Factors affecting appropriateness of hospital utilization in two hospitals in Turkey

Factors associated with low-acuity hospital admissions in a public safety-net setting: a cross-sectional study

Background

Given system-level focus on avoidance of unnecessary hospitalizations, better understanding admission decision-making is of utility. Our study sought to identify factors associated with hospital admission versus discharge from the Emergency Department (ED) for a population of patients who were assessed as having low medical acuity at time of decision.

Methods

Using an institutional database, we identified ED admission requests received from March 1, 2018 to Feb 28, 2019 that were assessed by a physician at the time of request as potentially inappropriate based on lack of medical acuity. Focused chart review was performed to extract data related to patient demographics, socioeconomic information, measures of illness, and system-level factors such as previous healthcare utilization and day/time of presentation. A binary logistic regression model was constructed to correlate patient and system factors with disposition outcome of admission to the hospital versus discharge from the ED. Physician-reported contributors to admission decision-making and chief complaint/reason for admission were summarized.

Results

A total of 349 (77.2%) of 452 calls resulted in admission to the hospital and 103 (22.8%) resulted in discharge from the ED. Predictors of admission included age over 65 (OR 3.5 [95%CI 1.1–11.6], p = 0.039), homelessness (OR 3.3 [95% CI 1.7–6.4], p=0.001), and night/weekend presentation (OR 2.0 [95%CI 1.1–3.5], p = 0.020). The most common contributing factors to the decision to admit reported by the responding physician included: lack of outpatient social support (35.8% of admissions), homelessness (33.0% of admissions), and substance use disorder (23.5% of admissions).

Conclusions

Physician medical decision-making regarding the need for hospitalization incorporates consideration of individual patient characteristics, social setting, and system-level barriers. Interventions aimed at reducing unnecessary hospitalizations, especially those involving patients with low medical acuity, should focus on underlying unmet needs and involve a broad set of perspectives.

Inappropriate hospital days of a tertiary hospital in Shanghai, China

Objective

This study aims to evaluate the prevalence of inappropriate hospital stays in a tertiary hospital in Shanghai, identify the causes for the inappropriateness and analyze the predictors.

Design

A retrospective review of medical records.

Setting

The cardiology and the orthopedics departments of a tertiary hospital in Shanghai, China.

Participants

About 806 patients discharged from the cardiology or the orthopedics department of a tertiary hospital from March 2013 to February 2014.

Interventions

Two reviewers audited 8396 hospital days of the cardiology department (n = 3606) and the orthopedics department (n = 4790) by adopting the Chinese Version of the Appropriateness Evaluation Protocol. Univariate and multivariate analysis were adopted to identify the predictors of higher levels of inappropriateness produced by internal causes.

Main outcome measure

The prevalence of inappropriate hospital days.

Results

It was found that 910 (25.2%) and 1940 (40.5%) hospital days were judged to be inappropriate in the cardiology and the orthopedics departments, respectively; and 753 (20.9%) and 1585 (33.1%) of these inappropriate hospital days were due to internal reasons, respectively. Awaiting tests, surgery or discharge were determined to constitute the main causes of inappropriateness for both departments. The predictors of higher levels of inappropriateness in the cardiology department were younger age, self-pay, outpatient admission and inappropriate admission. Self-pay, surgical and/or first-time admission patients exhibited the highest levels of inappropriateness in the orthopedics department.

Conclusions

The rates of inappropriateness in the involved departments were relatively high. Further interventions should be designed and implemented, accordingly.

Length of stay as risk factor for inappropriate hospital days: interaction with patient age and co-morbidity

RATIONALE, AIMS AND OBJECTIVES

The likelihood of a hospital day being inappropriate depends on patient characteristics, on the organization of in-hospital care and on the co-ordination between hospital care and the rest of the health care sector. The aim of the study was to assess if certain socio-demographic and medical factors affect inappropriate hospital stay including possible interactions between age and co-morbidity.

METHODS

To determine the appropriateness of length of hospitalization, a prospective study was carried out using the European version of the Appropriateness Evaluation Protocol (AEP). A total of 438 hospital days of stay was analysed in medical wards of a university-affiliated teaching hospital in the North of Italy for 3 days in September 2010.

RESULTS

44.6% of hospitalization days were classified as inappropriate. Unjustified hospital use was more frequent in patients whose hospital length of stay exceeded 10 days. Age and co-morbidity were not per se risk factors for inappropriateness; however, in young patients hospitalized for more than 10 days, absence of chronic illness was a predictor. Conservative patient management, lack of discharge planning and delays in scheduling diagnostic tests or therapeutic interventions were the most common causal or contributory doctor- and hospital-related factors.

CONCLUSIONS

Doctor attitudes and hospital organization are still among the most common reasons for inappropriate in-hospital days of care. Monitoring whether the length of stay is appropriate combined with protocol interventions for scheduling of diagnosis, treatment and discharge are likely to improve efficiency in this area of medical care.

Managerial Roles of Physicians in the Turkish Healthcare System

In recent years, many healthcare organisations in the world have been changing in the direction of a professional management leaving behind a model of physician dominance. As one of the most essential functions in hospitals, professional management is vital in order to achieve performance efficiently. The main point which must not be ignored is that the education, the knowledge and the skills are key elements for professional management in the healthcare sector. This issue is also currently one of the major topical issues in the Turkish healthcare system to overcome existing management problems. The study assesses the roles of physicians for the future environment by analysing the management roles of Turkish physicians based on available data.

Characteristics of patient and healthcare service utilization associated with inappropriate hospitalization days

AIM

This paper is a report of a study to examine the number of inappropriate days of hospitalization and to identify the characteristics of patient and healthcare service utilization associated with inappropriate hospital stays.

BACKGROUND

Inappropriate hospitalization stays are recognized as an important indication of the misuse of healthcare services, but the published literature shows inconsistent findings on factors influencing this.

METHOD

A descriptive, correlational study was carried out in September 2005, with a patient survey and a review of patient records. Data were collected for 383 patients discharged from eight general nursing care units in a tertiary teaching hospital in Korea. Inappropriate hospitalization days were defined as inpatient days not requiring continuous and active medical, nursing or paramedical treatment provided by hospital services, and were judged using the Korean version of the Appropriate Evaluation Protocol. Univariate and multiple regression analyses were performed to determine factors associated with inappropriate hospitalization days.

FINDINGS

A total of 3076 hospitalization days were reviewed. The average proportion that were inappropriate was 5.1% (+/-16.0) per patient, and 14.1% of patients were determined to have had at least one inappropriate hospitalization day. The most common reason judged as appropriate was need for nursing/life support services. Statistically significant factors associated with inappropriate stay included gender, age, primary disease, length of stay and ward bed occupancy level during the patient's hospitalization.

CONCLUSION

Managers should take into account patient and clinical characteristics to promote better utilization of hospital resources.

[Inappropriateness of hospital use in two acute geriatrics department: description of the phenomenon and analysis of risk factors]

BACKGROUND

Inappropriateness of hospital use occurs when a gap between the patient's needs and the level of care delivered exists. Taking into account the improvement of number of acute geriatric care, it appears relevant to study the rate and causes of inappropriate hospital use in this context.

METHODS

All patients in two services of acute geriatrics were included: medical and socioeconomic data were collected, the appropriateness of each day of their hospitalization was evaluated using the French version of the Appropriateness Evaluation Protocol and the inappropriate days' Causes Analysis Protocol. Risk factors of having at least one inappropriate day occurring during the stay were searched using relevant statistical tests. A logistic regression model assessed influence of independent variables on the risk of inappropriateness.

RESULTS

Only the existence of cognitive impairment and the department where the hospitalization takes place were found to be risk factors of inappropriateness. The ranking of inappropriateness according to the causes is the same in the two services, yet with statistically different rates, in particular for causes related to waiting for admission in subacute or long-term care institutional network and for a service provided outside the hospital where the patient was admitted. In the two departments, over 25% of the inappropriate days were related to a patient's or his family's choice.

CONCLUSION

Access to subacute or long-term care institution is the first cause of inappropriate hospital use in the two departments. The importance of the rate of inappropriate days related to a choice of the patient or his family was probably a Geriatric specificity. Furthermore, in view of reducing the inappropriate hospital use, attention should be particularly paid on patients with cognitive impairment.

Effects of a fix-payment method per outpatient on the procedures, in university hospitals, Turkey

The effects of payment methods on clinical practice are not well understood, in Turkey. In the middle of 2006, a fix-payment method for hospitals was implemented, and 5 months later was cancelled. The aim of the study was to evaluate the effects of the payment method on the clinical practice in the University hospitals. The data in this study was retrospectively obtained from six university hospital records. Main outcome measure is procedure number per outpatient. The overall mean procedure number per outpatient was found as 12.2. A significant decrease was observed in the mean procedure number during the period of fix-payment method (p<0.05). While the mean number remained at the level of 13.4+/-6.3 during the other months of the year (p<0.05), it came down to the level of 10.3+/-4.8 during the period of fix-payment method. A decrease of 23% in procedures was calculated during the new method. It was concluded that payment model for hospitals was an effective factor on clinical practice.

Appropriate utilization of hospital beds in internal medicine: evaluation in a tertiary care hospital

AIM

To assess the appropriateness of utilization of beds in the internal medicine department of a university hospital.

METHODS

The appropriateness of hospital stay was evaluated using the Appropriateness Evaluation Protocol. A random sample of 402 days of stay was assessed.

RESULTS

One hundred and thirty-nine days of stay (34.6%) were classified as inappropriate. The inappropriate stays were mostly secondary to hospital-related factors. The two major factors for inappropriate stays were 'inappropriate timing/delay in diagnostic procedures/consultations' (27%) and 'delay in obtaining test results' (27%). None of the factors including age, gender, residence and inpatient period was significantly related to inappropriate stay in univariate analysis.

CONCLUSION

This study indicated that a significant portion of stays were inappropriate. Efforts to decrease particularly hospital-related factors associated with inappropriate stay are needed.

The association between clinical pathways and hospital length of stay: a case study

Clinical pathways are the treatment protocol in order to reduce or eliminate variation of care by specifying to nursing and medical staff. The effectiveness of the clinical pathways to accomplish this goal, however, is in question. With the implementation of the clinical pathways in 2001, this study evaluates the effectiveness of clinical pathway in reducing the inpatient length of stay in a rural hospital in a Midwestern state. All inpatient cases were used with the primary diagnoses of chronic obstructive pulmonary disease, congestive heart failure, diabetes, myocardial infarction, and pneumonia from the years of 1999-2003. By controlling for gender, age, insurance type, and year, this study employs a multiple regression analysis to evaluate the association between clinical pathways and the length of stay. Only one (the clinical pathway for myocardial infarction) out of the five pathways studied showed an association with a statistical significance in decreasing the length of stay. Health care administrators should consider other aspects as well as the hospital length of stays when implementing clinical pathways in their facility.

Appropriateness of admission and length of stay in a Turkish Military Hospital

The purpose of this study was to determine the extent of inappropriate days of stay in a Turkish military hospital, and to explore the variables correlated with these. A review was made of the medical records of surgery patients admitted to the hospital of Gülhane Military Medical Academy. To determine the appropriateness of lengths of hospitalization, a Turkish version of the Appropriateness Evaluation Protocol (AEP) was applied retrospectively. A total of 375 patients'files were reviewed; and 21.3% of the hospital admissions were evaluated as inappropriate. Multiple logistic regression analysis showed that inappropriate length of stay was significantly increased with relation to age, emergency status, military rank, and distance from the hospital to the patient's home. The results of the study suggest that changes in physicians' behavior and in the organization of hospital activities may be effective in improving the quality and efficiency of hospital care.