Fried R A, Main D S, Calonge B N
Department of Family Medicine, University of Colorado School of Medicine, Denver.
J Am Board Fam Pract. 1994 May-Jun;7(3):229-35.
Reducing inappropriate hospital admissions could lead to lower total health care costs without compromising the quality of care. Research suggests that a sizeable portion of hospital admissions are inappropriate. Other studies indicate that family physicians use health care resources, including hospitalizations, less often than other primary care physicians. To gain additional insight into family physicians' decisions to admit patients, we performed an exploratory study using the Appropriateness Evaluation Protocol, a validated, clinically based utilization review instrument.
We assessed admissions by community-based and residency-based family physicians to a single university-affiliated hospital during calendar year 1988. A total of 905 patients were admitted to the hospital by family physicians during the study period. Of these, 889 records had complete data. Each was reviewed for appropriateness of admission. We calculated percentages of inappropriate admissions and used logistic regression to ascertain variables that were significant predictors of inappropriateness.
Overall, 5.4 percent of admissions were categorized as inappropriate. Omitting obstetric cases, the rate was 10.5 percent. Inappropriate admissions did not cluster around a small number of diagnoses or diagnosis-related groups. Using logistic regression, we found that urgency of admission, patient insurance status, and residency-based physician admission versus community-based physician admission were significant predictors of inappropriate hospital use. Of the inappropriate admissions, 70 percent were so rated because diagnostic procedures or treatments could have been performed on an outpatient basis.
In contrast with other studies for which physician specialty was not controlled, family physicians less frequently admitted patients inappropriately. Predictors of inappropriateness differed from those found in other studies. Changes in hospital systems, in addition to educational efforts directed toward individual physicians, hold promise as a strategy for reducing inappropriate hospital use.
减少不适当的住院治疗可在不影响医疗质量的情况下降低总体医疗费用。研究表明，相当一部分住院治疗是不适当的。其他研究表明，与其他初级保健医生相比，家庭医生较少使用包括住院治疗在内的医疗资源。为了更深入了解家庭医生收住患者的决策，我们使用适当性评估方案进行了一项探索性研究，该方案是一种经过验证的、基于临床的利用情况审查工具。
我们评估了1988年全年社区家庭医生和住院医师家庭医生向一家大学附属医院的住院情况。在研究期间，家庭医生共收治了905名患者。其中，889份记录有完整数据。每份记录都进行了入院适当性审查。我们计算了不适当入院的百分比，并使用逻辑回归来确定不适当性的显著预测变量。
总体而言，5.4%的入院被归类为不适当。不包括产科病例，该比例为10.5%。不适当的入院并非集中在少数诊断或诊断相关组。通过逻辑回归，我们发现入院紧迫性、患者保险状况以及住院医师家庭医生入院与社区家庭医生入院相比是不适当住院使用的显著预测因素。在不适当的入院中，70%被如此评级是因为诊断程序或治疗本可在门诊进行。
与其他未控制医生专业的研究相比，家庭医生不适当收治患者的情况较少。不适当性的预测因素与其他研究中发现的不同。除了针对个体医生的教育努力外，医院系统的变革有望成为减少不适当住院使用的策略。
