Smith C B, Goldman R L, Martin D C, Williamson J, Weir C, Beauchamp C, Ashcraft M
Health Services Research and Development Field Program, Seattle Department of Veterans Affairs Medical Center, WA 98108, USA.
Med Care. 1996 Jan;34(1):85-96. doi: 10.1097/00005650-199601000-00007.
The authors tested the hypothesis that the Department of Veterans Affairs (VA) hospitals would have substantial overutilization of acute care beds and services because of policies that emphasize inpatient care over ambulatory care. Reviewers from 24 randomly selected VA hospitals applied the InterQual ISD* (Intensity, Severity, Discharge) criteria for appropriateness concurrently to a random sample of 2,432 admissions to acute medical, surgical, and psychiatry services. Reliability of hospital reviewers in applying the ISD* criteria was tested by comparing their reviews with those of a small group of expert reviewers. Validity of the ISD* criteria was tested by comparing the assessments of master reviewers with the implicit judgments of panels of nine physicians. The physician panels validated the ISD* admission criteria for medicine and surgery (74% agreement with master reviewers, kappa > 0.4), whereas the psychiatry criteria were not validated (66% agreement, kappa 0.29). Hospital reviewers reliably used all three criteria sets (> 83% agreement with master reviewers, kappa > 0.6). Rates of nonacute admissions to acute medical and surgical services were > 38% as determined by the hospital and master reviewers and by the physician panels. Nonacute rates of continued stay were > 32% for both medicine and surgery services. Similar rates of nonacute admissions and continued stay were found for all 24 hospitals. Reasons for nonacute admissions and continued stay included lack of an ambulatory care alternative, conservative physician practices, delays in discharge planning, and social factors such as homelessness and long travel distances to the hospital. Using criteria that the authors showed to be reliable and valid, substantial overutilization of acute medicine and surgical beds was found in a representative sample of VA hospitals. Correcting this situation will require changes in physician practice patterns, development of ambulatory care alternatives to inpatient care, and modification of current VA policies determining eligibility for care.
退伍军人事务部（VA）医院由于强调住院治疗而非门诊治疗的政策，会大量过度使用急性护理床位和服务。来自24家随机挑选的VA医院的评审人员同时将InterQual ISD*（强度、严重程度、出院）适宜性标准应用于2432例急性内科、外科和精神科服务入院病例的随机样本。通过将医院评审人员的评审与一小群专家评审人员的评审进行比较，测试了医院评审人员应用ISD标准的可靠性。通过将主评审人员的评估与由九名医生组成的小组的隐性判断进行比较，测试了ISD标准的有效性。医生小组验证了内科和外科的ISD*入院标准（与主评审人员的一致性为74%，kappa>0.4），而精神科标准未得到验证（一致性为66%，kappa为0.29）。医院评审人员可靠地使用了所有三个标准集（与主评审人员的一致性>83%，kappa>0.6）。根据医院、主评审人员和医生小组的判断，急性内科和外科服务的非急性入院率>38%。内科和外科服务的非急性持续住院率均>32%。在所有24家医院中都发现了类似比例的非急性入院和持续住院情况。非急性入院和持续住院的原因包括缺乏门诊护理替代方案、医生的保守做法、出院计划延迟以及无家可归和到医院路途遥远等社会因素。使用作者证明可靠且有效的标准，在VA医院的代表性样本中发现了急性内科和外科床位的大量过度使用情况。纠正这种情况将需要改变医生的执业模式、开发住院治疗的门诊护理替代方案以及修改当前确定护理资格的VA政策。
