Primary Care and Public Health Center (Unisanté), University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland.
BMC Health Serv Res. 2022 Feb 7;22(1):158. doi: 10.1186/s12913-022-07569-3.
Inappropriate use of acute hospital beds is a major topic in health politics. We present here a new approach to measure unnecessary hospitalizations in Medicine and Pediatrics.
The necessity of a hospital admission was determined using explicit criteria related to the recorded diagnoses. Two indicators (i.e. "unjustified" and "sometimes justified" stays) were applied to more than 800,000 hospital stays and a random sample of 200 of them was analyzed by two clinicians, using routine data available in medical statistics. The validation of the indicators focused on their precision, validity and adjustment, as well as their usefulness (i.e. interest and risk of abuse).
Rates, adjusted for case mix (i.e. age of patient, admission planned or not), showed statistically significant differences among hospitals. Only 6.5% of false positives were observed for "unjustified stays" and 17% for "sometimes justified stays". Respectively 7 and 12% of stays had an unknown status, due to a lack of sufficiently precise data. Considering true positives only, almost one third of medical and pediatric stays were classified as not strictly justified from a medical point of view in Switzerland. Among these stays, about one fifth could have probably been avoided without risk. To enable a larger ambulatory shift, recommendations were made to strengthen the ambulatory care, notably regarding post-emergency follow-up, cardiac and pulmonary functions' monitoring, pain management, falls prevention, and specialized at-home services that should be offered.
We recommend using "unjustified stays" and "sometimes justified stays" indicators to monitor inappropriate hospitalizations. The latter could help the planning of reinforced ambulatory care measures to pursue the ambulatory shift. Nonetheless, we clearly advise against the use of these two indicators for hospitals financing purposes.
不合理使用急性医院病床是卫生政策的一个重要议题。我们在此提出一种新方法，用于衡量医学和儿科的不必要住院治疗。
使用与记录诊断相关的明确标准来确定住院的必要性。将两个指标（即“不合理”和“有时合理”的住院）应用于超过 80 万例住院病例，并由两名临床医生使用医疗统计学中可用的常规数据对其中 200 例进行随机抽样分析。该指标的验证重点在于其精度、有效性和调整，以及其有用性（即兴趣和滥用风险）。
针对病例组合（即患者年龄、是否计划入院）进行调整后，各医院的住院率存在统计学显著差异。对于“不合理住院”，仅观察到 6.5%的假阳性，对于“有时合理住院”，假阳性率为 17%。由于数据不够精确，分别有 7%和 12%的住院病例状态未知。仅考虑真实阳性病例，瑞士约有三分之一的医学和儿科住院病例从医学角度来看并非严格合理。在这些住院病例中，约有五分之一可能在没有风险的情况下得到避免。为了能够实现更大的门诊转移，建议加强门诊护理，特别是在急诊后随访、心脏和肺部功能监测、疼痛管理、跌倒预防以及提供专门的家庭服务方面。
我们建议使用“不合理住院”和“有时合理住院”指标来监测不合理的住院治疗。后者可帮助规划强化门诊护理措施，以推进门诊转移。然而，我们明确建议不要将这两个指标用于医院的融资目的。
