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

OBJECTIVE: To develop and validate a list of criteria to assess the causes of inappropriate hospital days for patients admitted to rehabilitation centres and sub-acute care units. DESIGN: The tool was developed by a multidisciplinary panel of 33 experts, using a formalized consensus method. It collects both the needs of patients (distinguishing healthcare needs (9 criteria) and accommodation needs (9 criteria)) and the reasons for inappropriateness (19 criteria). Inappropriate days were identified using the tool to assess appropriateness of hospital days validated previously. Reliability was studied by measuring agreement between two independent simultaneous ratings. SETTING: The validation study was performed on a randomized sample of 576 hospital days from 22 wards in France. MAIN OUTCOME MEASURES: Inter-rater reliability was evaluated using the κ-statistic and prevalence-adjusted and bias-adjusted kappa (PABAK). RESULTS: For patient accommodation needs, the inter-rater reliability was estimated by a κ-value of 0.80 (95% confidence interval (95% CI) 0.66-0.92) and a PABAK of 0.80 (95% CI 0.63-0.91). There was good agreement on the reasons for inappropriateness, with κ-values from 0.30 to 0.60 and PABAK from 0.46 to 0.69. The κ-coefficient varied from 0.33 to 0.49 for the assessment of patient healthcare needs, with PABAK ranging from 0.49 to 0.72. CONCLUSIONS: The instrument is suitable and valid to assess the causes of inappropriate hospital days in rehabilitation centres and sub-acute care units. The study showed that the tool can be easily used by healthcare workers, which makes it useful for quality improvement.

[Appropriateness of medical prescriptions, French experience]. / Pertinence des prescriptions médicamenteuses, expérience française.

Appropriateness of care, applied to medical prescription, is a fast-growing professional practice evaluation method, within a context of control spending and quality improvement. A literature review related to the last ten years found 38 publications, including 19 original studies. Results showed that only few studies were published, and that methodologies were not standardized. Development of pedagogical data tools is essential to increase doctor's awareness. Analysis of causes of inappropriateness has to be conducted, in order to plan improvement actions. A second evaluation is necessary to assess the impact of appropriateness review on professional practices.

[Appropriateness of days of hospitalization: a comparative study at Nantes University Hospital]. / Revue de pertinence des journées d'hospitalisation en médecine et chirurgie : un tiers de journées inappropriées au CHU de Nantes.

OBJECTIVE: To assess the rate of inappropriate hospital days at Nantes University Hospital, to compare Internal Medicine and General Medicine departments to other hospital departments and to describe the main reasons for inappropriateness. METHOD: A cross-sectional study was conducted during spring 2006, on a given day that differed in the 11 participating medical and surgical departments. All inpatients in the departments were included, except those admitted or discharged that day. The French version of the Appropriateness Evaluation Protocol was used to assess each day. RESULTS: Overall 32.4% of hospital days (71/219) (95% confidence interval: 26.1-38.7) were inappropriate. This rate did not vary significantly between internal and general medical, specialty, and surgical departments, although their inpatients had different characteristics. The risk factors for inappropriateness included long stays, unplanned admissions, behavioral disorders, and older age. Only a long stay was identified as a risk factor in all departments. Most of these inappropriate days (77.5%) were due to external causes (patients awaiting transfer). The decision of the patient (or family) was involved in 12.7%, and internal organizational reasons in 9.8%. DISCUSSION: This study showed a variety of risk factors for inappropriate days, differing according to department (except long stays, which were a risk factor in all departments). This confirms that patient characteristics play a major role, more significant than the department itself. Our analysis of the causes of these inappropriate hospital days, like those of most other studies, finds that only a few of these causes are susceptible to internal improvements. To optimize patient transfers, however, several units have begun training to make hospital staff aware of the importance of early planning. The impact of these measures on the number of inappropriate days should be assessed in the future.