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To be or not to be in hospital : a new approach to an old problem Cardiff, K. (Karen), 1953-; Sheps, Samuel Barry; Thompson, David M. Feb 28, 1997

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...TO BE OR NOT TO BE IN HOSPITAL:A NEW APPROACH TO AN OLD PROBLEMKaren CardiffSamuel B. ShepsDavid M. ThompsonHPRU 96:110 October 1996,'..TO BE OR NOT TO BE IN HOSPITAL:A NEW APPROACH TO AN OLD PROBLEMKaren CardiffSamuel B. ShepsDavid M. ThompsonIntroductionDespite its manysuccesses, the delivery of healthcarein Canada has comeunderserious scrutinyover the last several years,' and the currentsystem is nowin the process of undergoing majorreform?There aregrowing claimsregarding uncertainty about the future viability of thecurrenthealthcaresystem, givenan economic climate of fiLcal constraint accompanied withchanges infederal-provincial transferpayments, a trendtowards increasing accountability to the publicand thevalidperception that funds are not spentin themosteffective manner. Thus,it is notsurprising thatvirtually everykey stakeholder groupin the healthcarearena(healthpolicy-makers, administratorsand providers alike) aredirecting considerable attention towards refining the current system in orderto ensurethat the healthcare services, are necessary, and aredelivered in the mostappropriatesetting.Healthcare evaluation systems have the potential for playing a prominent rolein thisprocess bothatthe macro level,withpolicyformulation, and the microlevel,withthe management of specifichospital andcommunity-based services. Policydecisions aboutwhich services to provide, to whom,and in whatsettings, have frequently beenmadeadhoc, in the absence of accurate information.Healthcare utilization researchcanhavean impacton thisprocess by enhancing the capability ofboth administrative andclinical decision-makers to undertake research on a widevariety of healthcareservices andinterventions to monitor boththeutilization of healthservices andmoreimportantly the impacts of specific interventions on patient outcomes.As long as inpatient hospital carecontinues to account for a significant proportion of the total healthcare expenditures,' it is both necessary and relevant to ensure that the processes monitoring andcontrolling utilization of hospital resources arebotheffective andefficient Provincial healthcarepolicies aimedat controlling admissions to acute carehospitals havefocused primarily onconstraining the supplyof hospital beds. Bedneeds projections in mostprovinces havetraditionallybeenbasedon assumptions aboutthe future population and agestructure of a region(despiteevidence that ageper se is essentially lrretevann," along withinformation abouthospital utilizationrates, and referral patterns. Although thisinformation is important it maybe incomplete if it fails toconsiderotherfactors suchas the acuity andservice intensity characteristics of the populations beingserved Moreover, with a basictenetof thecurrentsystem of healthcarereformbeing,in one form1.:0"or another, theprinciple of providing care 'closerto home',a majorfocus of publicpolicygoverninghospitalreformover the coming yearswill be to provide services whichwereonce the domainof theacutecare hospital sector, eitherin thehomeor in sub-acute settings withinthe community.However, theprinciple of delivering care closerto homenecessarily implies, 1) that thereis anaccurateunderstanding of the various levelsof care whichare required by those in acutecare beds;and 2) that the services are indeedavailable. Withregard to health care reform,in particular,decisions aboutmoving variousaspects of careinto the community cannotbe made solelywithinthepoliticalmilieu, wheredifferent motives operate for the different levels of decision makers. Rather,the processof shifting thedelivery ofhealthcare to community-based settings requires accesstohealth information accurately reflecting the characteristics of the populationon a hospital-specific,regional,and system-wide basis.The majorobjective of this paperis to illustrate how routinely collectedhealth information can beused to createa datasetof clinicalinformation, and moreimportantly, how this information mightbeused to both monitorand assesshospital utilization, and supporthealth care reform, at both thehospital and community level. In particular, thispaper will describe a hospital-~ utilizationmanagement initiative undertaken by an acute-care teaching hospital with thecombined goal ofimprovingtheunderstanding, and themanagement of, bed utilization withinthe organization. Theapproachtakenby the hospitals described in this study was to first identifythe proportion ofpat'ents, whohavingreceivedcare on an in-patient basis, mighthave been amenable formanagement in a less service-intensive, and perhaps less costlysetting. Following from this,identifyingthe specificlevelsof care that these patients mighthave required. as an alternative to thein-patientcare that they received, was undertaken. This latter assessment is of particularrelevancefor planning of community-based care.MethodsStudyDesignThe Vancouver Hospital& HealthSciences Centre(VllliSC) is Canada's secondlargesthospitaland serves a continuum of patientneedsranging fromcommunity outreachprograms for the citizens2of Vancouver to specialized tertiary service for the people of BritishColumbia. Consisting of twohospitalsites (12th & Oak Site (VB) and University Hospital Site (UH)t VHHSC is a majorreferral, teaching, and research hospital in the province withacademic links to the FacultyofMedicine at the University of BrltishColumbia, VHHSC provides a widerangeof medtcat, surgicalandpsychiatric services exceptpediatrics andobstetrics.The hospital-based utilization management initiative described belowwas initiated by the VHHSCandwasdesigned to collectbaseline information aboutthe acuity of adultmedical patients onadmission to hospital, in orderto identifythe proportion of patients who did not need to be in acutecare beds, as defined by the ISD-A(Intensity of Service, Severity of Illness, Discharge Screens andAppropriateness of Admission to SpecialCareUnits) explicitcriteria.s For eachpatient whowasjudgednot to require in-patient caret a decision was madeas to whatlevel of caremighthavebeenmoreappropriate for thepatient Thepurpose of identifying an alternate levelof care was to provideaggregate data to supportdecisions to planfor, anddevelop the neededlevelsof care. Decisionsaboutalternate levelsof care were basedon thoseoutlined by the ISD-Areviewprocess. Adescription of the alternate levelsof care that wereusedin this study arebasedon the alternate levelsof carewhichhavebeendeveloped by InterQuaIs and canbe foundin Appendix ATo avoidthepossibility of contaminating the results of this studyby the Hawthorne Effect (if thedata werecollected on a concurrent basis)it wasdecided to collectthe datausing a retrospectiveapproach. The Hawthorne Effect refers to the influence on subjects (in this particularcase,providers and administrators) whoare aware that theyarepart of a study and altering theirbehaviorto obtain betterresults than wouldotherwise havebeenobtained.6 Ifwe had collected thedataconcurrently, providerand/oradministrative behavior (i.e. practices relatedto admitting anddischarging patients) mighthavebeeninfluenced and confounded by theirawareness thatdata,relatedto patientacuity and service delivery, werebeingcollected.Sample FrameThe sample frame for this studywas basedon data routinely collected by the respective hospitalsand included all separations from adultmedictne.' However, in orderto achievea sampleof routinemedical admissions, we excluded the following groups of patients: patients whosestay in hospital3had involved an admission to an intensive care, coronary care, rehabilitation or psychiatric unitPatients cared for in the Hyperbaric Uni~ or theSleep Disorder Clinic9 or who underwent a surgicalprocedure, other than minor diagnostic procedures (e.g. colonoscopy) were also excluded" Therecords of those patients who died during an admission selected for review, were excluded from thestudy." We also excluded records from the study if the particular patient admission being reviewedhad involved a transfer from another acute care facility. The sample frame encompassed theperiodfrom September 1992-August 1993. During this time period there were 2706 eligible (i.e, notexcluded) adult medical separations from the UH Site and 3044 adult medical separations from theVHsite.A sample of 18% of all adult medical patients separated from the respective hospital sites wasdecided to be more than adequate to 1) accurately determine the proportion ofpatients whose level ofacuity on admission to hospital suggested that they did not require in-patient care, and, 2) supportmeaningful multivariate analysis. The sample size for the respective hospital sites was 487 (18%)for the UH Site (40 separations for each month) and 726 (24%) for the VH Site (60 separations foreach month). A random sample ofpatient record numbers was generated from the sample frame,described above, using a 'random sample program'. 12Measurement InstrumentThe ISD-A is an instrument used to identify the presence of, and reasons for, inappropriate or non­acute use of acute care hospital facilities. Initially developed by InterQual in 1978, the ISD-Aconsists of a set of explicit. diagnosis-independent criteria.S The criteria are used to evaluatewhether inpatient acute care hospital services are justified, based on both the clinical characteristicsof thepatient (i.e, severity of illness criteria) and the specific services received by the patient (i.e.intensity of service criteria). The ISD-A criteria are updated on a regular basis by InterQual, in anattempt to keep pace with advances in health care technology which affect not only the type of carethat is delivered, but also, the location in which care can be safely provided. This particular studyused the 1992 version of the ISD-A criteria, the most recent version then available.The version of the ISD-A that we used consisted ofboth general criteria that can be applied to allpatients and system-specific criteria for 12 separate body systems. As already indicated, the criteria4are not diagnosis specific, but arebasedon patientsymptomatology (severity of illness) andtheutilization of acutecare hospital services (intensity of service). 'The elements of the severity ofillness(SI)criteriaare clinical findings, imaging, electrocardiogram and laboratory. Eachelementofthe SI criteriaincludes time definitions as partof the criterion statement, Le. acute(within24 hours),recent(within oneweek) and newly discovered (newfinding thisepisode of illnessfmjury). Theelements of the intensityof service (IS)criteria are treatments andmedications, and are designated aseitherIS or ·IS criteria. The criteriadesignated as IS reflectservices thatcan onlybe provided atthe acutecarelevel. Criteria that aredesignated with ·IS reflectservices that arejudged to be safelyprovided in a less intensive setting; however, the patientreceiving ·IS maycontinue to requirecomplex medical management in an in-patient setting, depending on whether or not theacutephaseof their illnesshas stabilized. Discharge screens evaluate the patient's readiness for discharge andconsider two key elements, the clinical stability of the patientand the necessity for continuing careatthe acutecare levelas explicitly defined.The ISD-Acriteriacan be applied to 1)assess the appropriateness of hospital admission, and 2)assessthe appropriateness of continued daysof stayin hospital. Whenthe criteriaare applied todetermine appropriateness on admission, the patientmustmeetat leastone severity of illnessand atleastone intensity of service to be considered appropdate."The ISD-Acriteriaare designed for review by a nonphysician and theinformation usedin thereviewcomesfromthe patientmedical record(i.e, admission history andphysical, progress notes, consultnotes, nurse's notes, and the notesof otherhealthcareproviders (e.g., rehabilitation therapy, socialwork), the laboratory, medication and clinical record. 'The criteria can be applied on a concurrentbasisor can be appliedretrospectively. The criteriacan alsobe used to targetpatientsbefore theyare admitted to hospital, with the intention of avoiding in-patient staysfor patients whomightotherwise be considered appropriate for management in a lessservice-intensive setting, suchas anout-patient department or home-based care. Although of considerable interest, this aspectofutilization assessment was not the focus of this study.5-.DataCQllectiQnTwQ nursereviewers werehired andtrainedin the application of theISD-A criteria.14 The trainingtookplaceover a periodof7 days, withconsiderable attention givento establishing inter-raterreliability, prior to beginning the datacollectton, The inter-rater reliability of the nurse reviewersrangedfrom Kappa0.70-0.85 for the admisslon reviews and0.70-0.75 for the continued stayreviews. The Kappascores werebasedon the review of 40 patientrecords.IS These resultsareconsistent withresultsobtained in an earlierstudyusingthe ISD-A criteria16Intra-rater reliabilitywas not assessedBetween October 1993 and December 1994, the 2 nursereviewers abstracted data fromthe hospitalmedical records at the respective hospital sites. Each hospital recordwasevaluated in termsofwhetherQr not the patientmet theISD-A criteria on admtssion"and on day sevenorme patient'sstay in hospital. Ourdecision to reviewday sevenof the patient's stayin hospital wasbasedon thedata available, suggesting that day sevenis a cut point for average lengthof stay. In additiontorecording information on appropriateness, demographic and clinical informatiQn werealsocollected.The inter-rater reliability of the reviewers was measured on three occasions throughout the datacollectioaperiod, and tookthe formorrandom 'spot checks' oa data thatwerebeingcollected by thenursereviewers for the study. The Kappascores obtained during thedatacollection period remainedcc..LSistent withthe scores that wereobtained at the beginning of thestudy. prior to data collection,The nursereviewers werein communication with the projectmanager of this studyon a regularbasisandif the reviewers had anyquestions related to the application of the criteriato particular recordsbeingreviewed, the projectmanager would relaytheirqueries to a designated physician whowouldreviewthe case (asperISD-A protocol) andoverride the criteria ifit wasdeemed necessary andappropriate to do SQ. Withrespectto the casesthat werebroughtto the attention of the physician,therewereonly threeinstances where the physician actually decided to override the criteria Oneorthe scenarios involved a patientadmitted forchemotherapy andthe othertwoinvolved patientsadmitted withan acuteexacerbation of a chronic illness.6Data AnalysisOur analysis focused on the data that were obtained fromthe application of the criteriato thepatientrecordat the time of admission to hospital. Therewere 3 stagesto the analysis. F1I'St, the frequencydistribution of a numberof demographicand clinicalcharacteristics weredetermined. Next,weappliedbivariateanalysis to selectedvariables of interest. In the final stageof analysis, weexamined the data usingmultivariate analysis (i.e. logisticregression) to determine iftherewere anyvariables that helpedto explainthe occurrence of non-acute or inappropriate admissions to hospital.We alsoexaminedif there were anyinteraction effects betweenthe variables.ResultsThe population characteristics of the respective hospitals are described in Table 1. The sampleatUH site included487 observanons" and the sampleat the VH site included726observanoas."Table 1 shows that there was a significant difference betweenthe hospitals with respectto theproportion of individuals greaterthan 74 yearsof age (p < 0.00(1) and therewere alsosignificantdifferences withrespect to gender(p < 0.009),both within and betweenthe hospitals. Whenweexamined genderby age group wefoundthat at the VHsite therewereslightly moremales thanfemales in the groupof patientswho were75 yearsof age or younger; whereas, at the UH site theratioof males to females was similarin the groupof patientswhowere75 yearsof age or youngerwhilethere wereslightlymorefemales than malesin the groupof patients whoweregreaterthan 75yearsof age. None of these differences weresignificant Although the majority of the patientsadmitted to the respective hospitals wereresidents of Vancouver, there weresomesignificantdifferences notedbetweenthe hospitals for admissions fromthe suburbs andthe rest of Be (p <0.00(1). The overwhelming majority of patients werelivingin theirownhomeat the timeofadmission to hospitaland similarly the majority of patientsreturnedto their ownhomefollowingdischarge, as opposedto beingdischarged to another levelof institutional care. 'Theroute ofadmission to hospitalis displayed in Table 2 and shows that in eitherhospitalthe majority of .patients were admitted indirectly to hospital via the emergency department Although the overallpatternof admission to hospital was similarfor both hospitals, we observed a large differencebetweenthe hospitals in the proportion of patientsadmitted via the respective routes, with more than778%of thepatients at the VHsite.beingadmitted indirectly via theemergency department, ascompared to 57%of the patients at the UH site (p < 0.00(1). There wasalsoa significantdifferencein howpatients werecategorized on admission to hospital (p < 0.00(1) At the VHsite.76%of thepatients in the sample werecategorized as 'emergent' on admission to hospital. whereas at the UHsite. 29% of the patients werecategorized as 'elective',40% as 'urgent' and 31% as 'emergent'.20Table 1University Hospital (UH) Site 12th & Oak (VH) SiteTotal Eligible Medical Sepantlonl(1992-1993)Sample Size'l(, ofTolai MecUeal Sep.allo••Age Group·<65 yean65-74 yean> 74 yeanFemaleMaleGenderFemale< 6S yean6S-74 yean> 74 yearsMale< 6S years6S-74 year.> 74 year.Residence·VancouverSuburbsReat ofBCOtherLocation From WhichPatient Was Admitted2.706 3,044487 72618'l(, 24'l(,60'l(, 66'l(,14'l(, 18'l(,26.. 16'l(,4S'J> S2'J>5S'J> 48'J>(n=269) (n=34S)S9'l(, 66'l(,13'l(, IS'l(,28'l(, 19'1(,(n=218) (n=380)61'l(, 65'l(,IS'l(, 20'l(,24'l(, IS'l(,64'l(, 62'l(,16'l(, 24'l(,19'1(, 12'l(,1'l(, 2'l(,HomeInstiwtional SettingLocation To WhichPatient Was DischargedHomeInatiwuonal Setting• indicates significant results94'l(,6'l(,94'l(,6'l(,896'l(,4'l(,91'l(,9'l(,Route or Admission to Hospital·DirectIndirectCatexorlmtion or Patient onAdmission to Hospital­ElectiveUrgentEmcrpt• indicates significant resultsTable 2University Hospital (UH) Site43~S7~29~40~31~12th & Oak (VB) Site22~78~9~lS~76~The diagnostic categories of the patientsin the respective hospital samples are described in Figure1.21 The majorityof the patientsexaminedin this studyfell into 5 diagnostic categories. Roughly20%of the patientsat both hospitalsites were admitted withproblems relatedto the gastro-intestinaltract (i.e. ICD-9 codes520-579). 12%of the samplefrom the UH site. and 10%of the samplefromthe VH site were admitted with circulatory systemproblems (i.e. ICD-9codes 390-459). 11% ofthe samplefrom the UH site. and 18%of the samplefrom the VH site were admittedfor respiratorysystemproblems(i.e. ICD-9 codes460-519). Diseases of the nervoussystem(i.e, ICD-9codes 320­389) accounted for 17%of the admissions to the UH site and 9% of the admissions to the VH site.Finally.neoplasms (ICD-9codes 140-239) accounted for 6% of the admissions to the UH site and10%of the admissions to the VH site.9:.-FJgUI'e 1Description or Diagnostic Categories by Hospital (N=1213)5040C Uoiversity Hospital (UH) Site(0=487)30 • 12th & Oak (VB) Site (0=726)%20100i j oj fi J i fIll i l t' 1 1 11 1 j fJ J 1 ~: J ""I ~ !~ tl fIl fIl = J Ilo< \1 ] , Ill; 1, l fIl I Jiii 5::s z isDiagnostic CategoriesFigure 2 describes the length ofstay (LOS) for the sample ofpatients examined in this study andshows that the mean LOS was 9 days for the UH site and 8.5 days for the VH site. In bothinstances. length of stay was skewed, with the median length of stay being identical at both hospitalsites. i.e. 6 days.FIKure 2: LeDKth of Stay by Hospital Site60so4 0.. 302010oE:!Un lvenlty HOlpltal Site (0=487)-12th &: Oat Site (n=726)< 6 7-14 1S-30 31-4SLength o f Stay (Oayl)1046+Table3 presents data whichdescribe the patients' level of acuityon admission to hospital. In thisstudythe patients areeitherdescribed as being 'acute' on admission to hospital, meaning thataccording to ISD-Acriteriathe patients required the services of an acute care facility, or, aredescribed as being 'non-acute', meaning that the patients did not require the services of an acutecare facility. 55%of the sampleof patients from the UH site and 36%of the sampleof patientsfrom theVH site werejudgedto be 'non-acute' at the timeof admission to hospital. The differencebetweenhospitals is significant (p < .0001). For thosepatients judged to be non-acute on admissionto hospital, a decision was made regarding the alternate level of care whichmighthavebeenmoreappropriate for the patient TIle resultsof this analysis are alsopresentedin Table 3 (the alternatelevelsof care that wereused in this studyare described in detailin Appendix A). TIle proportion ofpatientswhowerejudgedto not require anyfurther care (i.e.werereadyto go homewithoutthenecessity for any immediate follow-up) was5% at the UHsite and less than 1% at the VHsite.Thirty percentof thepatients at bothhospital siteswerejudged to requiresomelevel of outpatientcare and 2% of the patients at both hospital siteswereassessed as needing home-based care. Lessthan 1% of the patients in the sample from the UH site werejudgedto requiretheservices of arehabilitation unit andnoneof the patients fromthe VH site wereidentified as requiring this level ofcare. Fourpercentof the sample of patientsfrom the UH sitewerejudged to requirecarein anintermediate careor extended caresetting, whilethis levelof carewas assigned to le~s than 1% ofthe sample at the VHsite. Thirty-nine percentof the patientsat eitherhospital site, judgedto benon-acute on admission to hospital, werejudged to requiresomeformof observation. Fmally, 20%of the non-acute patients at the UH site wereplacedin a category called 'specialprogram,22 while29%of the non-acute patients from the VH sitewere assigned to this category.11Table 3Uoiversity Hospital (UH) Site 12th & Oak (VB) SiteAcuity of Patient on Admissioo*Awle 44'1> 64'1>Noo-Awle 55'1> 36'1>Alternate Levels or CareNo Care 5'1> 0.40'1>OutpUiCllt Care 30'1> 30%HOIJIDoBued Care 2'1> 2'1>Rebabiliatioo Unit 0.70'1> 0'1>I~Care 4'1> 0.40'1>Obstnatioo 39'1> 39'1>Special Program 20'1> 29%* indicates significant resultsUsing bivariate analysis wefurther examined the acuity of the patients by a number of variables,including age group, gender, marital status, location of homeresidence, routeof admission tohospital, timeof admission to the emergency department, periodof weekthe patientwas admitted tohospital, lengthof stayand diagnostic category. The results of this analysis areshownin Table4.Withrespectto acuity and the agegroupof the patient, thereweresignificant differences in acuitynoted, both within and between the respective hospital sites(p < 0.02). At the VHsitewe observedthat the proportion of non-acute patients (i.e. thosepatients whowerejudgedto not require theservices of an acutecare facility) wasgreatest in the youngest age category (t.e, thosepatients whowere under65 years of age). Although the breakdown of acuityby agegroupobserved at the UHsitewas significantly different fromthe VHsite (p < 0.00(1), the greatest proportion of non-acutepatients werestillobserved in the group of patients whowere65 to 74 yearsof age. Whenweexamined the acuity of the patients by gender, the patternof acuitywas virtually identical at the UHsite;however, therewas a significant difference (p < 0.009)in the patternof acuityat the VH site,witha higherproportion of non-acute patients found amongst the women. Thepatternof acuity forthosepatientswhohad someformof 'traditional' social support (i.e. married, livingcommon-law, orlivingwithan adultchild) versus thosewhodidnot (i.e. single, divorced, widowed) wasdifferent forboth hospitals.23 For the groupof patients at the UH site withno 'traditional' socialsupport, 51% ofthemwerejudgedto be non-acute; whereas 60%of thepatients withsomeformof 'traditional' social12Table 4Unlvenlty Hospital 12th & Oak UDlvenity Hospital 12th & OakSite Site SIte SiteAadty ofPadent on Admission· Aadty of AdmIssIon by the PerfocloftheAcute <65 yeAR 58... 61... Week thatPadent wasAdmitted6S-74yeAR 11... 19'1l> Maada,..1handay> 74 yeAR 31... 19... ~ 38... 63...Naa-Acute <6SyeAR 61'" 73... Nall-Aane 61... 37...6S-74 )'W' 17... 15'1. Friday-SlIDday>74yeAR 22'1. 11'1. ~ 56... 67'1.Nall-Aane 44... 33...Aadty ofPadent on Admission by Gende~Acute Female 57'1. 44'1. Aadty of Admission by Length of stayMAle 43... 56'1. 1-6da,. ~ 37... 62'1.Naa-Acute Female 54'" 54'1. Non-Aane 63... 38'1.MAle 46... 46'1. 7-14 da,. ~ 53... 71...Non-~ 47... 29'll>Acuity ofPadent on Admission 15-30da,. Aane 52... 64...by SocI.J Support· Non·Aane 48... 36...Tnditiaaal Social Suppcwt 31-45 da,. ~ 67... 59'1.AWle 4O'll> 62'1. Non-Aane 33... 41...Non·Aa1le 60'1. 3S'I. 46+da,. Aane SO... 67'1.NoTnditiaaal Social Support NOIl-Aane SO... 33'1.~ 49... 6S...Non·AOIle 51... 35'1. Acuity by Diagnostic Category4'Neoplasms (11=27) (B=15)Acnlty ofPadent on Admission ~ 30... 47'1.by LocatIon of Home Residence· Non-Aane 70~ 53'1.V..c:ou.... Aane 51... 73... NerYOWI S)'lItem (D:8ll11 (~)Nan-Acule 49... 27'1. ~ 12'10 ~...Suburbs ~ 41... 6O'll> Non-~ BSIJI 78~Non-Aa1le 59... 4O'll> Clrc:ulatOl'1 System (n:6i) (0=13)RestalBC ~ 24'1. 31... Acute 36~ 624:Non-AaJ!e 76'1. 69'll> Non·AaJ!e 64... 38'"RapiratOl'1 System (11=52) (0=12'1)Acuity on Admission by Route of Admission· ACUI6 831J1 91...NOIl-Aa1le 121J1 94DIred ~ 26... 27... Dlaative System (11:93) Cr.:o147)NOIl-Aa1le 74... 73... ~ 66... 821;IDcIIrect ~ 58'10 75'1. NOIl-Aa1le 34... IS'"Non·Aa1le 42'10 25... S1II1ptoms (11=48) (11=66)Aa1le 23... 33...Acnlty on Admission by Tbne of Admission NOIl-Aa1le 77... 67...to the Emergency Department·0001-0800 AaJ!e 62'1. 84'1.NOIl-AaJ!e 38... 16...0801-1600 Aa1le 51... 70'1.NOIl-Aa1le 43% 30CX>1601-2400 ~ 59% 77%NOIl-Aa1le 41... 23% • indicatessignificaD1 result13. ."."supportwere judged to be non-acute. At the VH site the patternofacuity was very similarbetweenthe group of patients with no 'traditional' socialsupport and those with some formof 'traditional'social support For both groups the proportion of non-acutepatients ranged from 35% (no'traditional' social support)to 38% (someformof 'traditional' social support). Interestingly andcounterintuitively,with respect to patientacuityand the locationof the patient'shome residence,there was a significantly greaterproportionof non-acute patientsamongstthe groupof patients whowere admitted to hospitalfrom outsideof the LowerMainland(p < 0.00(1).Patient acuity also varieddramatically, depending on whetherthe patient was a direct or indirectadmission. '!be overwhelming majority ofpatients examinedin this study,who weredirectadmissions to hospital (i.e. fromthe physician's office), werejudged to be non-acute on admission.In contrastto this, in the groupof patientswho were admitted indirectly, via the emergencydepartment, the proportion of non-acute patientswas markedly lower, with42% observedat the UHsite andonly 25% observed at the VH site. Selectingonly thosepatients who wereadmittedtohospitalindirectlyvia the emergency department, we nextexaminedacuityby thetime of admissionto the emergencydepartment We found that at theUH site time of admissionto the emergencydepartmentwas not significantly correlatedwith differences in patient acuity,whereas at the VH sitethere was a significantdifference in patientacuitydepending on what time the patientpresentedtoemergency. Patientswho wereadmittedto emergency betweenlate afternoon(4 p.m.) and earlymcrnlng(8 a.m.)were morelikely to be acuteversusthosepatientswho were admittedto emergencybetween 8 a.m. and 4 p.m. (p < .02).Withrespect to the periodof the week that the patientwas admittedto hospital, at the VH site therewas a smaIl,and insignificant difference in acuity, betweenthosepatientswho were admittedtohospital'during the week', i.e. Monday-Thursday (37%were non-acute) comparedto those whowere admitted 'on the weekend', i.e. Friday-Sunday(33%werenon-acute), with a largerproportionof the patientsbeing non-acute (37% versus33%)if they were admittedduringthe week. However,61% of the patientswho wereadmittedto the UH Site 'durlngthe week' werejudged to be non-acutewhile a significantly smaller(but still substantial) proportion of the patients who were admitted 'onthe weekend' (i.e,44%) werejudged to be non-acute (p < 0.0001),likely due to the resultingeffectof'direct' vs 'indirect' admission.14The pattern of acuityon admissionby lengthof staywas fairly homogeneous withinthe VH site,with the highestproportionof non-acute patientsbeingfound in the groupo.fpatientswhose lengthof stay was in the range of 31-45 days. On the contrary. the patternof acuity by length of stayvaried significantlywithin the UH site (p < 0.007),and the largestproportionof DOn-acute patientswas observedin the group whoselength of stay was in the range of 1-6 days.Finally, with respect to patient acuityand diagnostic categorywe have reported the results for 6 outof the 17 diagnosticcategories that were described earlier in Figure 1.2AIn the sample of patientsexamined,neoplasms accountedfor 6% ofthe admissions to the UH site and70% ofthese patientswerejudged to be DOn-acute on admission to hospital. At the VH site neoplasms accountedfor 10%of the admissionsand 53% of thesepatientswerejudged to be non-acuteon admissionto hospital.Diseasesof the nervoussystemaccountedfor 17%of the admissions to the UH site and88% ofthese were judged to be non-acute on admission to hospital. At the VH site diseasesof the nervoussystem accountedfor 9% of the admissions and78% of them werejudged to be non-acuteonadmissionto hospital. The proportionof patientsadmittedto hospital with diseasesof thecirculatorysystem was similarin both institutions; however, the acuity was significantlydifferentbetween the sites (p <0.004). At the UH site A 64% of these patients werejudged to be non-acuteon admissionto hospital whereasat the VH site 38% of thesepatientswere judged to be non-acuteon admission. Diseasesof the respiratory systemaccountedfor 11% of the admissions at the UHsite and 18% at the VH site, with the acuityof patientsin this diagnosticcategorybeing roughly thesame at both institutions: at the UH site 12%of the patientswith respiratory-relateddiseases and atthe VH site 9% werejudged to be DOn-acute. Diseases of the digestivesystem accountedfor 20% ofthe admissionsat both hospital sites;however, the proportion of patients in this diagnosticcategorywho werejudged to be non-acute on admissionto hospitalrangedfrom 18%at the VH site to 34% atthe UH site. The proportionof patients admittedto hospitalunder the broad category of'symptoms'2S was similar at both hospital sites, 10% at the UH site and 9% at the VH site and ofthese 77% at the UH site werejudged to be non-acute comparedto 67% at the VH site.The next stage of analysisused a multivariate procedure(i.e, logistic regression) to determineifanyof the variables that we examinedin this study mighthelp to explainthe patternofpatient acuity onadmissionto hospital. Moreover, we alsoexaminedthe data to find out ifthere were interactioneffects betweenthe variables. The results of this analysisare shownin Table 5. Length of stay,15route of admission(i.e. route) and type ofadmission(i.e. type!) all have significantvalues.Although the variableshospital and gender are not significant there appears to be an interactioneffect between hospital and gender (i.e. Hosp*Gen) and hospital and type ofadmission(i.e.Hosp*Type2). The odds ratio for all of these variables is weak with the exception of route ofadmission and suggests that route of admissionto hospital is a strong predictor of acuity of patientson admission to hospital. In particular the results suggest that patients who are admitted indirectlyto hospital. via the emergencydepartment,are twice as likely to be 'acute' on admissionto hospitalas patients who are admitteddirectly to hospital.Table 5LogIstic Regression Procedure Profile of Explanatory VariablesVariable Chi-Square P OddsRatioHospital 0.6763 0.4109Age 1.7754 0.1827Gender 0.0989 0.7531Length of Stay 6.6493 0.0099 1.019Hosp-Age 0.0422 0.8373HOIlp--OCn 4.7734 0.0289 0.558HOIlp*Type2 7.7147 0.0055 0.386Route 11.6502 0.0006 2.101Typel 36.0701 0.0001 0.18Type2 0.6286 0.4279DiscussionThe results of this study suggest that a large proportion of the patients admitted to the respectiveinstitutionsmight have been more appropriately managedin another level of care. Our findings areconsistentwith those obtained in similarstudies that have been undertaken elsewhere.12,26,27,28A major objectiveofthis study was to determine.for each patient who was judged to not require in­patient care, what level of care might have been more appropriate for thepatient. With the exceptionof the 5% of patients at the UH site and the less than 1% of the patients at the VH site who were16judged to requireno furthercare or observation. virtually allpatients were judgedto require somelevelof care. Although thereare someobvious limitations in usingretrospective datato identifyreliably the needfor specific levelsof care,nonetheless it cannot be ignored that theoverwhelmingmajority of patients in this study,who wereassessed as notrequiring acutecare, werejudgedtorequire someformofimmediate care. Moreover, that 30%of the patients at bothinstitutions wereassigned as requiring outpatient services suggests that substantial numbers of patients continue to beadmitted for diagnostic testingalone, and interestingly, alsosuggests that the patternofpracticearoundadmitting patientsfor diagnostic testing is similarat bothinstibltions. It wasjUdged that39%of the patients at both institutions required someformof observation. This category of carewas mostfrequently assigned to patients whowereadmitted witha historyof abdominal pain,headache (withsomeevidence thatit mightbe related to an impending infectious disorder orcerebrovascular accident), or headinjury, but eitherhad no associated clinical signsor symptomsthat wouldhavecausedthem to meeta severity of illness criteria and/orthe intensity of servicecriteria Thesepatients wereidentified as requiring observation because of the potential risk(s)associated witha deterioration in the patient's condition. Thiswasperhaps the most nebulouscategory to whichpatients wereassigned because the levelof observation required woulddependona hostof factors, including the patient's age,co-morbidities, the qualityof socialsupportstructuresavailable in the homeand proximity to hospital, an issueespecially important for patients whowereadmitted to hospital from rural areasoutside of theLowerMainland Finally, therewerea numberof patients at both hospitals (20% at the UH site;29%at the VH site)who,although theydid notmeetthe ISD-Aacutecarecriteria, wereadmitted to hospital largelyfor control and management ofproblems relatedto seizure activity, headaches or movement disorders. Although thesepatients didnot meetcriteria, the majority of themwerebeing closely monitored for theirresponse to medicationregimes beingused (or altered) to treat theirrespective clinical problems. Because we wantedtodistinguish the alternate levelof care that thesepatients mightrequire fromthose of thepatientsdescribed earlier(i.e. the patients assessed to require somelevelof observation), wedecidedto createan alternate levelof carecategory called 'specialprogram', to whichthesepatients wereassignedThe questionthen becomes where aresuchpatients mostappropriately treatedPatientswith neoplasms accounted for a relatively smallproportion of the patients in the sampleatbothhospitals (6% at the UH site and 10%at the VH site). Surprisingly, at the UH site themajority of thesepatients (70%) werejudgedto be non-acute at the timeof admission to hospital.17Thisfinding warrants further investigation as it mightsuggest that a largeproportion of cancerpatients are being admitted to acutecarefor management of pain or for reasons relatedto respiteforfamily members andraisesthe question of whether an acutehospital bedis the mostappropriatesetting for thesepatients.Whenwelookedat thepattern of acuity by thelocation of thepatient'shomeresidence we weresurprised to find that, for thosepatients whowere admitted to hospital fromoutside of the LowerMainland (N=180) acuity wasverylow at both hospital sites, a counterintuitive finding. At the UHsite 76%of thepatients admitted fromoutside of the LowerMainland werenon-acute, andat theVH site 69%of thepatients admitted fromoutside of the Lower Mainland werenon-acute. Thissuggests that a largenumber of patients from outside of the LowerMainland wereeitherbeingtransferred to thesetertiary centres for diagnostic purposes or for monitoring. Thisis supported bythe fact that at the UHsitethe majority of these non-acute patients werejudged to require theservices of an outpatient department (34%), someformof observation (21%) or theservices of whatwe have referredto in thisparticular study as a 'specialprogram' (30%). At the VH site40% ofthe patients werejudgedto require the services of anoutpatient department and50% werejudged torequirethe services of a 'specialprogram' . The meanlengthof stayfor these groups of patientswas 8.17days for theUHsite and 10.35daysfor theVHsite,with the medianlengthofstay forbothgroupsbeing6 days. 180patients represents 15% of our study sample, not an insignificantnumber, andwithratherlongLOSandwithmanyof thepatients in thisgroup assessed as requiringsomeformof observation (51%) it raises the question aboutthe feasibility of providing a level ofobservation for thesepatients 'closer to home' in one of theregional hospitals.With respectto the feasibility of providing carein alternate settings there havebeena numberofstudies whichhavedemonstrated that it is possible to provide various levelsof carein non-hospitalsettings usingoutpatient clinics or home-based care. These studies alsosuggestthat thealternatesettings are acceptable to patients andthat thereis a significant potential for cost-saving.29,.30,31,32,33,34,35Whatis perhapsmost striking aboutthe results of this studyis the observation that route ofadmission to hospital wasa strong predictor of the patternof acuityat both hospitals. The resultsof the bivariate analysis illustrated clearly thatpatients whowereadmitted via the emergency18department weresignificantly less likelyto bejudgednon-acute on admission to hospital and thelogistic regression technique verified that thisobservation was independent of othervariables. suchas the agegroupor genderof the patient An immediate response to this finding mightbe that itmakes perfectsenseto expecta largeproportion of the patients whoentera hospital through theemergency department to be acute. andit couldbe explained that this is thecasebecause patientswhopresentto theemergency department are obviously 'sicker' than thosewhoenteras directadmissions. Nevertheless the finding raises somepotentially Important issues around howwehavetraditionally managed and controlled access to acutecarein-patient beds. It couldbe arguedthat theemergency department already playsa veryimportant rolewithrespect to trlaging thosepatients whomightbe managed in another setting and/orprovides a periodof observation andcare for selectedpatients. whosubsequently are ablereturnto theirusual placeof residence. having avoided anunnecessary in-patient stay. We believe that thereis meritin considering howthisrole couldbefurther enhanced. although theissueof the socialcoststo families has notbeenadequatelyexamined.19-,References and Endnotes1 Some of this scrutiny is clearly ideological and some highly relevant2 Rachlis,M. M., Kushner, C. Strong Medicine. Toronto: Harper Collins Publishers Ltd.,1994:248-252.3 Information obtained from the BC Provincial Government Public Accounts Volume 21994-1995(Financial Statements and Schedules ofthe Consolidated Revenue Fund) indicates that in 199450% of the health care budget was spent on hospital care. Other sources have indicated thatinpatient hospital care accounts for about roughly 50% of the total hospital care budget, or 23% ofthe total health care budget4 Barer, M.L., Evans, RG., Hertzman, C. (1995). Avalanche or Glacier?: Health Care andDemographic Rhetoric. Canadian Journal on Aging. Volume 14, Number 2,1995: 193-224.S InterQuai. The ISD-A Review System with Adult Criteria, Westborough, Mass.: InterQualIncorporated, 1978.6 Shortell, Stephen M., Richardson, William C. Health Program Evaluation. C.V. MosbyCompany 1978.7 Adult was defined as anyone 16 years of age and older. Medical patients were selected on the basisof 'patient service codes' that are used by BC hospitals to identify medical patients. The patientservice codes included those from 'family practice' and 'general medicine' , as recorded in the BritishColumbia Ministry ofHealth Annotated Specifications for Patient Hospitalization Data (April,1991- March, 1992).8 The Hyperbaric Unit is a specialized unit at the Ith andOak.Site that is designed to deliver 100%oxygen under increased ambient pressure to particular patients (e.g. patients requiringdecompression, patients requiring enhanced healing of a compromised wound, patients with carbonmonoxide poisoning, patients with radiation injury).9 The Sleep Disorder Clinic is a specialized unit at the University Hospital Site that investigatesindividuals with sleep disorders.10 The rationale for the exclusion was both related to feasibility, given time constraints for this study,as well as the fact that admission to these units is based on well defined criteria and the criteria aredistinctively different from the ISD-A criteria that were created for application in an acute caresetting.11 Approximately 5% of the patients admitted to adult medicine at the UH Site are discharged 'dead'and approximately 8% of the patients admitted to adult medicine at the VH Site are discharged'dead'.2012 Random records wereselectedfrom a sample usingsoftware customized for SooOS whichexploits a 48-bitpseudo-random numbergenerator. lbis algorithm is muchmorethorough andmoreelaborate thancommonly used lowerprecision random-number generators.13 Updated versions of the criteria, Le. 199611996 versions, nowspecifythat the patientmustmeeteitherone IS criteriaor three *IS criteria on admission.14The training wasprovided by the projectmanager who wasa registered nurseand whowasalready highlyfamiliar with the ISD-Acriteria.IS Thepatientrecords that wereusedin the reliability studywerebasedon a random selection ofadultmedical separations from the hospital site at whichthe training took place.16 Cardiff,K., Anderson, G., Sheps, S. (1995). Evaluation of a hospital-based utilizationmanagement program. Healthcare Management FORUM, Volume 8. NumberI. Spring 1995: 38­45.17 Patientsweregiven48 hours,from the timeof theiradmission to the emergency ward(if anindirectadmission) or the ward (ifa directadmission). to meetthe criteria.18 lbis number of observations represented 18% of theseparations frommedicine during theperiodof time from September 1992- August1993.19lbis numberof observations represented 24%of the separations frommedicine during theperiodof timefrom september 1992- August 1993.20 It has beendocumented thatthereis a highdegreeof variation among acutecare hospitals withrespectto how patients are categorized on admission, andthat the variation is usuallynot explainedby differences in the acuityof the respective patients.21 The diagnostic categories that are described in this studyare basedon the ICD-9codesthat wererecorded in the data collection process (i.e. the 'most responsible diagnosis' (lCD-9code) that wasdocumented in the patient's medical record).22 We developed the category of 'specialprogram' in an effortto document situations where patientswereadmitted to hospital primarily for thepurpose of closely monitoring theirresponse toadjustments in theirmedication regimes. In particular we assigned patients to this category if theywereadmitted for changes in medication related to a historyof seizures or movement disorders.23 In this study 'traditional' socialsupportrefers to situations where the patienthad a spouse/partneror adultchildliving with themat home. 'This information was obtainedfromthe admission sheet ofthe respective medical records.24 Due to the verysmallnumber of patients within someof the diagnostic categories. wedecided toonlyreport findings from the diagnostic categories which represented morethan 5% of theadmissions from the respective samples usedin this study.2125 Includes symptoms, signs, abnormal results of laboratory or other investigative procedures, andill-defined conditions regarding which no diagnosis classifiable elsewhere in the ICD-9-CMClassification ofDiseases is recorded.26 DeCoster, C., Peterson, S., Kasian, P. Alternatives to Acute Care. Manitoba Centre for HealthPolicy and EValuation, University ofManitoba, July 1996.27 Smith, H.E., Sheps, S.• Matheson. D.S. Assessing the utilization of in-patient facilities in aCanadian Pediatric Hospital. Pediatrics, 1993; 92(4):587-593.28 Health Services utilization and Research Commission: Saskatoon, Saskatchewan. Barriers toCommunity Care.29 Williams, D.N. (1994). Reducing Costs and Hospital Stay for Pneumonia with Home IntravenousCefotaxime Treatment Results with a Computerized Ambulatory Drug Delivery System. AmericanJournal of Medicine. Volume 97, Number 2A: 50-55.30 Walsh, D. (1994). Palliative Care: Management of the Patient with Advanced Cancer. Oncology,Volume 4, Supplement 7: 100-106.31 Young, W., Goel, V. The Impact of Relocating Vasectomies from Hospital OutpatientDepartments to Non-Hospital Sites. Institute for Clinical Evaluative Sciences in Ontario, 1993.32 Talcott, J.A., Whalen, A., Clark, J., Rieker, P.P., Finbert, R. (1994). Home Antibiotic Therapyfor Low-Risk Cancer Patients with Fever and Neutropenia: A Pilot Study of 30 Patients Based on aValidated Prediction Rule. Journal of Clinical Oncology. Volume 12, Number 1:107-14.33 Milkovich. G. (1993). Outpatient Parenteral Antibiotic Therapy: Management of SeriousIr~ections. Part I: Medical, Socioeconomic, and Legal Issues; Costs and Benefits. Hospital Practice,Volume 28, Supplement 1:39-43.34 Williams, D.N., Bosch, D., Boots, J., Schneider, 1. (1993). Safety, Efficacy, and Cost Savings inan Outpatient Intravenous Antibiotic Program. Clinical Therapeutics, Volume 15, Number 1: 169­179.35 Hindes, R., Winkler. C., Kane, P. Kunkel, M. (1995). Outpatient Intravenous Antibiotic Therapyin Medicare Patients - Cost-Savings Analysis. Infectious Diseases in Clinical Practice. Volume 4,Number 3:211-217.22Appendix AAlternate Levelsof Care*Patient Residence(withno additional care/support required)• no further careis required; patient's condition andservices ordered/received indicatethat the patientdidnot needthe hospital or an alternative settingOutpatient services• provides services to patients whohavetests andprocedures that do not requireinpatientcare becauseof the nature of the procedure and the patient's goodhealthand whose treatments and procedurescannotbe provided by home-basedservices, physicians' offices or community centres• forout of townpatients: patients who needto be closeto the hospital but do not require admission• patients livinglong distances fromthe hospital and requiring frequent treatments thatcannotbeprovided by home-based services and transportation is unavailable• patients receiving dailychemotherapy or radiation therapy and do not requireprofessional observationHome-basedcare• for patients whoare notreceiving an acute levelof care anddo not require services provided as definedin 'outpatient services, level IV facility, intermediate care facility, rehabfacility'• patients withheavycare needs thatcan be accommodated at homewithgoodsupportfrom family, live­in or volunteer supportandhome-based services programs suchas:• skillednursing care (including iv therapy and dressings)• rehabservices (including physic, respiratory, occupational therapy, speechtherapy)• respite care• homemaintenance• laboratory services• meals on wheels• day surgeryaftercareMinimal Supervision Residence• patientrequires non-skilled care and continuous 24 hoursupervision and whocannotbe cared for athomedue to unavailable and/or unstable family or live-insupport• patients whohave special housing needs i.e.handicapped or senior's housingHospice• patients who are terminally ill and whocannotbe caredfor at homedue to unavailable and/orunstablefamily or live-insupportandmay utilize:• skillednursing care and otherservices suchas iv analgesia or nutritional support• socialservices andpastoral care23•.Rehabilitation Facility• patients who are not receiving an acutelevelof carebut require 24 hour supervision andassessment bya teamof rehabilitation personnel for a periodof up to approximately three months, or whoarereceiving a plannedtherapy program whichis delivered daily; the patientmaythenbe expected to bedischarged fullyrestored or transferred to a home-based program or to another levelof careaccommodation.Intermediate or Extended Care Facility• patients whoare not receiving an acutelevelof carebut do notrequireskilled nursing careandsupervision on a 24-hour basis and specialized techniques to arrestor retarddeterioration of advancedchronic illnesses or disabilities andwhocannotbe caredfor at homedue to unavailable and/orunstablefamily or live-insupportObservation• short stayS 24hours)for patients requiring closenursing observation for a shortperiodof timesuchas:• patients whohavehad day surgery procedures andare not readyfor discharge• patients referred fromthe emergency• patients receiving outpatient chemotherapy• patients requiring short-term observation because of high probability of onsetof acutecondition*Adapted fromISD-ACriteria 1992version24.


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