Validation of a tool assessing appropriateness of hospital days in rehabilitation centres

Inappropriate Hospital Admission According to Patient Intrinsic Risk Factors: an Epidemiological Approach

BACKGROUND

Inappropriate hospital admissions compromise the efficiency of the health care system. This work analyzes, for the first time, the prevalence of inappropriate admission and its association with clinical and epidemiological patient characteristics.

OBJECTIVES

To estimate the prevalence, associated risk factors, and economic impact of inappropriate hospital admissions.

DESIGN AND PARTICIPANTS

This was a cross-sectional observational study of all hospitalized patients in a high complexity hospital of over 901 beds capacity in Spain. The prevalence of inappropriate admission and its causes, the association of inappropriateness with patients' intrinsic risk factors (IRFs), and associated financial costs were analyzed with the Appropriateness Evaluation Protocol in a multivariate model.

MAIN MEASURES AND KEY RESULTS

A total of 593 patients were analyzed, and a prevalence of inappropriate admissions of 11.9% (95% CI: 9.5 to 14.9) was found. The highest number of IRFs for developing health care-related complications was associated with inappropriateness, which was more common among patients with 1 IRF (OR [95% CI]: 9.68 [3.6 to 26.2.] versus absence of IRFs) and among those with surgical admissions (OR [95% CI]: 1.89 [1.1 to 3.3] versus medical admissions). The prognosis of terminal disease reduced the risk (OR [95% CI]: 0.28 [0.1 to 0.9] versus a prognosis of full recovery based on baseline condition). Inappropriate admissions were responsible for 559 days of avoidable hospitalization, equivalent to €17,604.6 daily and €139,076.4 in total, mostly attributable to inappropriate emergency admissions (€96,805.3).

CONCLUSIONS

The prevalence of inappropriate admissions is similar to the incidence found in previous studies and is a useful indicator in monitoring this kind of overuse. Patients with a moderate number of comorbidities were subject to a higher level of inappropriateness. Inappropriate admission had a substantial and avoidable financial impact.

Psychometric validation of the Italian Rehabilitation Complexity Scale-Extended version 13

In Italy, at present, a well-known problem is inhomogeneous provision of rehabilitative services, as stressed by MoH, requiring appropriate criteria and parameters to plan rehabilitation actions. According to the Italian National Rehabilitation Plan, Comorbidity, Disability and Clinical Complexity should be assessed to define the patient's real needs. However, to date, clinical complexity is still difficult to measure with shared and validated tools. The study aims to psychometrically validate the Italian Rehabilitation Complexity Scale-Extended v13 (RCS-E v13), in order to meet the guidelines requirements. An observational multicentre prospective cohort study, involving 8 intensive rehabilitation facilities of the Emilia-Romagna Region and 1712 in-patients, [823 male (48%) and 889 female (52%), mean age 68.34 years (95% CI 67.69-69.00 years)] showing neurological, orthopaedic and cardiological problems, was carried out. The construct and concurrent validity of the RCS-E v13 was confirmed through its correlation to Barthel Index (disability) and Cumulative Illness Rating Scale (comorbidity) and appropriate admission criteria (not yet published), respectively. Furthermore, the factor analysis indicated two different components ("Basic Care or Risk-Equipment" and "Medical-Nursing Needs and Therapy Disciplines") of the RCS-E v13. In conclusion, the Italian RCS-E v13 appears to be a useful tool to assess clinical complexity in the Italian rehab scenario case-mix and its psychometric validation may have an important clinical rehabilitation impact allowing the assessment of the rehabilitation needs considering all three dimensions (disability, comorbidity and clinical complexity) as required by the Guidelines and the inhomogeneity could be reduced.

Developing of the appropriateness evaluation protocol for public hospitals in iran

Background:

Employment of utilization review instruments is a method for managing costs and efficiency in the healthcare systems.

Objectives:

This study developed an instrument for measuring the level of inappropriate acute hospital admissions and days of care in Iran.

Patients and Methods:

The American version of the Appropriateness Evaluation Protocol (AEP) was modified, using the agreement method, by a multidisciplinary group of physicians. We conducted a retrospective descriptive study of 273 randomly selected patients admitted to Imam Khomeini Hospital of Tehran University of Medical Sciences in Tehran, Iran. For the reliability study, two nurses were asked to review patients’ medical records using the instrument. Validity was appraised by pairs of clinicians, including two general surgeons, two internists and two gynecologists. The degree of consensus between the three pairs of clinicians was compared with that of the nurses.

Results:

Inter-rater and intra-rater reliability testing revealed an excellent level of consensus between the two nurses employing the AEP in all the studied departments. Overall agreement was > 92%, while the specific appropriate agreement and specific inappropriate agreement were > 88% and > 83%, respectively. External validity testing of the instrument yielded a sensitivity > 0.785, specificity > 0.55, and positive and negative predictive values > 0.775 and > 0.555, respectively. The kappa statistic for the nurses who applied the AEP and clinicians using personal judgment were perfect (k > 0.85) and substantial (k > 0.68), respectively.

Conclusions:

The results illustrate that the Iranian version of the AEP (IR-AEP) could be a reliable and valid instrument for assessing the level of inappropriate acute hospital admissions and days of care in the Iranian context.

Staff training effective in increasing learning opportunities for school-aged children with autism spectrum disorders

OBJECTIVE

This study examined the effectiveness of instruction and video feedback on staff's ABA skills during one-to-one play situations and initiations of children with autism spectrum disorder (ASD).

METHODS

Data were collected within a multiple baseline design across 5 dyads. A continuous 20 s interval recording system was used to record motivation, creating opportunities, prompting and reinforcement of staff and child initiations. Training included instruction, consisting of instructions, video examples and role-plays. After this, a 4-h delayed video feedback condition started.

RESULTS

Three staff members created significantly more learning opportunities during post-instruction and a significant increase occurred during video feedback for one staff member. Initiatives increased significantly in two children during post-instruction. During follow-up, three children showed unprompted initiatives. The mean percentage of spontaneous initiations increased during follow-up.

CONCLUSION

The findings provide support for training staff in a clinical setting to create learning opportunities, which also may result in concomittant improvement in child initiations.

Validity and reliability of a tool for determining appropriateness of days of stay: an observational study in the orthopedic intensive rehabilitation facilities in Italy

Objectives

To test the validity and reliability of a tool specifically developed for the evaluation of appropriateness in rehabilitation facilities and to assess the prevalence of appropriateness of the days of stay.

Methods

The tool underwent a process of cross-cultural translation, content validity, and test-retest validity. Two hospital-based rehabilitation wards providing intensive rehabilitation care located in the Region of Calabria, Southern Italy, were randomly selected. A review of medical records on a random sample of patients aged 18 or more was performed.

Results

The process of validation resulted in modifying some of the criteria used for the evaluation of appropriateness. Test-retest reliability showed that the agreement and the k statistic for the assessment of the appropriateness of days of stay were 93.4% and 0.82, respectively. A total of 371 patient days was reviewed, and 22.9% of the days of stay in the sample were judged to be inappropriate. The most frequently selected appropriateness criterion was the evaluation of patients by rehabilitation professionals for at least 3 hours on the index day (40.8%); moreover, the most frequent primary reason accounting for the inappropriate days of stay was social and/or family environment issues (34.1%).

Conclusions

The findings showed that the tool used is reliable and have adequate validity to measure the extent of appropriateness of days of stay in rehabilitation facilities and that the prevalence of inappropriateness is contained in the investigated settings. Further research is needed to expand appropriateness evaluation to other rehabilitation settings, and to investigate more thoroughly internal and external causes of inappropriate use of rehabilitation services.

Causes of inappropriate hospital days: development and validation of a French assessment tool for rehabilitation centres

OBJECTIVE

To develop and validate a list of criteria to assess the causes of inappropriate hospital days for patients admitted to rehabilitation centres and sub-acute care units.

DESIGN

The tool was developed by a multidisciplinary panel of 33 experts, using a formalized consensus method. It collects both the needs of patients (distinguishing healthcare needs (9 criteria) and accommodation needs (9 criteria)) and the reasons for inappropriateness (19 criteria). Inappropriate days were identified using the tool to assess appropriateness of hospital days validated previously. Reliability was studied by measuring agreement between two independent simultaneous ratings.

SETTING

The validation study was performed on a randomized sample of 576 hospital days from 22 wards in France.

MAIN OUTCOME MEASURES

Inter-rater reliability was evaluated using the κ-statistic and prevalence-adjusted and bias-adjusted kappa (PABAK).

RESULTS

For patient accommodation needs, the inter-rater reliability was estimated by a κ-value of 0.80 (95% confidence interval (95% CI) 0.66-0.92) and a PABAK of 0.80 (95% CI 0.63-0.91). There was good agreement on the reasons for inappropriateness, with κ-values from 0.30 to 0.60 and PABAK from 0.46 to 0.69. The κ-coefficient varied from 0.33 to 0.49 for the assessment of patient healthcare needs, with PABAK ranging from 0.49 to 0.72.

CONCLUSIONS

The instrument is suitable and valid to assess the causes of inappropriate hospital days in rehabilitation centres and sub-acute care units. The study showed that the tool can be easily used by healthcare workers, which makes it useful for quality improvement.