[Is it necessary to hospitalize so many children for so many days? Unnecessary pediatric hospitalization]

OBJECTIVE

A tendency exists towards an increase in hospital admissions of children whereas evidence shows that some of the admissions could have been avoided or the length of stays reduced. The aim of this study was to identify the proportion of unnecessary pediatric stays and the motive behind them.

PATIENTS AND METHODS

Three hundred eighty-eight hospital stays of 151 children between 6 months and 14 years of age which were discharged by the local pediatric hospital service have been reviewed. Patients and stays were selected at random. Admissions were stratified by age group and stays by episode length. The Pediatric Appropriateness Evaluation Protocol (PAEP) was used to evaluate the necessity of the hospital stay.

RESULTS

Of the admissions, 27.8% (42/151) were evaluated as unnecessary, as were 48.7% (189/388) of the hospital stays. Long stays (except for hospitalizations longer than 9 days), programmed admissions (93.5%), first admissions to a hospital (59.9%) and admissions evaluated as unnecessary (80.6%) were significantly associated with unnecessary stays. Hospital organization and doctors' style of practice accounted for 74.1% of the unnecessary stays and children familiar circumstances for 21.7%.

CONCLUSIONS

The high proportion of unnecessary stays and the motives, which explained them, justify the great concern about the criteria for the hospitalization of children and early discharge planning. To improve coordination among hospitals, central services, primary health care services and social services is probably required.

Chronic comorbidity and outcomes of hospital care: length of stay, mortality, and readmission at 30 and 365 days

This article evaluates the behavior of an adaptation of the Charlson Index (CHI) applied to administrative databases to measure the relationship between chronic comorbidity and the hospital care outcomes of length of stay (LOS), in-hospital mortality, and emergency readmissions at 30 and 365 days. These outcomes were analyzed in 106,673 hospitalization episodes whose records are registered in a minimum basic data set maintained by the public health authorities of the community of Valencia, Spain. The highest comorbidity measured by the CHI was associated with greater LOS and in-hospital mortality and increased readmission at 30 and 365 days. The rate of readmissions at 1 year dropped, however, in the group with the greatest comorbidity, probably owing to an increase in mortality after hospitalization. While comorbidity does appear to increase the risk of adverse outcomes in general and mortality and readmission specifically, the second outcome is only possible if the first has not occurred. For this reason, information and selection biases derived from administrative databases, or from the CHI itself, should be taken into account when using and interpreting the index.

[Do chronic diseases prevent intra-hospital mortality? Paradoxes and biases in information about hospital morbidity]

OBJECTIVE

Previous studies have demonstrated how the incomplete codification of the secondary diagnostics can bias the estimation of the risk of in-hospital death based on clinical-administrative databases. The objective of this study is to measure the trend of the association between in-hospital mortality and the secondary diagnostics register in the Minimum Basic Data Set (MBDS) of the Valencian Community.

METHODS

The 14,161 admissions of persons over the age of 64 were extracted from the MBDS (years 1993-94) for: stroke (S), bacterial pneumonia (BN), myocardial infarction (MI) and congestive heart failure (CHF). The relation was measured between the availability of some additional diagnostics (selected to dispose of a group of heterogeneous chronic and acute processes), and the risk of in-hospital death, relative risk (RR) and adjusted odds ratios (aOR) were calculated per age, gender, length of stay and number of diagnoses.

RESULTS

Many of the conditions are associated with a reduced risk of death such as the diabetes mellitus (Mortality for stroke, RR: 0.58; aOR: 0.53), old myocardial infarction (mortality for myocardial infarction, RR: 0.40; aOR: 0.35) or hypertension (mortality for stroke, RR: 0.54; aOR: 0.49): this also occurs in angina, coronary atherosclerosis, aortic and mitral valve disease, atrial fibrillation, chronic obstructive pulmonary disease and urinary tract infection.

CONCLUSIONS

Although there maybe other explanations, such as the existence of a bias in the hospital selection, the explanation which is most in agreement with the findings is the presence of an information bias in the MBDS due to the tendency to register less information about chronic antecedents of the persons who die.

Variations in diagnostic and therapeutic intensity between home and conventional hospitalization

OBJECTIVE

To analyse the variations in diagnostic and therapeutic intensity in patients with similar clinical conditions depending on whether they had hospitalization at home (HH) or remained in conventional hospitalization (CH).

DESIGN

Observational study of two patient cohorts (HH and CH) selected prospectively.

SETTING

University Hospital in the Valencia Health Service network, and the Hospital at Home Unit that it administers.

STUDY PARTICIPANTS

One hundred and forty-eight consecutive patients admitted to a Hospital at Home Unit, and 148 patients (matched by age, sex, disease group and hospital department) who remained in hospital in spite of fulfilling clinical criteria for HH as assessed by the nurses who normally evaluate suitability of admission to HH.

MAIN OUTCOME MEASURES

Number and cost of diagnostic tests, and cost of drugs and nursing materials per hospitalization in HH and CH.

RESULTS

The average number of tests for admission was significantly lower at home than in hospital (HH, 0.89; CH, 3.53); this translated into significant differences in the average diagnostic cost per hospitalization (HH, Pesetas 131; CH, Pesetas 3.316; US$1 approximately 130 Pesetas in 1994). Expenditures on drugs per episode (HH, Pesetas 7028; CH, Pesetas 16684) was also lower at home, but the differences were not significant for this or for expenditure for nursing materials (HH, Pesetas 3329; CH, Pesetas 2556).

CONCLUSIONS

Although some limitations of the study do not make it possible to establish unequivocal conclusions, the results point to the existence of different diagnostic and therapeutic patterns in HH and CH, which translate into significant differences in hospitalization costs.

[Effect of the presentation of results from clinical trials on the intention to prescribing: relativity of the relative risk]

OBJECTIVE

To determine if the methods of reporting results of clinical trials affects the physician views on prescribing.

DESIGN

Analysis of responses, from a convenience sample of primary care physicians, of one teaching exercise on prescribing intention which showed 5 different methods of reporting results: relative risk reduction (RRR), absolute risk reduction, the percent of event free patients, the number needed to treat (NNT) and RRR and mortality.

SETTING

Curses of clinical management in Valencia and Barcelona.

RESULTS

The willingness to prescribe was significantly influenced by the way in which data were presented, being major when they were showed as RRR and minor when mortality was added.

CONCLUSIONS

The method of reporting trial results has an important influence on the prescribing intention. The reporting of clinical trial results, and their abstracts or citations, should be include the NNT and negative results, for avoiding a subjective bias of treatment effect magnification.

[Automated analysis of the quality of the minimum set of basic data. Implications for risk-adjusting systems]

SETTING

Together with the age of the patient, the main diagnosis, secondary diagnosis (comorbility and complications) and the procedures performed are the critical variables for risk-adjusting. Therefore, its correct incorporation to CMBD is of great importance. However, several studies, especially in the United States, but also in Spain, have made evident the existence of important problems of quality in these data, difficulties for its improvement and the limitations which this has to assess the quality or the efficiency of hospitals. The objective of this study is to approach the quality of administrative and clinical collected in the CMBD of the Valencian Health Service (VHS) using an automatized process of analysis of data from the same CMBD, and discuss the implications for its management, as well as possible improvement strategies.

MATERIAL AND METHOD

An automatized analysis of the quality of CMBD 1994 of the VHS (20 hospitals, 241,341 admissions) was performed, using indicators of valid fulfilling of field values, relationship between fields of the same episode, relationship between variables in different episodes and volume and specificity of clinical information.

RESULTS

The analysed CMBD contains few errors in management variables, with the exception of residence, but it shows important problems of volume and specificity of clinical information, as well as a high variability in its fulfilling and quality in different hospitals.

CONCLUSIONS

The quality of the clinical data of CMBD may be biased in its use with management aims or when assessing quality, as well as in epidemiological studies, evaluation of technology or use of services.

[Hospital at home and conventional hospitalization. An economic evaluation]

BACKGROUND

To carry out an economic evaluation of hospital at home (HH) vs. conventional hospitalization (CH) from the hospital cost perspective.

METHODS

A minimization cost analysis were performed in 2 groups of patients (HH: 148 patients, 1,776 days of care; CH: 148 patients, 1,113 days) with similar characteristics. We used cost per hospital episode (only for the comparable period in HH and HC) and cost per day as outcome measures. The costs of health care professionals, pharmacy, sanitary material, diagnostic and therapeutic tests and transport were directly estimated for each patient. Other costs were indirectly assigned from the hospital accountability information system.

RESULTS

The average episode cost at home was 172,043 ptas. (about $1,300) less compared to the conventional hospitalization. Cost per diem for HH was 25,565 ptas. less than CH. Marginal costs were 14,987 and 2,913 ptas. minor in HH than CH, per episode and day respectively. When we consider HH staff as a differential cost (i.e. to establish a new hospital at home unit with new staff) marginal cost per episode was 2,276 pesetas higher than CH.

CONCLUSIONS

HH is a cost-effective option when decisions take into account the average cost (establishment of a new unit vs. a new ward) or when the HH unit is created as a substitute service through the conversion of pre-existent resources. However, HH is a disadvantaged cost option when it is created as an additional resource.

[Avoidable hospitalization using ambulatory surgery in the Community of Valencia: a Delphi study]

BACKGROUND

To estimate the number of hospital admittance's avoidable by means of ambulatory surgery, according to surgeons and anaesthetists who currently work with the National Health System (NHS).

METHOD

By means of a Delphi procedure of 25 surgeons or anaesthetists of the Valencia Health Survey (AServei Valencià de la Salut-SVS), a consensus was reached as to the objective criteria for excluding patients that could be treated outside a hospital and the percentage of certain operations that could be performed under day surgery. These criteria were applied to the Minimum Basic Data Set on hospital discharge within the Autonomous Region of Valencia in order to estimate the figure of hospital admittance and stays avoidable by means of ambulatory surgery in a selection of 29 surgery processes.

RESULTS

83% of medical personnel responded to the Delphi questionnaires. The median of the surveyed group's estimation on the proportion of cases that could be treated by means of external surgery varied from 40% for abdomen wall hernias or laparoscopic cholecystectomy and 90% for perianal tissue excision, anastomosis for dialysis or ganglionectomy. Application of the results of the Delphi survey would have meant that the SVS could have avoided 12,558 admittances in 1994, 75% of the operations surveyed, which is almost the same figure resulting from applying the medical personnel's opinion of the CMBD.

CONCLUSIONS

SVS professionals consider it feasible to perform a much higher number of ambulatory operations than those currently carried out, and that it is likely that the causes for the lack of such operations lie in SNS financing and incentive criteria, rather than medical issues.

[Structural analysis of the new model of primary care in the community of Valencia]

OBJECTIVES

To analyse the structure of the new model of primary care (NMPC) in the Community of Valencia, and to identify the strategic importance of its characteristic variables and the possibilities of intervention to affect these variables.

DESIGN

A qualitative study through a method of structural analysis (crossed impact method-multiplication applied to a classification) of the relationships between 37 variables characterising the NMPC which were identified by prior qualitative research, with interpretation of the results using the Téniere-Buchot Model.

SETTING

Community of Valencia.

RESULTS

The structural variables identified were those relating to the political-legal framework and to the allocation of primary care resources; and the resultant variables, those relating to efficiency and primary care quality. Between these two categories, the intervention variables covered management, NMPC professionals, health needs and the community's use of services.

CONCLUSIONS

The structural analysis gives the legal-political and economical framework a determining role in NMPC, which can hardly be influenced from within the system. Management and organisation are identified as key variables from which an intervention can be made in the short or medium term to achieve the aims of the system.

[Validity of the protocol for evaluating the inappropriate use of hospitalization]

BACKGROUND

The study was carried out in order to assess the inter-observer reliability and validity in respect of clinical appraisal given by the Appropriateness Evaluation Protocol (AEP), in the context of the Spanish Public Hospital System.

MATERIAL AND METHOD

In order to assess the reliability a total of 614 hospital stays chosen at random from 56 hospital admissions were independently analysed by three reviewers (two doctors and one nurse). In order to assess the validity, the findings obtained by the nurse were compared with the majority opinion given by the 7 hospital specialists in respect of each of hospital stays under evaluation. As part of the analytical procedure, indices for observed agreement, and specific agreement were calculated, as well as the Kappa statistic, all forming of various random samples of 614 hospital stays. In order to assess the predictive validity of the AEP, its sensitivity, specificity and predictive values were all measured against the majority clinical judgement.

RESULTS

The study exhibited a high degree of inter-observer reliability (specific agreement > 64%, kappa > 0.75) and a reasonable validity in comparison with the consensus of opinions formed by a least 4 or 5 of its 7 clinical reviewers (specific agreement > 61%, kappa > 0.64), these values decreasing notably when the consensus of 6 or 7 of the reviewers was required. The AEP revealed a high degree of sensitivity and a low degree of specificity in comparison with the majority clinical assessment, thus minimising the occurrence of false results when the stay was regarded as appropriate, and producing false negatives (appropriate hospital stays regarded as inappropriate) varying in degree from moderate to very high.

CONCLUSIONS

The results showing high reliability and moderate validity regarding clinical assessment shows the AEP to be a useful instrument in the sifting-out of inappropriate use of hospitalisation, although they do not allow a definitive judgement to be made concerning the efficiency of hospital services nor judgements regarding individual cases.

[Factors associated with emergency hospital readmission in digestive and hepatobiliary diseases]

OBJECTIVE

To describe the epidemiological characteristics of emergency readmissions due to digestive and hepatobiliary diseases within the hospitals of the Valencian Health Service (VHS), Spain, and to examine their relationship with defined variables related to patients or to previous periods of hospitalization.

PATIENTS AND METHODS

Out of the 212,947 episodes of patient hospitalization included in the Uniform Hospital Discharge Data Set of the VHS, excluding those persons under 16 years of age, those who had died in hospital or were discharged due to being transferred to another hospital and also excluding the two hospitals whose record were of poor quality, 18,075 patients were chosen whose principal diagnosis on first admission was one of a digestive or hepatobiliary disease. After a descriptive analysis the relationship was explored between risk of readmission and the variables of age, gender, hospital funding, whether the environment is a rural or urban one, the hospital itself, the diagnostic group, comorbidity, type of admission, length of stay, presence of surgical procedure, discharge criteria and service using an independent Cox Proportional Hazards analysis for each variable and a second Cox analysis adjusted for selected variables.

RESULTS

16.9% of those patients discharged for digestive disorders are re-admitted within a year. The risk of readmission is associated with age, comorbidity, male sex and chronic diseases and, with respect to the previous episode of hospitalization, it is associated with emergency admission, longer period of hospitalization, non-surgical discharge and admission to certain hospitals.

CONCLUSION

The risk of emergency readmission is associated with defined variables relating to patient or previous episodes of hospitalization connected with a more serious condition. The risk adjustment carried out could be used in order to identify high-risk cases which could then be paid special attention in order to delay or prevent readmission and as an indirect indicator for use in monitoring the quality of hospital care.

[What does the average stay say about the diagnosis-related groups?]

BACKGROUND

The systems for classifying patients into homogeneous groups of resource consumption such as diagnosis related groups (DRG) use mean stay (MS) as the principal predictive variable of this consumer entity. The standard of MS for each DRG is usually defined as the MS of this DRG in one group of hospitals. This method omits the existence of unnecessary days of hospitalization which are added to the standard and may be identified by review of hospitalary use.

METHODS

A retrospective review of the clinical need for 933 days of hospitalization (190 days of admission plus 743 successive stays for the same) in 190 cases of 167 DRG (appendicectomy without complications or comorbidity in those under the age of 70 years) in 8 public hospitals in Valencia (Spain) was performed by the Appropriateness Use Evaluation Protocol.

RESULTS

Four days of admission (2.1%) and 284 successive stays (38.2%) were considered unnecessary from a clinical point of view. Necessary MS was estimated as 3.4 days for GRD vs the 5.1 days of MS observed.

CONCLUSIONS

The common construction of standards of mean stay per disease demonstrates an important proportion of unnecessary use of hospitalization, the correction of which would allow a reduction in the mean costs of the process without a reduction in the quality of care.