Butler J S, Barrett B J, Kent G, Haire R, Parfrey P S
General Hospital Corporation, St. John's, Nfld.
Clin Invest Med. 1996 Aug;19(4):251-8.
To study the reliability and validity of concurrent review of hospital-bed utilization carried out by a trained nurse.
Analysis of interrater reliability and validity of utilization review.
Tertiary care hospital associated with a university.
Eighty patients randomly selected from 203 patients admitted to the hospital.
Appropriateness of days of stay in hospital was classified prospectively, on the basis of clinical judgement, by two nurses working independently, by a third nurse working with the Appropriateness Evaluation Protocol (AEP) and by a multidisciplinary review panel of nurses and physicians working retrospectively with the use of data gathered by the first nurse.
Agreement between different rates on the number of and reason for inappropriate admission days, total number of inappropriate days and of inappropriate days due to delayed discharge, to diagnostic procedures or to inefficient medical management.
Agreement between the two nurses who used clinical judgement was substantial (kappa or the intraclass correlation coefficient [RI] 0.77 to 0.98 on the number of and reason for inappropriate admission days, on the total number of inappropriate hospital days and on days due to delayed discharge, diagnostic procedures or inefficient medical management. Agreement was moderate (RI 0.47) on the number of inappropriate day's stay awaiting surgery. Agreement was substantial (kappa or RI 0.69 to 0.94) between the two nurses who used clinical judgement and the panel, except on the total number of inappropriate days; however, for this variable, exclusion of one case increased the RI from 0.35 to 0.80. Agreement was substantial between the two nurses who used clinical judgement and the nurse who used the AEP on appropriateness of admission days and the number of inappropriate days. Agreement between the panel and the nurse who used the AEP on the number of inappropriate days rose from 0.36 to 0.88 when the one outlying case was excluded. Some admissions were classified as premature when the AEP was used, whereas other raters considered the admissions unnecessary. There was poor agreement between the nurse who used the AEP and the other raters on the number of inappropriate days' stay awaiting surgery or diagnostic tests.
Data collection and judgement of appropriateness of hospital stay by a trained nurse is feasible and reliable. A nurse working prospectively and a panel working retrospectively sometimes disagree. The AEP provides a similar estimate of the number of inappropriate days but may be insensitive to patient factors that influence the timing of admission.
研究由一名经过培训的护士对医院床位使用情况进行同期审查的可靠性和有效性。
对使用情况审查的评估者间可靠性和有效性进行分析。
一所与大学相关的三级护理医院。
从203名入院患者中随机选取80名患者。
基于临床判断，由两名独立工作的护士前瞻性地对住院天数的合理性进行分类，由第三名护士依据适当性评估方案（AEP）进行分类，并由一组护士和医生组成的多学科审查小组利用第一名护士收集的数据进行回顾性分类。
不同评估者在不适当入院天数及原因、不适当天数总数以及因延迟出院、诊断程序或医疗管理效率低下导致的不适当天数方面的一致性。
使用临床判断的两名护士之间在不适当入院天数及原因、不适当住院天数总数以及因延迟出院、诊断程序或医疗管理效率低下导致的天数方面的一致性很强（卡方值或组内相关系数[RI]为0.77至0.98）。在等待手术的不适当住院天数方面一致性为中等（RI为0.47）。使用临床判断的两名护士与审查小组之间的一致性很强（卡方值或RI为0.69至0.94），除了不适当天数总数；然而，对于该变量，排除一个病例后RI从0.35提高到了0.80。使用临床判断的两名护士与使用AEP的护士在入院天数合理性和不适当天数方面的一致性很强。当排除一个异常病例后，审查小组与使用AEP的护士在不适当天数方面的一致性从0.36提高到了0.88。使用AEP时，一些入院被归类为过早，而其他评估者认为这些入院是不必要的。使用AEP的护士与其他评估者在等待手术或诊断检查的不适当住院天数方面的一致性较差。
由一名经过培训的护士进行住院合理性的数据收集和判断是可行且可靠的。一名前瞻性工作的护士和一个回顾性工作的小组有时会存在分歧。AEP对不适当天数的估计类似，但可能对影响入院时间的患者因素不敏感。
