Inappropriate hospital care and severity of illness: results from a nationwide study.

Little is known about the clinical characteristics of hospital patients who do not meet standard utilization review criteria for acute care settings. This study examined whether patients with either inappropriate hospital admissions or days of care were less severely ill on a number of indicators compared to those designated as appropriate by a widely used utilization review instrument. Using data from a probability sample of 6063 medical and surgical hospitalizations at 50 Department of Veterans Affairs medical centers, we found strong associations between the appropriateness of admissions and days of care and four indicators of severity of illness. These results suggest that utilization management programs and preadmission screening probably successfully screen out less severely ill patients who have less need of hospital-level services.

Utilization of acute inpatient services for alcohol detoxification.

This study indicates that the majority of patients admitted to VA hospitals for medical detoxification could have those services provided on an outpatient or less intensive basis. However, inpatient medical detoxification services appear to be appropriate for those alcoholics at risk for potential life-threatening complications of withdrawal such as delirium tremens, or those with concurrent associated medical conditions such as pancreatitis, gastrointestinal bleeding, or complications of cirrhosis. Data were obtained from a national random sample of hospitalizations in Department of Veterans Affairs (VA) inpatient medical and surgical units. Medical records for 144 alcoholism-related medical admissions to 35 VA medical centers were reviewed using the Appropriateness Evaluation Protocol (AEP), a clinically based utilization review instrument widely used in the private sector. The medical records for the admission and each day of medical/surgical inpatient stay were reviewed using clinical criteria for the appropriateness of acute inpatient care as opposed to lower levels of care.

Geographic variation in primary care visits in Iowa.

OBJECTIVE: This study investigates the determinants of primary care office visit rates. DATA SOURCES: Blue Cross and Blue Shield of Iowa subscriber information was sorted by residence into geographic health service areas. Cost-sharing information was also obtained from Blue Cross. Physician supply data were obtained from The University of Iowa, Office of Community-Based Programs. Hospital data were reported by the Iowa Hospital Association. STUDY DESIGN: Cases were classified into ambulatory care groups (ACGs). Use rates were computed for each group in each service area. Ordinary least squares regression models were developed to model geographic variation in each ACG-specific primary care visit rate. PRINCIPAL FINDINGS: Regression models were not significant for five out of eleven ACGs studied. Out-of-pocket expense significantly affected utilization in three out of six. The number of primary care practices per capita had a significant effect on utilization in two ACGs. The supply of hospital outpatient services was significant in one ACG. CONCLUSIONS: Study findings reveal that some ACGs are price-sensitive and some are not. Policies aimed at changing levels of primary care use should taken into account whether varying cost-sharing will influence consumer behavior in the desired direction.

Using comparative clinical and economic outcome information to profile physician performance.

This paper presents strategies and empirical examples of comparative physician profiling under conditions of limited patient sample sizes and varying patient severity. A method by which clinical and cost outcomes may be evaluated simultaneously is also presented. Physician economic and clinical performance are compared using data abstracted from nine hospitals into the MedisGroups clinical information management system for inpatients treated from July, 1990 through June, 1992. The main outcome measures are comparative total and ancillary adjusted charges, and morbidity status. Results suggest that objective comparative outcome data provide useful information to assist in evaluating physician performance. A simultaneous comparison of clinical outcomes and adjusted charges identifies physicians who experience favorable outcomes at lower charges, as well as those who have higher charges and/or poorer outcomes. Strategies outlined in this paper may be of value to clinicians, governing boards, and third party payors. These strategies may be used to assist with privileging and other peer review activities when pursued proactively within a Continuous Quality Improvement framework to improve care.

The contribution of hospitals to a local economy: a case study in Iowa and Illinois.

This study assessed the importance of the hospital sector to a regional economy by examining the estimated effects of direct and indirect hospital spending on the income and employment of a metropolitan region in Iowa and Illinois. The evaluation included the role of hospital services as a regional "export." In addition, the stabilizing impact of hospital spending during business cycles was examined. Results of the study indicated that the hospitals played a vital role in the economic stability and growth of the local community.

Reliability of a utilization review instrument in a large field study.

One important question for a utilization management program is whether the utilization review instrument is consistent or stable when used on many occasions by the same abstractor (intrarater reliability) or by several abstractors (inter-rater reliability). As part of a nationwide study of inappropriate utilization of inpatient services by the Department of Veterans Affairs, we conducted a thorough investigation of the inter-rater reliability of a widely used utilization review instrument by 27 nurse abstractors. All abstractors were extensively trained, both by the developers of the instrument and by use of practice medical records. A standard protocol for resolving questions was implemented, with immediate communication of decisions to abstractors. The results of three reliability assessments, conducted immediately after formal training, after several weeks of reviewing practice records, and midway through review of the study records, demonstrated good to excellent reliability, both when comparing the nurse abstractors with a physician gold standard and among themselves. Therefore, with appropriate training and monitoring, utilization management programs in large hospitals, multihospital systems, and other health care organizations needing to examine inpatient utilization should feel confident that they can achieve reviews that would be in close agreement with physician and other nurse abstractors. Such confidence should increase the acceptability of utilization management programs.

Relationship between early readmission and hospital quality of care indicators.

Readmission rates are being proposed as an outcome indicator of hospital-level quality despite the lack of evidence of a relationship between a readmission and the quality of care provided during the preceding hospital stay. This study examined this relationship by comparing the quality of care provided to samples of 134 unplanned readmissions and 158 nonreadmissions from 50 Department of Veterans Affairs medical centers. Four groups of commonly used quality indicators and seven readmission risk factors were included in a logistic regression analysis. Inclusion of the quality indicators significantly increased the predictive power of the logistic models, with "unexpected transfer to a special care unit" being the only significant variable.

Shifting the financial burden: the VA ambulatory care discharge policy.

The Department of Veterans Affairs is a primary source of health care services for many of the nation's uninsured and underinsured. Changes in congressionally mandated eligibility criteria and limited increases in appropriations have forced the Department to adopt a policy of discharging chronic but stable outpatients who have been treated for non-service-connected health conditions. Survey data from one VA medical center suggest that many, but not all, of those discharged: 1) have either Medicare or private insurance coverage; 2) have not sought or found alternative physician services in their local communities; 3) have discontinued taking previously prescribed medications; 4) report worsened health status since discharge; and, 5) have been hospitalized. In general, discharged patients from the lowest income group report the greatest financial access barriers. Preliminary analyses of the discharge policy suggest the potential for decreased access to needed medical services due to financial factors and cost-shifting from the VA to patients and other federal, state and local payers and providers.

Methods for estimating days of hospitalization due to nosocomial infections.

While there is little agreement at the individual patient level of analysis, estimates of mean NI-attributed days of stay for the two methods were essentially the same. The lack of agreement at the individual patient level may reflect fundamental differences in the methods used to derive these estimates: incorporation of noninfected patient data versus exclusive reliance on data from infected patients; and, focus on length of stay rather than the actual care being received. The potential advantages of the AEP-based method include the following: 1) all patients with NI can be included in developing estimates; 2) estimates are based on the care provided rather than simple length of stay differences; 3) data on which to form the NI-day estimates are readily available in the medical record; 4) the AEP is a validated and commonly used utilization review instrument; 5) the AEP-based method has acceptable reliability; 6) this method is designed to provide individual and group estimates of NI-attributed days; 7) because every day of stay is reviewed, additional information is available, which results in greater precision of study of the development, diagnosis, and treatment of the NI relative to the other care that originally brought the patient into the hospital. The AEP-based method for estimating NI-days is a promising alternative to the historical cohort approach. Additional applications of this approach are encouraged to further assess its reliability,validity, and additional information yield.

Rural hospitals' viability and strategic responses.

In 1989 the Catholic Health Association, in conjunction with the University of Iowa Center for Health Services Research, surveyed chief executive officers (CEOs) of rural hospitals regarding their hospital's viability and strategic behaviors and orientations. An extensive questionnaire was sent to the CEOs of all Catholic, all other religious not-for-profit, and all investor-owned rural hospitals, as well as to a 50 percent random sample of government and other not-for-profit rural hospitals. CEOs on average perceived that their hospital's viability relative to that of other rural hospitals was higher in 1989 than it had been in 1987. Ninety-four percent of hospitals whose CEOs perceived an increase in viability had been medium- or low-viability hospitals two years earlier. Thus, despite reports of deteriorating conditions for rural hospitals, rural hospital CEOs appeared to be relatively optimistic regarding their institution's viability. Changes in strategic direction accompanied these perceived increases in viability. The predominant strategic orientation adopted by rural hospitals in 1987 was that of the defender, but many hospitals that used this approach switched to the analyzer orientation by 1989. Significant shifts also occurred toward the reactor orientation from the analyzer and defender orientations. A greater percentage of hospitals with a perceived increase in viability between 1987 and 1989 altered their organizational role. The most common change for these hospitals was from limited care to basic care.

Relationship between inappropriate admissions and days of care: implications for utilization management.

A critical issue for utilization management programs is how much of the hospitalization should be reviewed and whether information relative to the admission provides information about the subsequent days of stay. This study evaluates the relationship between the appropriateness (defined as overutilization of acute, inpatient services) of admissions and all days of stay in a probability sample of 6,063 hospitalizations from 50 Department of Veterans Affairs medical centers (VAMCs). Results suggest that preadmission reviews in hospital-based utilization management programs may eliminate not only unnecessary admissions but also, in most cases, completely inappropriate hospitalizations. In addition, except where inpatient-appropriate surgeries are not performed in a timely manner, review of the rest of the stay may not be an efficient use of time and resources.

Surviving in rural America. Providers must adapt to the changing healthcare environment.

As the rural healthcare environment changes, the abilities to assess the situation quickly and to implement decisions under conditions of uncertainty are crucial success factors. Rural healthcare providers and rural communities must examine certain assumptions underlying the delivery of healthcare services in rural areas, including the following: The rural renaissance of the 1970s will return. Rural communities need and want hospitals. Local physicians are the backbone of rural healthcare delivery. Transportation is a major barrier to healthcare service delivery. Competition in the delivery of healthcare services is appropriate for rural areas. The questionable validity of these assumptions implies that the current infrastructures for delivering rural healthcare services may no longer be appropriate. To adapt to changes, providers must (1) ensure changes fit with local conditions, (2) consider regionalization, (3) integrate all human services, not just health services, into a cooperative arrangement, (4) consider alternative configurations for providing physician services, and (5) place greater emphasis on transportation and telecommunication systems as means for ensuring timely access.

Appropriateness of admissions and discharges among readmitted patients.

This study examined the relationships between appropriateness of readmission within two weeks of discharge and appropriateness of previous admission and discharge, bed section, type of readmission, and patient demographic, medical condition, and hospital stay characteristics. Using the Department of Veterans Affairs (VA) Patient Treatment File and medical records, 445 readmissions to a highly affiliated midwestern VA Medical Center in fiscal year 1984 were examined. Appropriateness was determined by four trained medical record abstractors using InterQual admission and discharge standards. Type of readmission was based on a pilot-tested flowchart. Appropriateness of readmission was significantly associated with that of the previous admission and discharge, with the relationship varying by admission, discharge, and readmission bed sections. Reasons for inappropriate admissions, discharges, and readmissions also varied by bed section. For the majority of inappropriate readmissions, there was clear written evidence in the medical record during the previous hospital stay that the patient was directed to return for readmission. Inappropriate readmissions were more likely than appropriate readmissions to have a primary diagnosis of neoplasm or digestive disorder. These results indicate the importance of examining both the operational efficiencies during the previous admission and the clinical criteria for admitting, discharging, and readmitting patients in assessing the appropriateness of readmissions.

An examination of the factors that influence patient referral decisions.

The results of a study to identify the factors that two types of referring physicians, general/family practitioners and general surgeons, consider when deciding whether or not to refer the patient, and where to refer the patient are presented and discussed. The factors for each type of decision were identified initially through interviews with physicians in active practice in Wisconsin and rank ordered according to their relative importance in making the referral decisions. These factors were then used in two alternative normative decision-making models to predict physician referral behavior. Factors related to the kind and quality of medical care the patient would receive appear to be most important in the decisions, with a high level of agreement between and among general/family practitioners and general surgeons as to the relative importance of the factors. Although the normative decision-making models correctly predicted a relatively high percentage of the referral decisions, not all of the factors were found to be important in explaining the behavior of physicians, and were not always consistent with the factors that were reported to be important.