Inappropriate hospital admissions and their impact on health care costs

Inappropriate Hospital Admission Raising Health Care Cost

Inappropriate health care refers to the fact that patients are admitted in the hospitals without discerning whether there is a particular need for the admission or not. It may also be concerned with the patient's admission in the wrong type of wards or providing them with unsuitable health care. Inaccurate results have come up from surveys which had been conducted to figure out the number of inappropriate hospital admissions taking place in a given period of time and selected hospitals (Campbell, 2001).

Researchers along with several hospital administrators and policy makers feel sure that at least 20% of hospital admissions are inappropriate or are allotted unsuitably. Others assert that the rates are higher than currently anticipated. The inaccuracy and changing results are due to the diversity and non-uniformity in business settings and features and also because of the changeable applications and the assessment procedures followed in hospitals (Campbell, 2001).

The needless hospital admissions not only occupy space, wastes time and resources but also increases costs for the hospitals. The number of extra hospital admissions crowds the hospital and decreases the level of quality of health care services provided by the health care personnel. The hospital's capacity of keeping needful patients is reduced while the services of physicians who are responsible for constant attendance of the patients are somewhat wasted. Thus, it is the wide opinion of people at large that abolishing the practice of admitting unnecessary patients will not only reduce the costs for the medical organizations but it will also improve the quality of the health care services provided for those people who need it the most (Chopard, Perneger, Gaspoz, Lovis, et al. 1998).

The inappropriate hospital admissions are a cause for concern in many countries as hospital care forms a major portion of the total health care expenditures budgeted. Reports and surveys have depicted a dismal picture of inappropriate health care in many countries but the increased awareness and statistics available have also helped many hospitals to keep a check on their hospital admissions and to reduce the unnecessary ones (Chopard, Perneger, Gaspoz, Lovis, et al. 1998).

There are a number of factors that may lead to inappropriate hospital admissions so tackling this issue can mean a lot of effort and stress for many countries. Some of the factors that may decide the inappropriateness of the hospital admission include the personal characteristics of the patients, the type of organizations in which the hospital care is provided and the relationship between the hospital care system and the other parts of the health care sector. The solution of this worrying concern can only be drawn up if the risk factors that decide the inappropriateness are identified but only a small amount of studies and researches have followed this issue or taken it to a higher level (Chopard, Perneger, Gaspoz, Lovis, et al. 1998).

As it is difficult to identify the factors involved in the needless hospital admissions, the situation is far from being resolved. This, as can be expected, is leading to a rise in costs and people are targeting hospitals for being a source of increasing expenses. Developed countries often spend half of their entire health expenditure on care of patients that are admitted in hospitals, like Malaysia reportedly spends 45% of its total health expenditure on patients' care. Many economic measures and offers have been taken up and made in an attempt to curtail the escalating costs of hospital care provided. However, the subsequent effects on the quality of health care of following these measures and incentives are debatable, even if these offers have been successful in reducing costs to an extent (Chakravarty, Parmar, Bhalwar, 2005).

Instead, the use of cost-inhibiting measures is suggested for inappropriate hospital care that should not affect the quality and accessibility of the health care services provided in general. It is highly important that measures should be taken to get the maximum use out of the limited resources available to the hospital, that the unnecessary medical care be checked while the mishaps and accidents are avoided. It is substantially important that every hospital conducts a utilization review of its services as according to recent reports every one admission in three is useless and 30% of the hospital days given are unsuitable. The utilization reviews taken up by hospitals have proved informative and beneficial as they show that the admission of patients in hospitals was unnecessary and/or justifiable (Chakravarty, Parmar, Bhalwar, 2005).

DeCoster, Roos, Carriere, Peterson (1997) in their study evaluated the records kept in hospitals and tried to discern the data available into classifying the admissions of patients into 2 categories (1) appropriate and (2) inappropriate. Their research report have been extremely quite useful when it comes to depicting data as they use up a lot of information and resources while assessing the appropriateness and inappropriateness of hospital admissions (DeCoster, Roos, Carriere, Peterson, 1997).

In their study, they cite and use an example of a 1993 report that used 16 authentic Canadian and international research studies to come up with different questions to decide upon the appropriateness of hospital care. Some of the questions were "Were the admissions of patients in hospitals appropriate?" And "Were the number of days patients received in house treatment appropriate (DeCoster, Roos, Carriere, Peterson, 1997)?"

The report results of the international studies depicted that seven to forty-three percent of hospital admissions were inappropriate while around 20% to 48% days of stay were needless. The Canadian reviews that made three studies on adult patients showed that percentage of adults treated and admitted inappropriately ranged from 24% to a whopping 90% while as much as 66% of days of stay were unnecessary with a minimum percentage of stay being 27% (DeCoster, Roos, Carriere, Peterson, 1997).

Patients who were receiving care were also reviewed at the Manitoba Centre for Health Policy and Evaluation (MCHPE) and 26 Manitoba hospitals were visited for the review in the year 1993-94. The findings of the report also revealed that 51% of the hospital admissions and sixty-seven percent of the days of stay for adults with examined medical conditions were deemed to be unnecessary or inappropriate (DeCoster, Roos, Carriere, Peterson, 1997).

This article will also attempt to use the terms "acute" and "non acute" which can be used interchangeably for appropriate and inappropriate. This paper revolves around the issue of non-acute care given to patients and how it has contributed in increasing hospitals costs and has led to the inefficient use of resources and finance. The effects and ways to resolve the adverse effects of non-acute hospital care will also be examined in this paper.

Literature Review

Inappropriate hospital admissions during the 1990's

The management of hospitals and other health care providing centers is primarily concerned with the provision of efficient, effective and appropriate care and medical attendance given to patients. In spite of this concern, during the 1990's, very little attention was paid to the acuteness of the care a patient needs at the time of admissions and under review, hospitals were revealed to have admitted quite a large percentage of non-acute patients (Coast, Peters and Inglis, 1996).

The reports that showed an almost 25% of inappropriate admissions in hospitals generally were drawn up with skewed methods and it is probable that they may not be realistic. Moreover, these kinds of reviews and reports totally chose to ignore the effect of varying factors on the initial admissions in hospital. Other reports came up with varying results; with some depicting 5% of the admissions inappropriate while some even claiming that 60% of the admissions were non-acute (Coast, Peters and Inglis, 1996).

The studies taken up in the period of 1960s and thereafter mainly questioned and investigated the issue of inappropriate stay in hospital beds. These studies had been characterized by the problems related to the discharging of patients and the issues related to bed blocking which is the unnecessary stay of a patient in the hospital lasting for more than a month, or specifically 28 days. These reviews had also given importance to the factors that played a major role in admitting patients to the hospitals and problems that followed inappropriate stays (Coast, Peters and Inglis, 1996).

Patients afflicted with some mental disease or dementia are more likely to stay for non-acute reasons in the hospitals. Other factors which may make the patients stay in a hospital inappropriately include immobility, progressing age factor, problems attributed to self-care, gender (females are more likely to be inappropriate admissions by the hospitals as compared to males), marital status, type of accidents, the loneliness of patients and so on (Coast, Peters and Inglis, 1996).

The significant issue for the public policy makers and cost reducing programs is whether the inappropriateness of the health care services provided has anything to do with the changeable admission rates in different hospitals. If this link is confirmed, then the need for costly reviews is eliminated as the sources of data in population based area can be used to ascertain the areas with a high rate of unnecessary admissions. Therefore, a basis is formed on which to reduce the inappropriate admissions after the correct rates are determined (Restuccia, Shwartz, Ash, and Payne, 1996).

The connection between hospitalization rates and the inappropriateness of the admissions cannot be confirmed. A study of adults revealed that there was no link between the rates of hospitalization and the inappropriateness of the admission while a similar study conducted with no age limits produced contrary results. Three procedures of coronary angiography, upper gastrointestinal endoscopy, and carotid endarterectomy were used in another study to find out the relationship between the varying admission rates and their appropriateness (Restuccia, Shwartz, Ash, and Payne, 1996).

It was revealed that there was more inappropriateness in high-use areas. When this study was repeated for a small area, the outcomes were quite different. This showed that inappropriateness cannot be used as a basis to find out the cause for the differing hospitalization rates (Restuccia, Shwartz, Ash, and Payne, 1996). These studies have two major limitations. First and foremost, mainly the target of the studies has been to investigate large geographical regions that might have neglected the basic factors present in the small areas, the localized patterns of medical practices and the varying hospitalization rates that are crucial for scientific and policy related studies. Secondly, the focus of the study was either on procedural admissions or on the combination of medical and surgical admissions. Thus, the factors underlying hospital admissions rates were largely ignored (Restuccia, Shwartz, Ash, and Payne, 1996).

Another study was undertaken with the purpose of predicting the number of inappropriate hospital days in an internal medicine department so that quality enhancing measures could be properly adopted (Chopard, Gaspoz, Lovis, et al., 1998). The study was undertaken on the basis of Appropriateness Evaluation Period that attempted to determine the appropriateness of 5665 days in the hospital stayed by 500 patients in the Department of Internal Medicine, Geneva University Hospital, Switzerland. Some of the predicting factors that were considered were the patient's age, gender, the ways of admission and discharge and the nature of the days spent in the holidays (Chopard, Gaspoz, Lovis, et al., 1998).

The overall results revealed that 15% of the medical admissions and 28% of the hospital days were inappropriate. In other models of study, inappropriate admissions of patients were also accompanied by unnecessary hospital stays. The possibility of inappropriateness of the stay rose with each extra hospital day stayed ending on the day of discharge (Chopard, Gaspoz, Lovis, et al., 1998).

The study concluded that both the manners of admission and discharge were significant ways of discerning the appropriateness of hospital use in the Department of Internal Medicine. Even the longest staying patients were likely to stay further unnecessarily. However, longer hospital stays did not indicate a high rate of inappropriateness in the hospital and neither did shorter stays depict a lower rate. This piece of information became crucial in improving the health care services (Chopard, Gaspoz, Lovis, et al., 1998).

Another study was conducted with the objective of signifying that the high rate of inappropriateness in hospital use can be curbed by reducing the provision of medical care and saving resources. It identified the possibility of health gains and the costs from admissions to the Department of Internal Medicine (Eriksen, Kristiansen, Nord, Pape, Almdahl, Hensrud, Jaeger, 1998).

It made use of two expert panels which included an internist, a surgeon and a GP. They approximated the gains in DeltaHYE, or the healthy year equivalents and the advancement in the quality of life after the hospital stay, DeltaSTQoL, following the admissions to the department. The period was of six weeks (Eriksen, Kristiansen, Nord, Pape, Almdahl, Hensrud, Jaeger, 1998).

The expert panels were given the task of gauging each admission with the help of summary information provided in relation to the stay. The computation of costs was done by allocating the nursing, doctor services, and the hospital costs in line with the duration of the stay for each admitted patient and by recording all remedial interventions. The step down allocation method was used to allocate the overhead costs to the departments (Eriksen, Kristiansen, Nord, Pape, Almdahl, Hensrud, Jaeger, 1998).

The results showed that 17% of the patient benefited from no health gains whereas 83% had gains. The costs of the non-health gaining 17% made up 7% of the total costs of wards and the 22% with a low degree of DeltaSTQoL made up for 16%. The study concluded that the savings made from excluding no-gain patients from admission would have been self-effacing. It showed that 23% of the total costs could have been saved by excluding the patients with a low degree of DeltaSTQoL too (Eriksen, Kristiansen, Nord, Pape, Almdahl, Hensrud, Jaeger, 1998).

A further study was undertaken with the objective of describing characteristics related to inappropriate hospital use in Manitoba to help focus on utilization review. This review which requires a high use of resources can be an important tool for the identification of ways to curb increasing hospital costs. A total of 3904 patients were examined who were benefiting from health care at 26 different hospitals. The appropriate and inappropriate hospital use was studied along with the duration of the stay at hospitals by patients (DeCoster, Roos, Carriere, Peterson, 1997).

After a week, the results showed that about 53.2% of the patients who were entitled to receive acute health care did not require it any longer. 50% of the days of stay were utilized by patients who were 75 years old or older. Also, 74.8% of these hospital days were revealed to be inappropriate. The four diagnostic categories formed up to a 60% of admissions and days while more than 50% of them were inappropriate. Patients admitted by emergency departments stayed longer and required more acute care. The factors of patient's incomes and the nature of the days was not a useful tool in determining the appropriateness of hospital use (DeCoster, Roos, Carriere, Peterson, 1997).

The study concluded that it is more informative and economical for the hospitals to gain insight into the appropriateness of hospital use by knowing their patients, their duration of stay, diagnosis, and the nature of their admission instead of using expensive utilization review for every patient (DeCoster, Roos, Carriere, Peterson, 1997).

One more study was conducted targeting the appropriateness of hospital use and it aimed to develop a connection between the hospital admission and stay of the adult population with the inappropriateness of either admission or stay. A modified version of Appropriateness Evaluation Protocol (AEP) was used on a sample of 1082 patients staying in the hospital (Apolone, Fellin, Tampieri, et al., 1997).

The results indicated that 27% of the total admissions and 40% of the stays were inappropriate. The rate of inappropriate admissions was related to the nature of the day of admission and also presented a connection with the age of the patient. It was concluded that quite a major part of hospital use was known to be inappropriate. The properties of high interrelated reliability and predictability of expected associations in AEP was ascertained (Apolone, Fellin, Tampieri, et al., 1997).

Discussion

Inappropriate hospital use is a matter that demands urgency as it is fast using up the resources and funds reserved for quality health care. It can create major problems at the time when a country is suffering from bouts of severe epidemics or other major diseases.

Inappropriate hospital care is given to those people who do not require acute care but are using up the hospital's capacity to provide health care services. Moreover, managing patients becomes difficult because the hospital, when it reaches its maximum capacity, gets crowded and if the personnel are not trained accordingly, the service might get inefficient and ineffective. Pediatric Appropriateness Evaluation Protocol is used to measure up the appropriateness of hospital admissions and stays. Many countries are reportedly trying to tackle the problems related with inappropriate hospital use, especially the under developed countries who are not wealthy enough to bear the increasing costs.

Australia reported that 24% of its hospital admissions were inappropriate while in Canada they accounted for 29%. Similarly, in the United States, the reported inappropriate hospital use ranged from as low as 10% to as high as 70% whereas in Italy, there had been approximately 30% unnecessary hospital admissions and stays. The different in admission rates and their appropriateness can be attributed to the difference in medical practices of the countries (Marco, Mangani, Correra, et al., 2005).

An efficient, high quality and care providing health system can only be achieved when information management enjoys good quality standards. The information collected needs to be reliable, flawless, and accurate to some extent, complete and certifiable. Moreover, it should consist of the necessary facts that are required in the process of decision making (Lorenzi, Abel, and Ricci, 2004). To enhance the accuracy level of the decision making process in organizations, CBR or case-based reasoning has proved to be a valuable instrument, especially when it comes to the support of the definition of information management policies. This is useful especially when it comes to the provision of services that need to be fast, flexible and accurate while using the resources sparingly or as required (Lorenzi, Abel, and Ricci, 2004).

These CBR systems have been tested in many countries and have proven to be a beneficial aid in justifying and supporting the management's decisions. Its use is not only limited to the hospital but has been used by the governments as well. It is an ideal tool when it comes to the health care services, as this system is quick and provides the necessary information in a user friendly way. It can also be easily incorporated in other business programs (Lorenzi, Abel, and Ricci, 2004).

Conclusion

In a nutshell, providing inappropriate services to patients or admitting them for much longer than the situation demands will only increase the costs of hospitals. The hospital capacity will be greatly reduced and many needful patients will have to do without the right treatment that they deserve to get. The government expenditure on health care will not be efficiently utilized and the increasing hospital costs will mean an even higher expenditure by the government will be needed. Increasing the funds will not be able to resolve the current problem. This is because the inappropriate services and admissions will go largely unnoticed and costs incurred will keep on adding up. This situation might greatly endanger the quality of health care services provided by the hospitals. In addition, the entire health care system might have to face serious deterioration.

In order to reduce the hospital cost increases due to inappropriate hospital admissions and stay, it is imperative that appropriateness assessment tools are used. Majority of the practitioners consider the most suitable assessment tool developed thus far to be "Appropriateness Evaluation Protocol." It is being widely and successfully used in many countries throughout the world. This is because it presents a general criterion of patients that deserve to be under acute care. It makes use of clinical reports and therapy requirements to present its findings.

In addition to that, using "utilization reviews" has been proven to be a good practice. However, it is an expensive method of finding out whether the hospital stays and admissions are appropriate or inappropriate. These reviews have been found to be time consuming and expensive. However, their utility lies in the fact that they examine the information from the hospital records and attempt to examine the records of each patient. Generally, utilization reviews in countries have shown a large amount of inappropriate hospital use.

One advantage of this form of assessment is that the hospitals can acquire an idea of what factors and aspects are making the health care providers give inappropriate admissions and stays to patients. The patients' characteristics can also be gauged and compared with the number of inappropriate hospital admissions, as well as, the duration of their stay in the hospital and a connection can be outlined.

In addition to "utilization reviews" and "Appropriateness Evaluation Protocol," CBR or "case-based reasoning" is an even more advanced, flexible and useful tool. It makes uses of past occurrences in order to assist in future decision making. When a particular target problem is inserted in the program, it recalls previous cases to resolve the problem. It revises and retains information for future cases. However, critics of CBR use assert that without the availability of relevant, accurate, verifiable and complete past information, the results of the case-based reasoning can not be relied upon as it bases its decision on past occurrences and knowledge of cases.

Inappropriateness of admissions and hospital stays can be identified through CBR by maintaining past records of patients who were inappropriately treated. The findings of the CBR for the new cases can provide a support structure for managers to base their decisions on. This system can be easily updated and new cases can easily serve as an input. It is without doubt that inappropriate hospital use needs to be avoided to reduce the increasing costs that may lead to other problems for the patients, the health care system and the government. There are many tools, surveys and reports available to determine the appropriateness of hospital use, which can be used easily.