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International Journal for Quality in Health Care 14:431-432 (2002)
© 2002 International Society for Quality in Health Care

Letter to the Editor

Assessing inappropriate hospital stay in Internal Medicine using the Dutch Appropriateness Evaluation Protocol

Lambert J. G. G. Panis, Frank W.S.M. Verheggen, Peter Pop and Martin H. Prins

Department of Clinical Epidemiology & Medical Technology Assessment, University Hospital Maastricht, The Netherlands
Quality Council, University Hospital Maastricht, The Netherlands
Dutch Institute for Healthcare Improvement (CBO), Utrecht, The Netherlands
Department of Internal Medicine, University Maastricht, The Netherlands
Transmural & Diagnostic Center, University Hospital Maastricht, The Netherlands
Department of Clinical Epidemiology & Medical Technology Assessment
University Hospital Maastricht, The Netherlands

To the Editor: As stated in several international studies [1–14], the Appropriateness Evaluation Protocol (AEP) [15–18] is a useful tool to detect the overuse of hospitalization resources. We modified the AEP to the Dutch health care system in order to assess appropriateness of care in Dutch hospitals [19,20]. Since we expected to find in this study a rate of inappropriate stay similar to that of other international studies (approximately 30%), we were indeed very surprised to find a rate of only 14% for the Department of Internal Medicine. Unfortunately, we were not able to maintain this rate over the years. Our research has shown that the rate of inappropriate stay in the Department of Internal Medicine in 2001 increased to 21.2% (our unpublished data). However, this is still lower than the 30% mentioned above.

Inappropriate stay should be monitored in order to use hospital resources as efficiently as possible. Therefore, in the past, several actions to decrease the length of hospital stay have been implemented in the Dutch health care setting (e.g. reduction of hospital beds, financial budgeting, restrictive admission policies, treatment as much as possible in day care or the outpatient setting). It is conceivable that these actions have also affected inappropriate hospital stay. When trying to explain the relatively low rate of inappropriate stay in Internal Medicine we should mention that the primary objective of the study was to modify and validate the United States AEP (US-AEP) for practical use in the Dutch health care setting. Data allowing in-depth analyses of reasons for inappropriate stay and relating these reasons to the underlying medical condition have not been collected. A possible reason for the low rate of inappropriate stay in Internal Medicine might be the relatively large proportion of days of hospital stay in this subgroup generated by hematology/oncology patients (n = 251, 27.9%); among these patients there were practically no inappropriate days of stay (n = 4, 1.6%). If these days were removed, the rate of inappropriate stay in Internal Medicine would increase to 19.0%. Still, this percentage is lower than the average rate found in other international studies (30%).

We can answer the questions of Dr Rodríguez-Vera [21] as follows.

  1. Cardiac catheterization, angiography, biopsy of an internal organ, tests requiring dietary control and respiratory care are indeed not criteria listed in the Dutch AEP (D-AEP). Normally, these procedures are performed on an outpatient or a day care basis. These patients will be admitted only if threatening situations requiring acute hospital care are expected to occur. In that case, these patients are mostly not admitted to an internal medicine ward, but to cardiology, or intensive or coronary care units. If these procedures take place during the patients’ stay it is likely that the specific nursing care, intravenous medication, or monitoring of the patient will render the stay ‘appropriate’ according to the D-AEP. Although we do not have exact figures, we presume that the percentage of these patients in the Internal Medicine subgroup of our study is <5%.
  2. In 3.3% (n = 148) of all days of stay analyzed in this study (n = 4497), the override option was used. Within the Internal Medicine subgroup (n = 899), the override option was used in only 43 days of stay (4.8%). Therefore we think it unlikely that the low percentage of our inappropriate stay is related to the use of the override option.
  3. As stated by Dr Rodríguez-Vera, inappropriate admissions are of great influence in causing inappropriate stay [21]. In current follow-up studies we too found a statistically significant relationship (P = 0.043) between the type of admission and the incidence of inappropriate stay (within Internal Medicine; our unpublished data). In our view, the interventions described in Dr Rodríguez-Vera’s letter to the editor focus merely on reducing inappropriate admissions [21]. In our pilot study, however, the inappropriateness of the admission was not assessed. We focused rather on inappropriate stay, since in the Dutch health care system there is a strict policy for admission to an acute care hospital. Except for emergency admissions, every patient has to consult a general practitioner or medical specialist before he or she can be admitted to a hospital. If a general practitioner is seen, this general practitioner consults a medical specialist for an opinion on whether an admission to a hospital is indicated. Only if this is so will the patient be admitted. If a patient presents to an emergency facility of the hospital, the need for admission is assessed there. If possible, the patient is treated there or referred to another health care facility. This approach reduces the risk of inappropriate admissions.

The existence of comorbidities in internal medicine patients is very likely, and these comorbidities can prolong the stay of patients. As long as during this prolonged stay the D-AEP criteria are met in accordance with the protocol, no additional inappropriate stay will be indicated. Thus, comorbidity may cause appropriate as well as inappropriate stay. However, data on comorbidity were not collected due to the limited objective of the study.

We would be very happy to compare our findings in our more recent D-AEP studies with the findings of Dr Rodríguez-Vera and co-workers in order to exchange further experiences in the measurement and reduction of inappropriate stay.

REFERENCES

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  19. Smeets P, Verheggen F, Pop P, Panis L, Carpay J. Assessing the necessity of hospital stay by means of the appropriateness evaluation protocol: how strong is the evidence to proceed? Int J Qual Health Care 2000; 12: 483–493.[Abstract/Free Full Text]

  20. Panis L, Verheggen F, Pop P. To stay or not to stay. The assessment of appropriate hospital stay: a Dutch report. Int J Qual Health Care 2002; 14: 55–67.[Abstract/Free Full Text]

  21. Rodríguez-Vera FJ, Barón Franco B, Rodríguez Ortega P, Pujol de la Llave E. The AEP in the assessment of appropriate hospital stay. Int J Qual Health Care 2002; 14: 429–430.[Free Full Text]


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