized.
EUROPEAN JOURNAL OF PUBLIC HEALTH VOL 6 1996 NO. 2 some of die patients' characteristics and their hospitalization episodes. The dependent variable was appropriateness for stay (yes/no) and included as explanatory variables were (die basal is quoted last) grouped hospital departments (gynaecology/traumatology-orthopaedics/ surgery/medicine), sex (male/female), level of education (no education/primary/secondary or tertiary education/ university), type of admission (emergency/programmed), distance of home from hospital by car (less than 15 min/between 16 and 30 min/more than 30 min), die day Table 2 Characteristics of the patients and hospitaltzation episodes (%) %
211 123
63J 36.7
165 169
49J 50.7
University Secondary Primary No formal education Distance to hospital (min) >30 15-30
21 26 133 144
6.5 8.0 41.2 44.6
55 43 235
16.6 12.8 70.4
312 22
93.5 6.5
Family support Yes
No Marital status Single Married Widowed Divorced/separated Day of the week evaluated Friday Thursday Wednesday Tuesday Monday Sunday Hospital department Medical Surgical Trauma tology Gynaecology Type of admission Programmed Emergency Length of stay (weeks) 1-3 >3
49 236 41 8
14.5 70.7 12J 2.5
18 44 65 62 68
5.4 13.2 19.5 18.6 23.1 20.4
155 99 48 32
46.4 29.6 14.4 9.6
115 219
34.3 65.6
77
RESULTS The characteristics of patients and the episodes of hospitalization are shown in table 2. The average LOS, in relation to die exclusion of paediatric, obstetric and cases of LOS under 2 days, was very high: 24.2 days (median 16; interquartile range (1QR) 9—32). The median of preoperative LOS was 4.5 days (IQR 2-10) and the median of time from admission until die review was 6 (IQR 2-14-25). With regard to die proportion of inappropriate use, 43.9% of stays and 27.6% of admissions corresponding to diese stays were considered inappropriate, widi a significant association between inappropriate stays and admissions (table 3), in such a way that when stays of patients were inappropriate admissions were also inappropriate in 42.8% of the cases and when diey were appropriate, admissions had also been so in 8 4 3 % of cases. Inappropriate stays were also associated (table 4) widi lengdi of stay, programmed admission and lack of family support, but not with sex, age, marital status, level of education, number of household members or distance of home from hospital. Sixty per cent of inappropriate stays (table 5) were due to inefficient management of the case attributable to the doctor or to die hospital (patients who medically did not require further hospitalization but who had not been discharged for different reasons: doctor's indecision, awaiting results of a test which would not have changed die discharge order, discharge report had not been carried out, administration of treatment which did not require hospitalization of the patient and similar motives). Another 20% of inappropriate stays were due to premature admission of die patient (the patient had to be admitted for tests, diagnostic examinations or elective surgery procedures, but diese were not carried out during the 24 h following admission widiout justified medical cause). The Table 3 Appropriateness of admission according to appropriateness of nay (%) Stays
Appropriate
Inappropriate
Total
n
%
n
%
N
%
158
84.3
29
15.7
84 63
57.2 42.8
242 92
72.4 27.6
187
56.1
147
43.9
334 100
Admissions
79 123 132
23.5 36.9 39.7
Appropriate Inappropriate
Total a: N»334; occasionally N-333 due to weight! b: N-324 (miistng data)
X1 - 29.03; p
