Assessing the necessity of hospital stay by means of the appropriateness evaluation protocol: how strong is the evidence to proceed?

OBJECTIVE: To review the Appropriateness Evaluation Protocol (AEP) with respect to assessing the necessity of hospital stay at the University Hospital of Maastricht. DESIGN: Literature search in Medline focusing on the validity, reliability and possibilities for intervention plus a description and the first results of pilot studies with a Dutch version of the Adult-Medical AEP (days of stay). SETTING: The University Hospital of Maastricht, a 700-bed university and regional hospital in the south of The Netherlands. MAIN OUTCOME MEASURES: Face, content, and convergent validity, and reliability in terms of overall or specific agreement and by kappa, of the Adult-Medical AEP when used by physicians and nurses. RESULTS: In comparison with other instruments, a comparatively good performance by the AEP has been reported in the literature. Literature review revealed limitations in the AEP as a general and truly valid and reliable instrument for assessing the necessity of hospital stay. In applying a Dutch version (azM-AEP) similar difficulties were encountered. CONCLUSION: Based on the literature review and our own findings, we conclude that the validity and reliability of the different versions of the AEP are not yet up to standard. Regarding the results of the interventions thus far, we do not encourage further use until additional improvements to both the instrument and the review conditions have been made. Perhaps a more disease-specific modulation and assessments based on computerized medical records could improve its applicability in clinical practice in general.

Explaining cost variations in DRGs 'Acute Myocardial Infarction' by severity of illness.

The empirical relationship is analyzed between the severity of illness and costs of medical care for 464 patients classified into DRGs 121-123, Acute Myocardial Infarction (AMI), in the University Hospital, Maastricht. Severity of cardiac and cardiovascular disorders characteristic of acute myocardial infarction is defined and operationalized in a sense that closely resembles the clinical practice of cardiologists. The effect of the severity of illness on DRG cost variations is studied separately for the costs of acute care (such as thrombolytic therapy, cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA)), length of hospital stay, costs of intensive nursing care at the coronary care unit (CCU) and the costs of ECGs, laboratory tests, echocardiography, exercise tests and drugs. For AMI patients, severity of illness measured by specific clinical criteria is found to give better predictions (higher R2) for costs of medical care than the DRG classification.

Quality of dental restorations and dental treatment in Dutch schoolchildren.

The quality of dental restoration and treatment need have been defined and investigated in a survey of primary schoolchildren in the Netherlands. Measurements were made using respectively a quality of dental restorations index and a dental treatment index. A statistical analysis was carried out on these data. Six criteria were used to classify the technical quality of restorations. Quality was analysed in relation to the child's region of residence and the type of dental professional regularly visited. Three other variables were also considered to be relevant in the analysis; the size of the restorations (one or more surface fillings), the child's age, and whether the restorations were polished (finished) or not. An overall index to measure the intrinsic quality of dental restorations (QDRI) based upon five qualitative criteria was constructed. A proportional dental treatment index (DTI) was developed on the basis of sets of fillings placed and fillings needed.