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Samanta S, Bandyopadhyay A, Mukherjee A, Bhattacherjee S. Appropriateness of Hospital Admission and Length of Stay in the Pediatric Department of a Tertiary Care Hospital in West Bengal. Indian J Community Med 2023; 48:841-845. [PMID: 38249697 PMCID: PMC10795871 DOI: 10.4103/ijcm.ijcm_20_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 09/15/2023] [Indexed: 01/23/2024] Open
Abstract
Background Appropriateness of admissions and inpatient length of stay (LOS) are important factors controlling health-care expenditure. The current study was conducted to assess the proportion of appropriate admissions among 29-day to 12-year--old aged patients admitted to pediatric wards of a tertiary health-care center in one month and evaluate inappropriate LOS among them. Materials and Methods An observational longitudinal study was carried out for two months among patients admitted to the pediatric inpatient department using Pediatric Appropriateness Evaluation Protocol (PAEP)-II tool. All patients admitted to the institution during the study period were included in the study. Results Among 495 children, 438 (88.5%) were appropriately admitted. Inappropriate admission was mostly found in children aged 1 to 5 years (29, 16.6%), those who lived >5 km from the hospital (45, 15.2%), and those who presented with other systemic illnesses (13, 31.7%). Among the appropriately admitted children, 333 (76%) met the criteria of appropriate LOS during their hospital stays. Multivariable logistic regression showed that the age of the children (AOR = 0.99; 95% CI = 0.98, 0.99), age-appropriate feeding (AOR = 2.12;95% CI = 1.30,3.47), and hematological disorder (AOR = 0.16; 95% CI = 0.05, 0.52) were found to be associated with the children being kept at the hospital inappropriately. Conclusions The current study observed a high proportion of appropriate admission in children. However, a higher proportion of inappropriate LOS among them was seen. The younger age group, age-appropriate feeding, and type of illness were found as the primary predictors for inappropriate LOS.
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Affiliation(s)
- Sampriti Samanta
- Department of Community Medicine, North Bengal Medical College, Darjeeling, West Bengal, India
| | - Alapan Bandyopadhyay
- Department of Community Medicine, North Bengal Medical College, Darjeeling, West Bengal, India
| | - Abhijit Mukherjee
- Department of Community Medicine, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India
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Rate and causes of inappropriate stays and the resulting financial burden in a single specialty burns hospital. BMC Health Serv Res 2022; 22:1538. [PMID: 36527082 PMCID: PMC9758030 DOI: 10.1186/s12913-022-08772-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 11/01/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND One of the most important challenges facing hospitals is inappropriate admissions and stays the reduction of which can contribute to a decline in healthcare costs without reducing the quality of services. The aim of this study was to estimate the rate and causes of inappropriate stays and their financial burden in a single specialty burns hospital. METHODS This is mixed methods study conducted in 2021. In the quantitative phase, all medical records of patients admitted to a burn hospital were reviewed and 260 cases were randomly selected. The records were evaluated based on the Appropriateness Evaluation Protocol to estimate the rate and preliminary causes of inappropriate stays and their direct costs. Frequencies and logistic regression were used for the rates and the influential factors in causing inappropriate stay, respectively. In the qualitative phase, 13 senior and middle managers of the hospital were interviewed for their interpretation of the quantitative data and the main causes of inappropriate stays. Qualitative data were analyzed by using Graneheim-Lundman method. RESULTS About 28.5% of the patients had at least 1 day of inappropriate stay and about 6% of the total hospitalization days were inappropriate. Marital status, insurance status, and the length of stay were significantly associated with inappropriate admission (p < 0.05). In addition, the annual inappropriate admission days and the direct cost imposed on the patients were estimated at 1490 days and $ 66,848.17. The main causes of inappropriate stays are categorized under themes of healthcare providers, service recipients, financial issues, extra-organizational features, and equipment. CONCLUSION A significant percentage of patients experience inappropriate admissions. The number of inappropriate stays, which imposes a high cost on patients, can be reduced by considering the standard criteria for appropriate admissions. In addition, hospital officials can prevent inappropriate stays as much as possible and reduce the costs and increase the productivity of hospitals through proper management and planning as well as a regular monitoring of physicians and patients.
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Doshmangir L, Khabiri R, Jabbari H, Arab-Zozani M, Kakemam E, Gordeev VS. Strategies for utilisation management of hospital services: a systematic review of interventions. Global Health 2022; 18:53. [PMID: 35606776 PMCID: PMC9125833 DOI: 10.1186/s12992-022-00835-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
Background To achieve efficiency and high quality in health systems, the appropriate use of hospital services is essential. We identified the initiatives intended to manage adult hospital services and reduce unnecessary hospital use among the general adult population. Methods We systematically reviewed studies published in English using five databases (PubMed, ProQuest, Scopus, Web of Science, and MEDLINE via Ovid). We only included studies that evaluated interventions aiming to reduce the use of hospital services or emergency department, frequency of hospital admissions, length of hospital stay, or the use of diagnostic tests in a general adult population. Studies reporting no relevant outcomes or focusing on a specific patient population or children were excluded. Results In total, 64 articles were included in the systematic review. Nine utilisation management methods were identified: care plan, case management, care coordination, utilisation review, clinical information system, physician profiling, consultation, education, and discharge planning. Primary case management was shown to effectively reduce emergency department use. Care coordination reduced 30-day post-discharge hospital readmission or emergency department visit rates. The pre-admission review program decreased elective admissions. The physician profiling, concurrent review, and discharge planning effectively reduced the length of hospital stay. Twenty three studies that evaluated costs, reported cost savings in the hospitals. Conclusions Utilisation management interventions can decrease hospital use by improving the use of community-based health services and improving the quality of care by providing appropriate care at the right time and at the right level of care.
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Affiliation(s)
- Leila Doshmangir
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. .,Department of Health Policy & Management, Tabriz Health Services Management Research Center, School of Management & Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Roghayeh Khabiri
- Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Jabbari
- Department of Community Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Edris Kakemam
- Clinical Research Development Unit of Tabriz Valiasr Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vladimir Sergeevich Gordeev
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Li H, Tao H, Li G. Predictors and reasons for inappropriate hospitalization days for surgical patients in a tertiary hospital in Wuhan, China: a retrospective study. BMC Health Serv Res 2021; 21:900. [PMID: 34470637 PMCID: PMC8408966 DOI: 10.1186/s12913-021-06845-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/02/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Inappropriate hospitalization day (IHD) is recognized as an important indication of the excessive demand for health-care services, especially for surgical patients. We aim to examine the degree of IHDs, predictors associated with higher incidences of IHDs, and reasons for each IHD in different periods of hospitalization. METHODS A total of 4586 hospital days from 408 cases were evaluated by a cross-sectional and retrospective audit program carried out in a tertiary hospital with 5613 beds and 9623 faculty in Wuhan, China. This study used the revised Chinese version of the Appropriateness Evaluation Protocol (C-AEP) to assess IHDs, and the Delay Tool to ascertain each reason for IHDs. A binary logistic regression model was performed to examine the predictors of higher incidences of IHDs. RESULTS The average frequency of IHDs was 23.24 %, and a total of 322 cases (78.92 %) were reported to have experienced at least one IHD. The multivariate analysis showed that patients at the age of 60-69 with respect to under 50, and with overlength of stay were predictors of higher incidences of preoperative IHDs, while admission from outpatient, multiple diagnosis, higher surgical incision level, and overlength of stay were predictors of higher incidence of postoperative IHDs. The most frequent reasons related to health providers for IHDs were doctor's conservative views of patient management and delays in inspection, prescription, appointment, or result report. Patient factors gave rise to nearly a quarter of postoperative IHDs. CONCLUSIONS Findings from this study indicate that measures including paying more attention to the construction of MDT for diagnosis and treatment in general surgery, reducing laboratory turnaround time, dispelling distrust among health-care providers and patients, setting stricter discharge standards and, providing integrated out-of-hospital services could be adopted accordingly to improve the inappropriateness of hospital stays.
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Affiliation(s)
- Hao Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, China
| | - Hongbing Tao
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, China
| | - Gang Li
- Department of Outpatient Management, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, China
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Isaia G, Brunetti E, Presta R, Salone B, Carignano G, Sappa M, Fonte G, Raspo S, Lauria G, Riccardini F, Lupia E, Bo M. Prevalence, determinants and practical implications of inappropriate hospitalizations in older subjects: A prospective observational study. Eur J Intern Med 2021; 90:89-95. [PMID: 33947625 DOI: 10.1016/j.ejim.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/02/2021] [Accepted: 04/09/2021] [Indexed: 11/30/2022]
Abstract
In a context of high demand for hospital services among older people, we aimed to assess the rate and determinants of inappropriate hospitalizations of older patients, and to what extent they were associated with inappropriate hospital stay. This prospective observational multicentre study evaluated a random sample of consecutive patients aged ≥ 70 years accessing the Emergency Department (ED) of two Italian tertiary hospitals. A standardized comprehensive geriatric assessment was carried out in each patient, including the Blaylock Risk Assessment Screen Scale (BRASS) for identification of patients at risk of difficult discharge. Inappropriate hospitalization was defined by the ED physician when patients did not necessitate hospital-provided procedures but was due to social reasons or lack of an alternative care-setting. Among 1877 patients (median age 80.7 years, 50.1% male), with a high prevalence of functional dependence and social isolation (around 30% and 25%, respectively), 767 (40.9%) were hospitalized. Incidence of inappropriate hospitalization was 14.6% (95% CI 12.1%-17.1%) and was associated with moderate-high risk of difficult discharge at BRASS (OR = 1.98, 95% CI 1.16-3.39, p = 0.013) and the presence of dementia with behavioural disorders (OR = 1.79, 95% CI 1.10-2.91, p = 0.020). Compared with patients appropriately admitted, inappropriate hospitalizations had shorter length of hospital stay but accounted for 1059/9154 days of stay (11.6%). Inappropriate hospitalizations occurred in less than 15% of cases, mainly accounted for by patients no longer manageable at home, but contributed to the greatest proportion of inappropriate hospital stay. These findings highlight the need of implementing appropriate home-care services and ensuring rapid access to suitable care-facilities for community-dwelling frail older patients.
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Affiliation(s)
- Gianluca Isaia
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Enrico Brunetti
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Roberto Presta
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy.
| | - Bianca Salone
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Giulia Carignano
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy; Section of Geriatrics, AO Santa Croce e Carle, Cuneo, Italy
| | - Matteo Sappa
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy; Section of Geriatrics, AO Santa Croce e Carle, Cuneo, Italy
| | - Gianfranco Fonte
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Silvio Raspo
- Section of Geriatrics, AO Santa Croce e Carle, Cuneo, Italy
| | - Giuseppe Lauria
- Emergency Medicine Department, AO Santa Croce e Carle, Cuneo, Italy
| | - Franco Riccardini
- Emergency Medicine Department, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Enrico Lupia
- Emergency Medicine Department, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
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Ye Q, Zhang Y, Gao HX, Chen YC, Li HM, Zhang H, Hu XM, Lei SH, Jiang D. Distribution of the Indicator of the Appropriate Admission of Patients with Circulatory System Diseases to County Hospitals in Rural China: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16091621. [PMID: 31075865 PMCID: PMC6539859 DOI: 10.3390/ijerph16091621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 11/16/2022]
Abstract
Background: The inappropriate admission of patients with circulatory system diseases (CSDs) have contributed to the rapid increase in hospitalisation rates in China. The purpose of this study is to identify the key indicators of appropriate admission and their distribution by analysing CSD cases. Methods: A total of 794 records of inpatient CSD cases were collected from county hospitals in five counties in midwestern rural China through stratified random sampling and evaluated by using the Rural Appropriateness Evaluation Protocol (RAEP). RAEP has two parts: Indicator A, which represents requirement for services, and Indicator B, which represents diseases severity. Indicator distribution was analysed through frequency analysis. A three-level logistic regression model was used to examine the sociodemographic determinants of the positive indicators of appropriate CDSs admissions. Result: The inappropriate admission rate of CSDs was 33.4% and varied between counties. A2 (Varying dosage/drug under supervision, 58.22%), A8 (Stopping/continuing oxygen inhalation, 38.19%), A7 (Electrocardiogram per 2 hours, 34.22%), A3 (Calculation of intake and output volume, 31.19%) and B14 (Abnormal blood condition, 27.98%) were the top five positive indicators of CSDs. Indicator A (requirements for services) was more active than Indicator B (disease severity). The limitation of the role of Indicator B over time may be attributed to the different policies and environments of rural China and stimulated the increase in inappropriate admission rates. The results of three-level logistic regression suggested that the influence of gender, year, region and disease type on positive indicators should receive increased attention in the evaluation of CSDs admissions. Conclusion: This study found that A2, A8, A7, A3 and B14 were the key indicators and were helpful to determine the appropriate admission of CSDs in rural China. Managers may focus on these indicators, particularly the use of indicator A.
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Affiliation(s)
- Qing Ye
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Hubei Provincial Department of Education, Key Research Institute of Humanities & Social Sciences, Research Centre for Rural Health Service, Wuhan 430030, China.
| | - Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Hubei Provincial Department of Education, Key Research Institute of Humanities & Social Sciences, Research Centre for Rural Health Service, Wuhan 430030, China.
| | - Hong-Xia Gao
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Hubei Provincial Department of Education, Key Research Institute of Humanities & Social Sciences, Research Centre for Rural Health Service, Wuhan 430030, China.
| | - Ying-Chun Chen
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Hubei Provincial Department of Education, Key Research Institute of Humanities & Social Sciences, Research Centre for Rural Health Service, Wuhan 430030, China.
| | - Hao-Miao Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Hubei Provincial Department of Education, Key Research Institute of Humanities & Social Sciences, Research Centre for Rural Health Service, Wuhan 430030, China.
| | - Hui Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Hubei Provincial Department of Education, Key Research Institute of Humanities & Social Sciences, Research Centre for Rural Health Service, Wuhan 430030, China.
| | - Xiao-Mei Hu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Hubei Provincial Department of Education, Key Research Institute of Humanities & Social Sciences, Research Centre for Rural Health Service, Wuhan 430030, China.
| | - Shi-Han Lei
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Hubei Provincial Department of Education, Key Research Institute of Humanities & Social Sciences, Research Centre for Rural Health Service, Wuhan 430030, China.
| | - Di Jiang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Hubei Provincial Department of Education, Key Research Institute of Humanities & Social Sciences, Research Centre for Rural Health Service, Wuhan 430030, China.
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Hu X, Gao H, Zhang Y, Li H, Su D, Chang J, Jiang D, Lei S, Chen Y. Determinants of inappropriate admission of elderly people in county-level hospitals: a cross-sectional study in rural China. BMJ Open 2019; 9:e026443. [PMID: 31048441 PMCID: PMC6502026 DOI: 10.1136/bmjopen-2018-026443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE The purpose of this paper is to investigate the characteristics and determinants of inappropriate admission to hospital of elderly people in rural China. DESIGN A cross-sectional study of a comparison between the elderly and non-elderly groups of people. SETTING The survey was conducted on the largest county-level general hospitals in four counties in central and western China. PARTICIPANTS A total of 652 rural patients admitted in hospitals were surveyed, who were divided into two groups according to age: elderly group (n=230, age ≥60 years) and non-elderly group (n=422, age <60 years). PRIMARY MEASURES The Chinese version of the appropriateness evaluation protocol was used to evaluate the inappropriate admission rates. The interactive regression models based on the relationship of age (elderly and non-elderly) with other factors and binary logistic regression models were used in the analysis of the specific factors and determinants of the inappropriate admission of elderly people. RESULT The inappropriate admission rate for the rural elderly was 30%, which was lower than that of the non-elderly people (40.8%). Compared with the non-elderly group, women in the elderly group (OR=0.33, 95% CI 0.15 to 0.73) had a lower incidence of inappropriate admission, and elderly people with chronic diseases (OR=3.33, 95% CI 1.23 to 9.04) were more prone to being inappropriately admitted than non-elderly people with chronic diseases. The binary logistic regression analysis shows that county, age (OR=0.94. 95% CI 0.90 to 0.99), gender (OR=0.49, 95% CI 0.25 to 2.98), department and response to doctor's admission request were the determinants of the inappropriate admission of elderly patients. CONCLUSION The inappropriate admission rate of elderly people in rural China was high. We found that gender and chronic disease are the specific factors that were specific to non-elderly people. County, age, gender, department and response to a doctor's admission request had substantial influence on the inappropriate admission of the elderly in rural China.
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Affiliation(s)
- Xiaomei Hu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Province, Wuhan, Hubei, China
| | - Hongxia Gao
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Province, Wuhan, Hubei, China
| | - Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Province, Wuhan, Hubei, China
| | - Haomiao Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Province, Wuhan, Hubei, China
| | - Dai Su
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Province, Wuhan, Hubei, China
| | - Jingjing Chang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Province, Wuhan, Hubei, China
| | - Di Jiang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Province, Wuhan, Hubei, China
| | - Shihan Lei
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Province, Wuhan, Hubei, China
| | - Yingchun Chen
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Province, Wuhan, Hubei, China
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Zhang Y, Niu Y, Zhang L. Determinants of patient choice for hospital readmission after township hospitalisation: a population-based retrospective study in China. BMJ Open 2018; 8:e021516. [PMID: 30093517 PMCID: PMC6089325 DOI: 10.1136/bmjopen-2018-021516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The lack of coordinated and appropriate healthcare across sectors has produced more patients for county hospitals in China. This study examined differences in patient choice between township and county hospitals for readmission after a first township hospitalisation, and the determinants that influenced this choice. DESIGN A retrospective study of readmissions across hospitals after a first admission in township hospital. A township-township (TT) inpatient group and a township-county (TC) inpatient group were compared. A two-level logistic regression model was used to examine the determinants of choice for hospital readmission. SETTING Data were drawn from a population-based health utilisation database for Qianjiang District, China, from 1 January 2008 to 31 December 2013. PARTICIPANTS This study focused on readmitted patients whose first admission was in a township hospital. Readmission cases were identified as the same diagnosis (International Classification of Diseases, Tenth Revision) in a subsequent hospitalisation within 30 days. In total, 6764 readmissions had first admissions in township hospitals. PRIMARY OUTCOME MEASURES Patient choice for hospital readmission after a first township hospitalisation. RESULTS The TT group accounted for 62.5% (4225) and the TC group for 37.5% (2539) of readmissions in 6 years, and the proportion of TC readmissions in total inpatients increased from 1.66% to 1.89%. Readmission rates varied among towns (p<0.001). Differences between the TC and TT groups included: length of stay (LOS) of first admission (6.96 days vs 9.23 days), average interval between admissions (6.03 days vs 14.95 days) and disease category. Admission year, age, travel time to county hospital, interval between admissions, first admission LOS and disease category were determinants of choice for hospital readmission. CONCLUSIONS Patients whose first admission was in a township hospital were more likely to be readmitted to a county hospital. A combination of first LOS and interval between admissions may be an effective identification index for TC readmission. TRIAL REGISTRATION NUMBER ChiCTR-OOR-14005563.
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Affiliation(s)
- Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Research Institute of Humanities and Social Sciences of Hubei Provincial Department of Education, Research Centre for Rural Health Service, Wuhan, China
| | - Yadong Niu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Research Institute of Humanities and Social Sciences of Hubei Provincial Department of Education, Research Centre for Rural Health Service, Wuhan, China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Research Institute of Humanities and Social Sciences of Hubei Provincial Department of Education, Research Centre for Rural Health Service, Wuhan, China
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Zhang Y, Zhang L, Li H, Chen Y. Determinants of Inappropriate Admissions in County Hospitals in Rural China: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15061050. [PMID: 29789496 PMCID: PMC6025444 DOI: 10.3390/ijerph15061050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/15/2018] [Accepted: 05/21/2018] [Indexed: 11/16/2022]
Abstract
Inappropriate admissions have contributed to the rapid increase in hospitalisations in rural China. This study characterised the degree and determinants of inappropriate admissions in county hospitals. We used expert consultation to develop an appropriateness evaluation protocol that included nine requirements for services and 21 indicators of disease severity. A total of 2230 medical records from 2014 were collected from five county hospitals by stratified cluster sampling and evaluated for appropriateness using the protocol in 2016. The determinants of inappropriate admissions were analysed by two-level logistic regression. The overall inappropriate admission rate was 15.2%. Patients aged.
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Affiliation(s)
- Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan 430030, China.
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan 430030, China.
| | - Haomiao Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan 430030, China.
| | - Yingchun Chen
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
- Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan 430030, China.
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Bosch X, Sanclemente-Ansó C, Escoda O, Monclús E, Franco-Vanegas J, Moreno P, Guerra-García M, Guasch N, López-Soto A. Time to diagnosis and associated costs of an outpatient vs inpatient setting in the diagnosis of lymphoma: a retrospective study of a large cohort of major lymphoma subtypes in Spain. BMC Cancer 2018; 18:276. [PMID: 29530002 PMCID: PMC5848556 DOI: 10.1186/s12885-018-4187-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/06/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mainly because of the diversity of clinical presentations, diagnostic delays in lymphoma can be excessive. The time spent in primary care before referral to the specialist may be relatively short compared with the interval between hospital appointment and diagnosis. Although studies have examined the diagnostic intervals and referral patterns of patients with lymphoma, the time to diagnosis of outpatient compared to inpatient settings and the costs incurred are unknown. METHODS We performed a retrospective study at two academic hospitals to evaluate the time to diagnosis and associated costs of hospital-based outpatient diagnostic clinics or conventional hospitalization in four representative lymphoma subtypes. The frequency, clinical and prognostic features of each lymphoma subtype and the activities of the two settings were analyzed. The costs incurred during the evaluation were compared by microcosting analysis. RESULTS A total of 1779 patients diagnosed between 2006 and 2016 with classical Hodgkin, large B-cell, follicular, and mature nodal peripheral T-cell lymphomas were identified. Clinically aggressive subtypes including large B-cell and peripheral T-cell lymphomas were more commonly diagnosed in inpatients than in outpatients (39.1 vs 31.2% and 18.9 vs 13.5%, respectively). For each lymphoma subtype, inpatients were older and more likely than outpatients to have systemic symptoms, worse performance status, more advanced Ann Arbor stages, and high-risk prognostic scores. The admission time for diagnosis (i.e. from admission to excisional biopsy) of inpatients was significantly shorter than the time to diagnosis of outpatients (12.3 [3.3] vs 16.2 [2.7] days; P < .001). Microcosting revealed a mean cost of €4039.56 (513.02) per inpatient and of €1408.48 (197.32) per outpatient, or a difference of €2631.08 per patient. CONCLUSIONS Although diagnosis of lymphoma was quicker with hospitalization, the outpatient approach seems to be cost-effective and not detrimental. Despite the considerable savings with the latter approach, there may be hospitalization-associated factors which may not be properly managed in an outpatient unit (e.g. aggressive lymphomas with severe symptoms) and the cost analysis did not account for this potentially added value. While outcomes were not analyzed in this study, the impact on patient outcome of an outpatient vs inpatient diagnostic setting may represent a challenging future research.
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Affiliation(s)
- Xavier Bosch
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
| | - Carmen Sanclemente-Ansó
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital of Bellvitge, University of Barcelona, Barcelona, Spain
| | - Ona Escoda
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Esther Monclús
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Jonathan Franco-Vanegas
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital of Bellvitge, University of Barcelona, Barcelona, Spain
| | - Pedro Moreno
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Mar Guerra-García
- Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Neus Guasch
- Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Alfons López-Soto
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Cardona-Morrell M, Kim JCH, Brabrand M, Gallego-Luxan B, Hillman K. What is inappropriate hospital use for elderly people near the end of life? A systematic review. Eur J Intern Med 2017; 42:39-50. [PMID: 28502866 DOI: 10.1016/j.ejim.2017.04.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 03/25/2017] [Accepted: 04/19/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Older people with advance chronic illness use hospital services repeatedly near the end of life. Some of these hospitalizations are considered inappropriate. AIM To investigate extent and causes of inappropriate hospital admission among older patients near the end of life. METHODS English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-December 2016) covering community and nursing home residents aged ≥60years admitted to hospital. OUTCOMES measurements of inappropriateness. A 17-item quality score was estimated independently by two authors. RESULTS The definition of 'Inappropriate admissions' near the end of life incorporated system factors, social and family factors. The prevalence of inappropriate admissions ranged widely depending largely on non-clinical reasons: poor availability of alternative sites of care or failure of preventive actions by other healthcare providers (1.7-67.0%); family requests (up to 10.5%); or too late an admission to be of benefit (1.7-35.0%). The widespread use of subjective parameters not routinely collected in practice, and the inclusion of non-clinical factors precluded the true estimation of clinical inappropriateness. CONCLUSIONS Clinical inappropriateness and system factors that preclude alternative community care must be measured separately. They are two very different justifications for hospital admissions, requiring different solutions. Society has a duty to ensure availability of community alternatives for the management of ambulatory-sensitive conditions and facilitate skilling of staff to manage the terminally ill in non-acute settings. Only then would the evaluation of local variations in clinically inappropriate admissions and inappropriate length of stay be possible to undertake.
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Affiliation(s)
- Magnolia Cardona-Morrell
- South Western Sydney Clinical School, The Simpson Centre for Health Services Research and Ingham Institute for Applied Medical Research, Level 3, Ingham Institute Building, 1 Campbell Street, Liverpool, NSW 2170, Australia.
| | - James C H Kim
- Department of General Practice, Medical School, Western Sydney University, Building 30, Narellan Rd, Campbelltown Campus, NSW 2560, Australia.
| | - Mikkel Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Finsensgade 35, DK-6700 Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Sdr. Boulevard 29, Entrance 64, ground floor, DK-5000 Odense C, Denmark.
| | - Blanca Gallego-Luxan
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW 2113, Australia.
| | - Ken Hillman
- South Western Sydney Clinical School, The Simpson Centre for Health Services Research and Ingham Institute for Applied Medical Research, Level 3, Ingham Institute Building, 1 Campbell Street, Liverpool, NSW 2170, Australia; Intensive Care Unit, Liverpool Hospital, Level 2, Elizabeth Street, Liverpool, NSW 2170, Australia.
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12
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Montori-Palacín E, Prieto-González S, Carrasco-Miserachs I, Altes-Capella J, Compta Y, López-Soto A, Bosch X. Quick outpatient diagnosis in small district or general tertiary hospitals: A comparative observational study. Medicine (Baltimore) 2017; 96:e6886. [PMID: 28562538 PMCID: PMC5459703 DOI: 10.1097/md.0000000000006886] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
While quick diagnosis units (QDUs) have expanded as an innovative cost-effective alternative to admission for workup, studies investigating how QDUs compare are lacking. This study aimed to comparatively describe the diagnostic performance of the QDU of an urban district hospital and the QDU of its reference general hospital.This was an observational descriptive study of 336 consecutive outpatients aged ≥18 years referred to the QDU of a urban district hospital in Barcelona (QDU1) during 2009 to 2016 for evaluation of suspected severe conditions whose physical performance allowed them to travel from home to hospital and back for visits and examinations. For comparison purposes, 530 randomly selected outpatients aged ≥18 years referred to the QDU of the reference tertiary hospital (QDU2), also in Barcelona, were included. Clinical and QDU variables were analyzed and compared.Mean age and sex were similar (61.97 (19.93) years and 55% of females in QDU1 vs 60.0 (18.81) years and 52% of females in QDU2; P values = .14 and .10, respectively). Primary care was the main referral source in QDU1 (69%) and the emergency department in QDU2 (59%). Predominant referral reasons in QDU1 and 2 were unintentional weight loss (UWL) (21 and 16%), anemia (14 and 21%), adenopathies and/or palpable masses (10 and 11%), and gastrointestinal symptoms (10 and 19%). Time-to-diagnosis was longer in QDU1 than 2 (12 [1-28] vs 8 [4-14] days; P < .001). Malignancy was more common in QDU2 than 1 (19 vs 13%; P = .001). Patients from both groups with malignancy, aged ≥65 years and requiring >2 visits to be diagnosed were in general more likely to be males, to have UWL and adenopathies and/or palpable masses but less likely anemia, to undergo more examinations except endoscopy, and to be referred onward to specialist outpatient clinics.Despite some differences, results showed that, for diagnostic purposes, the overall performance and effectiveness of QDUs of urban district and reference general hospitals in evaluating patients with potentially serious conditions were similar. This study, the first to compare the performance of 2 hospital-based QDUs, adds evidence to the opportunity of producing standardized guidelines to optimize QDUs infrastructure, functioning, and efficiency.
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Affiliation(s)
| | - Sergio Prieto-González
- Department of Systemic Autoimmune Diseases, Hospital Clínic, University of Barcelona, Biomedical Research Institute August Pi i Sunyer (IDIBAPS)
| | | | | | - Yaroslau Compta
- Neurology Service, Hospital Clínic/Department of Biomedicine, University of Barcelona
| | - Alfons López-Soto
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
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Bosch X, Monclús E, Escoda O, Guerra-García M, Moreno P, Guasch N, López-Soto A. Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients. PLoS One 2017; 12:e0175125. [PMID: 28388637 PMCID: PMC5384681 DOI: 10.1371/journal.pone.0175125] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/21/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Whereas there are numerous studies on unintentional weight loss (UWL), these have been limited by small sample sizes, short or variable follow-up, and focus on older patients. Although some case series have revealed that malignancies escaping early detection and uncovered subsequently are exceptional, reported follow-ups have been too short or unspecified and necropsies seldom made. Our objective was to examine the etiologies, characteristics, and long-term outcome of UWL in a large cohort of outpatients. METHODS We prospectively enrolled patients referred to an outpatient diagnosis unit for evaluation of UWL as a dominant or isolated feature of disease. Eligible patients underwent a standard baseline evaluation with laboratory tests and chest X-ray. Patients without identifiable causes 6 months after presentation underwent a systematic follow-up lasting for 60 further months. Subjects aged ≥65 years without initially recognizable causes underwent an oral cavity examination, a videofluoroscopy or swallowing study, and a depression and cognitive assessment. RESULTS Overall, 2677 patients (mean age, 64.4 [14.7] years; 51% males) were included. Predominant etiologies were digestive organic disorders (nonmalignant in 17% and malignant in 16%). Psychosocial disorders explained 16% of cases. Oral disorders were second to nonhematologic malignancies as cause of UWL in patients aged ≥65 years. Although 375 (14%) patients were initially diagnosed with unexplained UWL, malignancies were detected in only 19 (5%) within the first 28 months after referral. Diagnosis was established at autopsy in 14 cases. CONCLUSION This investigation provides new information on the relevance of follow-up in the long-term clinical outcome of patients with unexplained UWL and on the role of age on this entity. Although unexplained UWL seldom constitutes a short-term medical alert, malignancies may be undetectable until death. Therefore, these patients should be followed up regularly (eg yearly visits) for longer than reported periods, and autopsies pursued when facing unsolved deaths.
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Affiliation(s)
- Xavier Bosch
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Esther Monclús
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ona Escoda
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Mar Guerra-García
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Pedro Moreno
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Neus Guasch
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Alfons López-Soto
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
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In the face of increasing subspecialisation, how does the specialty ensure that the management of ENT emergencies is timely, appropriate and safe? The Journal of Laryngology & Otology 2016; 130:516-20. [DOI: 10.1017/s0022215116007957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground:The field of ENT surgery is one of the most varied specialties, with numerous subspecialties and continuing divergence. With this evolution there comes, however, a risk that specialists become de-skilled in certain areas. In the case of ENT emergencies, this can be particularly dangerous.Methods:Current guidance from relevant UK professional membership bodies regarding emergency surgery provision was inspected and a literature search was performed to identify studies relating to management of ENT emergencies in the context of increasing subspecialisation.Results and conclusion:The specialty currently has provisions in place to ensure timely, appropriate and safe management of emergencies, in the form of guidelines and emergency clinics; however, there is scope for improvement of the system.
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Sanclemente-Ansó C, Bosch X, Salazar A, Moreno R, Capdevila C, Rosón B, Corbella X. Cost-minimization analysis favors outpatient quick diagnosis unit over hospitalization for the diagnosis of potentially serious diseases. Eur J Intern Med 2016; 30:11-17. [PMID: 26944565 DOI: 10.1016/j.ejim.2015.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Quick diagnosis units (QDUs) are a promising alternative to conventional hospitalization for the diagnosis of suspected serious diseases, most commonly cancer and severe anemia. Although QDUs are as effective as hospitalization in reaching a timely diagnosis, a full economic evaluation comparing both approaches has not been reported. AIMS To evaluate the costs of QDU vs. conventional hospitalization for the diagnosis of cancer and anemia using a cost-minimization analysis on the proven assumption that health outcomes of both approaches were equivalent. METHODS Patients referred to the QDU of Bellvitge University Hospital of Barcelona over 51 months with a final diagnosis of severe anemia (unrelated to malignancy), lymphoma, and lung cancer were compared with patients hospitalized for workup with the same diagnoses. The total cost per patient until diagnosis was analyzed. Direct and non-direct costs of QDU and hospitalization were compared. RESULTS Time to diagnosis in QDU patients (n=195) and length-of-stay in hospitalized patients (n=237) were equivalent. There were considerable costs savings from hospitalization. Highest savings for the three groups were related to fixed direct costs of hospital stays (66% of total savings). Savings related to fixed non-direct costs of structural and general functioning were 33% of total savings. Savings related to variable direct costs of investigations were 1% of total savings. Overall savings from hospitalization of all patients were €867,719.31. CONCLUSION QDUs appear to be a cost-effective resource for avoiding unnecessary hospitalization in patients with anemia and cancer. Internists, hospital executives, and healthcare authorities should consider establishing this model elsewhere.
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Affiliation(s)
- Carmen Sanclemente-Ansó
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain.
| | - Xavier Bosch
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques Auguts Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Albert Salazar
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Ramón Moreno
- Department of Economic Development, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Cristina Capdevila
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Beatriz Rosón
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Xavier Corbella
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain; Albert J. Jovell Institute of Public Health and Patients, Faculty of Medicine and Health Sciences, Universitat International de Catalunya, Barcelona, Catalonia, Spain
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16
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Pinkney J, Rance S, Benger J, Brant H, Joel-Edgar S, Swancutt D, Westlake D, Pearson M, Thomas D, Holme I, Endacott R, Anderson R, Allen M, Purdy S, Campbell J, Sheaff R, Byng R. How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundHospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown.AimsTo investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.MethodsThe project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.FindingsPatients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity.ConclusionsThis research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.
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Affiliation(s)
- Jonathan Pinkney
- Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Susanna Rance
- Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Institute for Health and Human Development, University of East London, London, UK
| | - Jonathan Benger
- Department of Nursing and Midwifery, University of the West of England, Bristol, UK
| | - Heather Brant
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Dawn Swancutt
- Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Debra Westlake
- Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Daniel Thomas
- Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Ingrid Holme
- Faculty of Social Sciences, University of Ulster, Londonderry, UK
| | - Ruth Endacott
- Faculty of Health and Human Sciences, Plymouth University, Plymouth, UK
| | | | | | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Rod Sheaff
- School of Government, Faculty of Business, Plymouth University, Plymouth, UK
| | - Richard Byng
- Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
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Sanclemente-Ansó C, Salazar A, Bosch X, Capdevila C, Giménez-Requena A, Rosón-Hernández B, Corbella X. Perception of quality of care of patients with potentially severe diseases evaluated at a distinct quick diagnostic delivery model: a cross-sectional study. BMC Health Serv Res 2015; 15:434. [PMID: 26420244 PMCID: PMC4589195 DOI: 10.1186/s12913-015-1070-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 09/17/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although hospital-based outpatient quick diagnosis units (QDU) are an increasingly recognized cost-effective alternative to hospitalization for the diagnosis of potentially serious diseases, patient perception of their quality of care has not been evaluated well enough. This cross-sectional study analyzed the perceived quality of care of a QDU of a public third-level university hospital in Barcelona. METHODS One hundred sixty-two consecutive patients aged ≥ 18 years attending the QDU over a 9-month period were invited to participate. A validated questionnaire distributed by the QDU attending physician and completed at the end of the first and last QDU visit evaluated perceived quality of care using six subscales. RESULTS Response rate was 98 %. Perceived care in all subscales was high. Waiting times were rated as 'short'/'very short' or 'better'/'much better' than expected by 69-89 % of respondents and physical environment as 'better'/'much better' than expected by 94-96 %. As to accessibility, only 3 % reported not finding the Unit easily and 7 % said that frequent travels to hospital for visits and investigations were uncomfortable. Perception of patient-physician encounter was high, with 90-94 % choosing the positive extreme ends of the clinical information and personal interaction subscales items. Mean score of willingness to recommend the Unit using an analogue scale where 0 was 'never' and 10 'without a doubt' was 9.5 (0.70). On multivariate linear regression, age >65 years was an independent predictor of clinical information, personal interaction, and recommendation, while age 18-44 years was associated with lower scores in these subscales. No schooling predicted higher clinical information and recommendation scores, while university education had remarkable negative influence on them. Having ≥4 QDU visits was associated with lower time to diagnosis and recommendation scores and malignancy was a negative predictor of time to diagnosis, clinical information, and recommendation. DISCUSSION It is worthy of note that the questionnaire evaluated patient perception and opinions of healthcare quality including recommendation rather than simply satisfaction. It has been argued that perception of quality of care is a more valuable approach than satisfaction. In addition to embracing an affective dimension, satisfaction appears more dependent on patient expectations than is perception of quality. CONCLUSIONS While appreciating that completing the questionnaire immediately after the visit and its distribution by the QDU physician may have affected the results, scores of perceived quality of care including recommendation were high. There were, however, significant differences in several subscales associated with age, education, number of QDU visits, and diagnosis of malignant vs. benign condition.
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Affiliation(s)
- Carmen Sanclemente-Ansó
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Biomedical Research Institute (IDIBELL), Consultas Externas, Area de Gestión Administrativa, c/Feixa Llarga s/n, 08907-L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Albert Salazar
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Xavier Bosch
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), c/Villarroel 170, 08036, Barcelona, Spain.
| | - Cristina Capdevila
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Amparo Giménez-Requena
- Department of Quality, Bellvitge University Hospital, University of Barcelona, Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Beatriz Rosón-Hernández
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Biomedical Research Institute (IDIBELL), Consultas Externas, Area de Gestión Administrativa, c/Feixa Llarga s/n, 08907-L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Xavier Corbella
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Biomedical Research Institute (IDIBELL), Consultas Externas, Area de Gestión Administrativa, c/Feixa Llarga s/n, 08907-L'Hospitalet de Llobregat, Barcelona, Spain. .,Global Institute of Public Health and Health Policy, School of Medicine, International University of Catalonia, Barcelona, Spain.
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Emergency department patients with acute severe hypertension: a comparison of those admitted versus discharged in studying the treatment of acute hypertension registry. Crit Pathw Cardiol 2015; 13:66-72. [PMID: 24827883 DOI: 10.1097/hpc.0000000000000014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare the characteristics, treatments, and outcomes for emergency department (ED) patients with severe hypertension by disposition (admitted versus discharged home). METHODS Studying the Treatment of Acute hyperTension (STAT) is a multicenter registry of 1566 patients with blood pressure ≥180/110 mm Hg who were treated with intravenous antihypertensive medications in an ED or intensive care unit. Presenting and in-hospital variables, and postdischarge outcomes for the 1053 patients in the ED subset were compared by disposition. RESULTS In the multivariable analysis, ED patients were less likely to be discharged if >75 years of age (odds ratio [OR] = 0.3, 95% confidence interval [CI] = 0.1-0.9) or if they had shortness of breath (OR = 0.4, 95% CI = 0.2-0.8) or alteration of mental status (OR = 0.1, 95% CI = 0.02-0.9) on arrival. Nondialysis patients with an admission creatinine concentration >1.5 mg/dL were 80% less likely to be discharged than those ≤1.5 mg/dL (OR = 0.2, 95% CI = 0.08-0.5). In the bivariate analysis, patients with a decrease in systolic blood pressure of <10% 2 hours after medication administration were more likely to be admitted than those discharged (57% vs. 44%; P = 0.041). Disposition did not correlate with 90-day or 6-month mortality or 30-day readmission. However, admitted patients had a higher 90-day readmission rate (38% vs. 24%; P = 0.038). CONCLUSIONS ED patients with severe hypertension were more likely to be admitted to the hospital if they were >75 years of age, presented with shortness of breath or altered mental status, or had a creatinine >1.5 mg/dL and were not on hemodialysis.
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Ghods AA, Khabiri R, Raeisdana N, Ansari M, Hoshmand Motlagh N, Sadeghi M, Zarei E. Predictors of inappropriate hospital stay: experience from Iran. Glob J Health Sci 2014; 7:82-9. [PMID: 25948427 PMCID: PMC4802064 DOI: 10.5539/gjhs.v7n3p82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 10/07/2014] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Hospital services are the most expensive component of modern health care systems and inappropriate hospital stay is one of the most important challenges facing hospitals in many countries. The purpose of this study was to determine the extent of inappropriate hospital stay and investigate the related factors in Semnan city (Iran). METHODS In this study, the Iranian version of Appropriateness Evaluation Protocol (AEP) was used in a representative sample of 300 hospital admissions and 905 hospital days. Data collection was performed during six weeks in January and February 2014 in four wards (two internal medicine and two surgical wards) of two hospitals in Semnan city (Iran). RESULTS The results showed that 7.4% of admissions and 22.1% of stays have been inappropriate. Inappropriate stays were mainly concerned to the factors, including length of stay, inappropriate admissions, as well as factors related to hospitals. The most frequent causes of unjustifiable days were due to waiting for diagnostic or therapeutic procedures (35.1%), and 20.6% delay in discharge of patients by physicians due to conservative medical policy. CONCLUSION In conclusion, this study confirms the existence of inappropriate hospital stays which may be due to patient characteristics and hospital factors. The most unjustifiable reasons for inappropriate hospital stay were related to internal processes of hospital, which mostly could be prevented through appropriate management Therefore, some steps must be taken to decrease inappropriate hospital stay and preserve hospital resources for patients who need them.
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Brito-Zerón P, Nicolás-Ocejo D, Jordán A, Retamozo S, López-Soto A, Bosch X. Diagnosing unexplained fever: can quick diagnosis units replace inpatient hospitalization? Eur J Clin Invest 2014; 44:707-18. [PMID: 24920307 DOI: 10.1111/eci.12287] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 06/06/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outpatient quick diagnosis units (QDUs) have become an increasingly recognized alternative to hospitalization for the diagnosis of a number of potentially serious diseases. No study has prospectively evaluated the usefulness of QDU for the diagnosis of unexplained fever. MATERIALS AND METHODS We prospectively assessed patients referred to QDU due to fever of uncertain nature (FUN), defined as a temperature > 38 °C during at least 1 week and no diagnosis after a previous evaluation. We also evaluated consecutive patients with FUN who were hospitalized during the same period. QDU and hospital costs were analysed by micro-costing techniques. RESULTS We evaluated 176 QDU patients and 168 controls. QDU patients were younger and required fewer investigations than controls. QDU patients had higher prevalence of viral infections (36% vs. 8%, P < 0·001) and lower prevalence of bacterial infections (6% vs. 46%, P < 0·001) and malignancies (2% vs. 14%, P < 0·001). While time-to-diagnosis of QDU patients was longer than length-of-stay of controls (25·82 vs.12·89 days, P < 0·001), 56% of QDU patients only required up to two visits. Cost per QDU patient was €644·59, while it was €4404·64 per hospitalized patient. CONCLUSIONS QDU patients with FUN were younger and had less serious diseases than controls including more viral and less bacterial infections and fewer malignancies. Mainly owing to untimely diagnostic reports, time-to-diagnosis was longer in QDU patients. Cost-savings in QDU were substantial. Using objective tools to evaluate the condition severity and general health status of FUN patients could help decide the most appropriate setting for their diagnostic study.
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Affiliation(s)
- Pilar Brito-Zerón
- Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Gupta S, Sukhal S, Agarwal R, Das K. Quick diagnosis units--an effective alternative to hospitalization for diagnostic workup: a systematic review. J Hosp Med 2014; 9:54-9. [PMID: 24323789 DOI: 10.1002/jhm.2129] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 10/03/2013] [Accepted: 10/21/2013] [Indexed: 11/06/2022]
Abstract
INTRODUCTION This era of healthcare reform emphasizes improving value of care. Inpatient admissions for diagnostic evaluation put economic pressure on an already strained healthcare system. We conducted a systematic review of effectiveness of quick diagnosis units (QDUs), an established outpatient model for early diagnostic workups in Europe. METHODS We searched MEDLINE and Embase for studies that focused on implementation of quick/rapid diagnosis units, with relevant Medical Subject Headings terms and keywords. Of 2047 studies, we selected 13 for full-text screening and bibliography review. Of these, 5 studies included at least 2 primary outcomes of interest and were included in our review. These units functioned as outpatient clinics, staffed by internists, nurses, and clerical staff, with expedited scheduling of outpatient diagnostic tests. Our primary outcome measures were final diagnosis, the mean time to final diagnosis, inpatient bed-days saved per patient, and costs saved per patient. We also studied discharge disposition, care preferences, and safety data. RESULTS About 18% to 30% of patients were diagnosed with malignancy, with an average time to diagnosis of 6 to 11 days. Inpatient bed-days saved per patient ranged from 4.5 to 7. Savings from fixed costs of hospitalization ranged from $2336(€1764) to $3304(€2514) for each patient enrolled in the protocol. The QDU model was preferred by 88% of patients, and patient satisfaction rates were 95% to 97%. CONCLUSIONS QDUs seem an effective and cost-saving alternative to inpatient hospitalization, and appear to be a safe approach for diagnostic workup of potentially severe diseases in select patient populations, although there are limited safety data available.
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Affiliation(s)
- Shweta Gupta
- Department of Hematology-Oncology, John H. Stroger Hospital of Cook County, Chicago, Illinois
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The Appropriateness Evaluation Protocol is a poor predictor of in-hospital mortality. Ir J Med Sci 2013; 183:417-21. [PMID: 24170692 DOI: 10.1007/s11845-013-1031-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Appropriateness Evaluation Protocol (AEP) proposes admission criteria based only on physiological and laboratory parameters and has recently informed an Irish national bed utilisation review. Severity of illness tools can be poorly predictive of outcomes, particularly in older patients. AIMS To assess the clinical utility of the AEP in moribund older and younger patients. METHODS The study was conducted in four acute hospitals in South Munster, Ireland, and was of retrospective analytical cohort study design. The Hospital In-Patient Enquiry Scheme was used to ascertain patients who died within 10 days of hospital admission, over a 2-year period. Proximate death was used as a robust measure of validity of admission. Emergency department (ED) records were screened retrospectively to allocate the AEP criteria. RESULTS There were 803 eligible in-hospital deaths. Establishment of AEP criteria was available in 72.9 % (585 patients, 50.8 % female). The median length of stay until death was 4 days. Just over 30 % (179/585) of patients did not meet AEP criteria, two-fifths (72/179) of whom had been coded as severely unwell on arrival to the ED. There was no significant difference in AEP identification rates between older and younger age groups. CONCLUSIONS Our study illustrates that the AEP is a poor predictor of mortality in all age groups, having failed to identify approximately one-third of our cohort. Based on our findings, we feel that this tool should not be used to assess the appropriateness of admission.
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Lappegard Ø, Hjortdahl P. The choice of alternatives to acute hospitalization: a descriptive study from Hallingdal, Norway. BMC FAMILY PRACTICE 2013; 14:87. [PMID: 23800090 PMCID: PMC3698089 DOI: 10.1186/1471-2296-14-87] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 06/19/2013] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hallingdal is a rural region in southern Norway. General practitioners (GPs) refer acutely somatically ill patients to any of three levels of care: municipal nursing homes, the regional community hospital or the local general hospital. The objective of this paper is to describe the patterns of referrals to the three different somatic emergency service levels in Hallingdal and to elucidate possible explanations for the differences in referrals. METHODS Quantitative methods were used to analyse local patient statistics and qualitative methods including focus group interviews were used to explore differences in referral rates between GPs. The acute somatic admissions from the six municipalities of Hallingdal were analysed for the two-year period 2010-11 (n = 1777). A focus group interview was held with the chief municipal medical officers of the six municipalities. The main outcome measure was the numbers of admissions to the three different levels of acute care in 2010-11. Reflections of the focus group members about the differences in admission patterns were also analysed. RESULTS Acute admissions at a level lower than the local general hospital ranged from 9% to 29% between the municipalities. Foremost among the local factors affecting the individual doctor's admission practice were the geographical distance to the different places of care and the GP's working experience in the local community. CONCLUSION The experience from Hallingdal demonstrates that GPs use available alternatives to hospitalization but to varying degrees. This can be explained by socio-demographic factors and factors related to the medical reasons for admission. However, there are also important local factors related to the individual GP and the structural preparedness for alternatives in the community.
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Affiliation(s)
- Øystein Lappegard
- Department of Hallingdal Sjukestugu, Medical Clinic of Ringerike General Hospital, Vestre Viken Hospital Trust, Ål, Norway
| | - Per Hjortdahl
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Pericás JM, Aibar J, Soler N, López-Soto A, Sanclemente-Ansó C, Bosch X. Should alternatives to conventional hospitalisation be promoted in an era of financial constraint? Eur J Clin Invest 2013; 43:602-15. [PMID: 23590593 DOI: 10.1111/eci.12087] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/10/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow-up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded. MATERIALS AND METHODS Narrative review. RESULTS The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost-effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital-at-home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness. CONCLUSIONS Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.
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Affiliation(s)
- Juan M Pericás
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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The ENT emergency clinic: does senior input matter? The Journal of Laryngology & Otology 2012; 127:15-9. [PMID: 23171602 DOI: 10.1017/s0022215112002538] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many ENT conditions can be treated in the emergency clinic on an ambulatory basis. Our clinic traditionally had been run by foundation year two and specialty trainee doctors (period one). However, with perceived increasing inexperience, a dedicated registrar was assigned to support the clinic (period two). This study compared admission and discharge rates for periods one and two to assess if greater registrar input affected discharge rate; an increase in discharge rate was used as a surrogate marker of efficiency. METHOD Data was collected prospectively for patients seen in the ENT emergency clinic between 1 August 2009 and 31 July 2011. Time period one included data from patients seen between 1 August 2009 and 31 July 2010, and time period two included data collected between 1 August 2010 and 31 July 2011. RESULTS The introduction of greater registrar support increased the number of patients that were discharged, and led to a reduction in the number of children requiring the operating theatre. CONCLUSION The findings, which were determined using clinic outcomes as markers of the quality of care, highlighted the benefits of increasing senior input within the ENT emergency clinic.
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Tzeel A, Lawnicki V, Pemble KR. "Hidden" value: how indirect benefits of health information exchange further promote sustainability. AMERICAN HEALTH & DRUG BENEFITS 2012; 5:333-41. [PMID: 24991331 PMCID: PMC4031695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Health information exchanges (HIEs) have already demonstrated direct value in controlling the costs associated with utilization of emergency department services and with inpatient admissions from the emergency department. HIEs may also affect inpatient admissions originating from outside of the emergency department. OBJECTIVE To assess if a potential association exists between a community-based HIE being used in hospital emergency departments and inpatient admissions emanating from outside of the emergency department. METHODS The study design was observational, with an eligible population of fully insured plan members who sought emergency department care on at least 2 occasions over the study period between December 2008 and March 2010. Utilization data, obtained from medical and pharmacy claims, were matched to a list of emergency department utilizers where HIE querying could have occurred. Of the eligible members, 1482 underwent propensity score matching to create two 325-member groups-(1) a test group in which the HIE database was queried for all members in all of their emergency department visits, and (2) a control group in which the HIE database was not queried for any of the members in any emergency department visit. RESULTS A post-propensity matching analysis showed that although the test group had more admissions per 1000 members overall (199 more admissions per 1000 members) than the control group, these admissions might have been more appropriate for inpatient treatment in general. The relative risk of an admission by the time of a first emergency department visit was 28% higher in the control group than the test group, although by the time of a second emergency department visit, it was only 8% lower in the control group. Moreover, test group admissions resulted in less time spent as inpatients, which was denoted by bed days per 1000 members (771 fewer bed days per 1000 members) and by average length of stay (4.27 days per admission for all admissions and 0.95 days per admission when catastrophic cases were removed). CONCLUSIONS Based on these results, HIE availability in the care of patients presenting to the emergency department is associated with fewer inpatient hospital days and a shorter length of stay, even when catastrophic cases are removed from the analysis. Although many factors can play a role in this finding, it is possible that HIE promotion of more appropriate hospital admissions from outside of the emergency department is one cause. Such "indirect" value shows that the return on investment found by HIEs may even be greater than previously calculated. Additional study is warranted to further the business case for HIE investment for the various stakeholders who are interested in supporting HIE sustainability.
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Affiliation(s)
- Albert Tzeel
- National Medical Director, HumanaOne, Clinical Leadership and Policy Development, Humana, Inc, Milwaukee, WI
| | - Victor Lawnicki
- Econometrician, Business Intelligence and Informatics Competency Center, Humana, Inc, Louisville, KY
| | - Kim R Pemble
- Executive Director and Chief Executive Officer, Wisconsin Health Information Exchange, Mequon, WI
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Woodhams V, de Lusignan S, Mughal S, Head G, Debar S, Desombre T, Hilton S, Al Sharifi H. Triumph of hope over experience: learning from interventions to reduce avoidable hospital admissions identified through an Academic Health and Social Care Network. BMC Health Serv Res 2012; 12:153. [PMID: 22682525 PMCID: PMC3476394 DOI: 10.1186/1472-6963-12-153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 05/24/2012] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Internationally health services are facing increasing demands due to new and more expensive health technologies and treatments, coupled with the needs of an ageing population. Reducing avoidable use of expensive secondary care services, especially high cost admissions where no procedure is carried out, has become a focus for the commissioners of healthcare. METHOD We set out to identify, evaluate and share learning about interventions to reduce avoidable hospital admission across a regional Academic Health and Social Care Network (AHSN). We conducted a service evaluation identifying initiatives that had taken place across the AHSN. This comprised a literature review, case studies, and two workshops. RESULTS We identified three types of intervention: pre-hospital; within the emergency department (ED); and post-admission evaluation of appropriateness. Pre-hospital interventions included the use of predictive modelling tools (PARR - Patients at risk of readmission and ACG - Adjusted Clinical Groups) sometimes supported by community matrons or virtual wards. GP-advisers and outreach nurses were employed within the ED. The principal post-hoc interventions were the audit of records in primary care or the application of the Appropriateness Evaluation Protocol (AEP) within the admission ward. Overall there was a shortage of independent evaluation and limited evidence that each intervention had an impact on rates of admission. CONCLUSIONS Despite the frequency and cost of emergency admission there has been little independent evaluation of interventions to reduce avoidable admission. Commissioners of healthcare should consider interventions at all stages of the admission pathway, including regular audit, to ensure admission thresholds don't change.
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Affiliation(s)
- Victoria Woodhams
- Department of Health Care Management and Policy, University of Surrey, GUILDFORD, GU2 7XH, UK
| | - Simon de Lusignan
- Department of Health Care Management and Policy, University of Surrey, GUILDFORD, GU2 7XH, UK
- Division of Population Health Sciences and Education, Hunter Wing, St. George’s – University of London, LONDON, SW17 0RE, UK
| | - Shakeel Mughal
- Central Wandsworth Community Ward, Southfield Group Practice, 492a Merton Road, London, SW18 5AE, UK
| | - Graham Head
- The Sollis Partnership Ltd 20 Hook Road, Epsom, Surrey, KT19 8TR, UK
| | - Safia Debar
- Portobello Clinic, 12 Raddington Road, LONDON, W10 5TG, UK
| | - Terry Desombre
- Department of Health Care Management and Policy, University of Surrey, GUILDFORD, GU2 7XH, UK
| | - Sean Hilton
- Division of Population Health Sciences and Education, Hunter Wing, St. George’s – University of London, LONDON, SW17 0RE, UK
| | - Houda Al Sharifi
- Room 147, 1st Floor, Wandsworth Town Hall, Wandsworth High Street, London, SW18 2PU, UK
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Bosch X, Jordán A, Coca A, López-Soto A. Quick diagnosis units versus hospitalization for the diagnosis of potentially severe diseases in Spain. J Hosp Med 2012; 7:41-7. [PMID: 22135217 DOI: 10.1002/jhm.931] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 03/20/2011] [Accepted: 03/21/2011] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We describe the functioning of a quick diagnosis unit (QDU) in a Spanish public university hospital to ascertain the utility and cost of the model compared to conventional hospitalization. DESIGN Observational study with a prospective and retrospective cohort. SETTING Spanish tertiary public university hospital. PATIENTS Two thousand consecutive patients evaluated between December 2007 and July 2010 with potentially severe diseases normally requiring hospitalization for diagnosis. For comparative purposes, we analyzed a randomized, retrospective cohort of 1454 hospitalized patients. MEASUREMENTS Variables measured included source of referral, reason for consultation, time to diagnosis and length-of-stay, hospitalizations avoided, Charlson comorbidity index, costs, and patient satisfaction using a telephone survey. RESULTS Suspected anemia, cachexia-anorexia syndrome, febrile syndrome, adenopathies and/or palpable masses, abdominal pain, diarrhea, and lung abnormalities accounted for 88% of QDU patients. The most-frequent diagnoses were cancer (26.3%) and iron-deficiency anemia. QDU patients with anemia were significantly younger than hospitalized patients with the same diagnosis (P < 0.0001). Other parameters were similar between QDU and hospitalized patients. The mean cost of treatment was 3153.87 Euros for hospitalization and 702.33 Euros for the QDU. Patients expressed a high degree of satisfaction with QDU care. CONCLUSIONS QDUs can manage the diagnosis of patients with potentially severe diseases equally as well as traditional hospitalization, and saves costs. QDU patients expressed a high degree of satisfaction, with most preferring this model to hospitalization.
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Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
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Bosch X, Moreno P, Ríos M, Jordán A, López-Soto A. Comparison of Quick Diagnosis Units and Conventional Hospitalization for the Diagnosis of Cancer in Spain: A Descriptive Cohort Study. Oncology 2012; 83:283-91. [DOI: 10.1159/000341658] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 07/02/2012] [Indexed: 11/19/2022]
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Can an emergency department-based Clinical Decision Unit successfully utilize alternatives to emergency hospitalization? Eur J Emerg Med 2011; 17:89-96. [PMID: 19823093 DOI: 10.1097/mej.0b013e32832f05bf] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate a Clinical Decision Unit (CDU) designed to utilize alternatives to emergency hospitalization. CDUs are one model of care designed to strengthen the gatekeeper role of Emergency Departments (EDs). METHODS This retrospective cohort study was carried out in a UK NHS acute hospital. All 854 patients in the CDU cohort were compared with three age-stratified, historical cohorts from the same clinical centre. The median age was 62 years (range 16-94).The main outcome measures were discharge to general practitioner, outpatient services or hospitalization, the 30-day unplanned reattendance rate for those not hospitalized, and monthly medical admission figures. RESULTS Approximately 511 [59.8%, 95% confidence interval (CI): 56.5-63.1%] to 560 (65.6%, 95% CI: 62.3-68.7%) patients were admitted in the comparison cohorts, compared with only 186 (21.8%, 95% CI: 19.1-24.7%) in the CDU cohort (P≤0.05). Approximately 243 (28.5%, 95% CI: 25.5-31.6%) to 289 (33.8%, 95% CI: 30.7-37.1%) patients were discharged to general practitioner services in the comparison groups, compared with 562 (65.8%, 95% CI: 62.6-68.9%) in the CDU group (P≤0.05). Approximately eight (0.9, 95% CI: 0.5-1.8%) to 17 (2%, 95% CI: 1.2-3.2%) patients in the comparison groups were discharged to outpatient clinics, compared with 82 (9.6%, 95% CI: 7.8-11.8%) in the CDU group (P≤0.05). There was no consistent trend towards statistically significant rises in unplanned reattendance (P>0.05). Monthly medical admissions fell substantially during CDU operation. CONCLUSION This CDU model was associated with statistically and clinically significant reductions in hospital admissions. The judicious application of this CDU model to other ED environments can be expected to yield similar benefits.
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Bosch X, Foix A, Jordan A, Coca A, López-Soto A. Outpatient Quick Diagnosis Units for the evaluation of suspected severe diseases: an observational, descriptive study. Clinics (Sao Paulo) 2011; 66:737-41. [PMID: 21789373 PMCID: PMC3109368 DOI: 10.1590/s1807-59322011000500005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 02/02/2011] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hospitals in countries with public health systems have recently adopted organizational changes to improve efficiency and resource allocation, and reducing inappropriate hospitalizations has been established as an important goal. AIMS Our goal was to describe the functioning of a Quick Diagnosis Unit in a Spanish public university hospital after evaluating 1,000 consecutive patients. We also aimed to ascertain the degree of satisfaction among Quick Diagnosis Unit patients and the costs of the model compared to conventional hospitalization practices. DESIGN Observational, descriptive study. METHODS Our sample comprised 1,000 patients evaluated between November 2008 and January 2010 in the Quick Diagnosis Unit of a tertiary university public hospital in Barcelona. Included patients were those who had potentially severe diseases and would normally require hospital admission for diagnosis but whose general condition allowed outpatient treatment. We analyzed several variables, including time to diagnosis, final diagnoses and hospitalizations avoided, and we also investigated the mean cost (as compared to conventional hospitalization) and the patients' satisfaction. RESULTS In 88% of cases, the reasons for consultation were anemia, anorexia-cachexia syndrome, febrile syndrome, adenopathies, abdominal pain, chronic diarrhea and lung abnormalities. The most frequent diagnoses were cancer (18.8%; mainly colon cancer and lymphoma) and Iron-deficiency anemia (18%). The mean time to diagnosis was 9.2 days (range 1 to 19 days). An estimated 12.5 admissions/day in a one-year period (in the internal medicine department) were avoided. In a subgroup analysis, the mean cost per process (admission-discharge) for a conventional hospitalization was 3,416.13 Euros, while it was 735.65 Euros in the Quick Diagnosis Unit. Patients expressed a high degree of satisfaction with Quick Diagnosis Unit care. CONCLUSIONS Quick Diagnosis Units represent a useful and cost-saving model for the diagnostic study of patients with potentially severe diseases. Future randomized study designs involving comparisons between controls and intervention groups would help elucidate the usefulness of Quick Diagnosis Units as an alternative to conventional hospitalization.
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Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigacio Biomèdica August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
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Wong ELY, Yam CHK, Chan FWK, Cheung AWL, Wong FYY, Griffiths S, Yeoh EK. Perspective from health professionals on delivery of sub-acute care in Hong Kong: a qualitative study in a health system. Health Policy 2010; 100:211-8. [PMID: 21109327 DOI: 10.1016/j.healthpol.2010.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/29/2010] [Accepted: 10/31/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The perception and understanding of health professionals of the role of sub-acute care in the health system will have an impact on the potential effectiveness in preventing unnecessary hospitalization. This study aims to explore the perceived role and quality of sub-acute care services in the context of Hong Kong from the perspective of health service providers and to identify barriers to effectiveness. METHODS Seven focus groups were conducted and the discussion was led by a guide covering three main areas: definition/component/role of sub-acute, difficulties in the sub-acute care services provision, and suggestion for further improvement in the provision of sub-acute care. RESULTS The participants highlighted the positive role of sub-acute to promote patient's health and quality of life so as to reduce unnecessary hospitalization. The potential barriers in the sub-acute care identified were interrelated and focused mainly on systemic issues including lack of service coordination, specialist input and resources. The participants also suggested a number of practical ways to improve the quality of sub-acute care services. CONCLUSIONS The findings showed a need for further improvement in the process of sub-acute care by developing operation guideline and re-evaluating the allocation of resources to support the sub-acute care provision.
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Affiliation(s)
- Eliza L Y Wong
- Division of Health Systems, Policy and Management, School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
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Bosch X, Aibar J, Capell S, Coca A, López‐Soto A. Quick diagnosis units: a potentially useful alternative to conventional hospitalisation. Med J Aust 2009; 191:496-8. [DOI: 10.5694/j.1326-5377.2009.tb02912.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Accepted: 07/01/2009] [Indexed: 11/17/2022]
Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jesús Aibar
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | - Antonio Coca
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Alfons López‐Soto
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Otero García L. Admisiones y estancias hospitalarias inapropiadas: los profesionales sanitarios exponen sus porqués y buscan soluciones. ENFERMERIA CLINICA 2009; 19:291-2. [DOI: 10.1016/j.enfcli.2009.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Accepted: 07/24/2009] [Indexed: 10/20/2022]
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Hammond CL, Pinnington LL, Phillips MF. A qualitative examination of inappropriate hospital admissions and lengths of stay. BMC Health Serv Res 2009; 9:44. [PMID: 19265547 PMCID: PMC2655293 DOI: 10.1186/1472-6963-9-44] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Accepted: 03/05/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research has shown that a number of patients, with a variety of diagnoses, are admitted to hospital when it is not essential and can remain in hospital unnecessarily. To date, research in this area has been primarily quantitative. The purpose of this study was to explore the perceived causes of inappropriate or prolonged lengths of stay and focuses on a specific population (i.e., patients with long term neurological conditions). We also wanted to identify interventions which might avoid admission or expedite discharge as periods of hospitalisation pose particular risks for this group. METHODS Two focus groups were conducted with a convenience sample of eight primary and secondary care clinicians working in the Derbyshire area. Data were analysed using a thematic content approach. RESULTS The participants identified a number of key causes of inappropriate admissions and lengths of stay, including: the limited capacity of health and social care resources; poor communication between primary and secondary care clinicians and the cautiousness of clinicians who manage patients in community settings. The participants also suggested a number of strategies that may prevent inappropriate admissions or reduce length of stay (LoS), including: the introduction of new sub-acute care facilities; the introduction of auxiliary nurses to support specialist nursing staff and patient held summaries of specialist consultations. CONCLUSION Clinicians in both the secondary and primary care sectors acknowledged that some admissions were unnecessary and some patients remain in hospital for a prolonged period. These events were attributed to problems with the current capacity or structuring of services. It was noted, for example, that there is a shortage of appropriate therapeutic services and that the distribution of beds between community and sub-acute care should be reviewed.
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Affiliation(s)
- Christina L Hammond
- Rehabilitation Research and Education Group, School of Community Health Sciences, University of Nottingham, Derby, UK
| | - Lorraine L Pinnington
- Rehabilitation Research and Education Group, School of Graduate Entry Medicine & Health, University of Nottingham, Derby, UK
| | - Margaret F Phillips
- Rehabilitation Research and Education Group, School of Graduate Entry Medicine & Health, University of Nottingham, Derby, UK
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Hammond CL, Phillips MF, Pinnington LL, Pearson BJ, Fakis A. Appropriateness of acute admissions and last in-patient day for patients with long term neurological conditions. BMC Health Serv Res 2009; 9:40. [PMID: 19250523 PMCID: PMC2653500 DOI: 10.1186/1472-6963-9-40] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 02/27/2009] [Indexed: 11/16/2022] Open
Abstract
Background To examine the appropriateness of admissions and in-patient stay for patients with long term neurological conditions (LTNCs). To identify variables predictive of appropriateness and explore management alternatives. Methods Adults admitted as acute patients to Derby Hospitals NHS Foundation Trust (England). Data were collected prospectively and examined by a multi-disciplinary expert panel to determine the appropriateness of admission and length of stay (LoS). Management alternatives were discussed. Results A total of 119 participants were recruited. 32 admissions were inappropriate and 83 were for an inappropriate duration. Whether a participant lived in their own home was predictive of an inappropriate admission. The number of LTNCs, number of presenting complaints and whether the participant lived alone in their own home were predictive of an inappropriate LoS. For admissions judged to be inappropriate, the panel suggested management alternatives. Conclusion Patients with LTNCs are being admitted to hospital when other services, e.g. ambulatory care, are available which could meet their needs. Inefficiencies in hospital procedures, such as discharge planning and patient transfers, continue to exist. Recognition of the need to plan for discharge at admission and to ensure in-patient services are provided in a timely manner may contribute towards improved efficiency.
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Affiliation(s)
- Christina L Hammond
- Rehabilitation Research and Education Group, School of Community Health Sciences, University of Nottingham, UK.
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Luthy C, Rentsch D, Cedraschi C, Sigaud P, Perneger TV, Allaz AF. Durée d’hospitalisation, programmation de la sortie et politique de raccourcissement des séjours : avis des patients et des soignants. Rev Epidemiol Sante Publique 2005; 53:629-34. [PMID: 16434935 DOI: 10.1016/s0398-7620(05)84742-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In the context of health care cost containment, we interviewed hospitalized patients and their health care teams concerning the length of stay they considered necessary and hospital discharge. Patients were also interviewed on the present tendency to shorten hospital stays. METHODS Prospective study conducted in a subacute internal medicine ward with 254 consecutive patients and their health care teams. RESULTS The mean evaluation of the length of stay considered as necessary was not significantly different between patients (9.7 days, SD=9.5) and their health care teams (9.6, SD=8.5). However, agreement between the two parties was moderate (r=0.64). Hospital discharge was considered as planned in similar proportions (18% vs 22% respectively), but was reported as more 'assured' by health care teams than by patients (p<0.001). Health care teams and patients approved discharge planning in 200 cases (63.3%), but agreement was only moderate (Kappa 0.43, IC 95%=0.34-0.51). Regarding the tendency to shorten hospital stays, patients'responses were favorable in only 9%, clearly unfavorable in 17% and disclosed explicit fears in 54% of the cases. CONCLUSIONS These results show that what patients and health care teams consider the necessary length of stay and the right time for hospital discharge can diverge notably. They highlight the difficulties of medical decisions in the context of cost containment, and the fundamentally asymmetrical character of the relationship between patients and health care teams.
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Affiliation(s)
- C Luthy
- Service de Médecine Interne de Réhabilitation, Département de Médecine Interne, Hôpitaux Universitaires de Genève, CH-1211 Genève 14, Suisse.
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