|Year : 2022 | Volume
| Issue : 2 | Page : 113-120
Appropriateness of hospital admissions in a university hospital in Egypt: Analyzing a preintervention phase
Aya Mostafa Abdellatif1, Mahi Mahmoud A L Tehewey2, Mervat Hassan Rady2, Amany Mokhtar Abdelhafez2, Mai Ahmed Eldeeb3, Hebat Allah Mohammed Salah Gabal4
1 Assistant Lecturer of Public Health, Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2 Professor of Public Health, Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
3 Assistant Professor of Internal Medicine, Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
4 Assistant Professor of Public Health, Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||30-Aug-2021|
|Date of Decision||15-Nov-2021|
|Date of Acceptance||20-Nov-2021|
|Date of Web Publication||12-Jul-2022|
Aya Mostafa Abdellatif
Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Identifying the magnitude of this improper use and applying interventions to eliminate unnecessary hospitalization will reduce health-care expenditure, improve the quality of care for patients, and increase the accessibility to care for actual patients in need on waiting lists. Aim of Work: To measures the rate of inappropriate admissions at the Ain Shams University Hospital. Methods: This research is the preintervention phase of a study conducted to improve the appropriateness of patient admission at this hospital. The appropriateness evaluation protocol (AEP) was used to review the appropriateness of 576 hospital admissions over 100 days. The patients' medical records were stratified according to the admission route into two groups, namely emergency and outpatient admission. Next, the systematic random samples were taken from each stratum based on the admission list of the previous day. Results: The results showed that 20.5% of the sampled cases were inappropriately admitted. Furthermore, a statistically significant difference was observed between appropriately and inappropriately admitted cases regarding gender and shifts during which admission occurred in addition to body systems affected; inappropriate admissions were more among females, and admissions occurred most frequently during the morning shifts (8:00 am–2:00 pm). The remaining other factors that were studied also proved insignificant. Conclusion: It can be concluded that a considerable proportion of hospital admissions is inappropriate, especially in the elective surgery department, and these admissions vary according to patient's gender, shifts during which admission occurred, and the affected body systems. Recommendations: Adopting hospital admission policies based on the AEP criteria in addition to training of physicians on these criteria would help prevent inappropriate admission and ensure optimization during use of hospital facilities.
Keywords: Appropriateness, appropriateness evaluation protocol, hospital admission, utilization management
|How to cite this article:|
Abdellatif AM, A L Tehewey MM, Rady MH, Abdelhafez AM, Eldeeb MA, Gabal HA. Appropriateness of hospital admissions in a university hospital in Egypt: Analyzing a preintervention phase. Indian J Public Health 2022;66:113-20
|How to cite this URL:|
Abdellatif AM, A L Tehewey MM, Rady MH, Abdelhafez AM, Eldeeb MA, Gabal HA. Appropriateness of hospital admissions in a university hospital in Egypt: Analyzing a preintervention phase. Indian J Public Health [serial online] 2022 [cited 2022 Aug 13];66:113-20. Available from: https://www.ijph.in/text.asp?2022/66/2/113/350654
| Introduction|| |
Utilization management (UM) is considered the main component of a cost management approach in health-care facilities. UM programs curb overutilization and are defined as “unnecessary use of services and procedures resulting in waste of the health-care system's resources without any measurable improvement in quality,” e.g., routine laboratory tests on admission to the hospital.
Utilization review (UR) is an essential principle in UM that can be used to minimize inappropriate hospital use and restrain hospital costs. It is used to assess the appropriateness and efficiency of hospital use by reviewing hospital records. UR cycles include interventions before, during, and after the clinical encounter.
Appropriateness is one dimension of quality in health care, which means that “people get the care they need,” and “they get it in the right way.” The Canadian Medical Association has defined the appropriateness of care as “The right care provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care.”
Inappropriate hospital utilization includes unnecessary hospital admission or hospital stay to receive care that would have been provided on a less complex level with lower cost. Among the reported causes for inappropriate admissions include conducting diagnostic or preoperative investigations after admission, the need for nursing care, the absence of clinical guidelines, poor medical record systems, and the absence of admission policies.,
Furthermore, inappropriate hospital admission rates vary widely from one country to another, ranging from approximately 7% to 75.7%. Thus, from a meta-analysis conducted to estimate the prevalence and determinants of inappropriate admission of patients in Iran, the study reported that the pooled inappropriate admission rate was 11% (95% confidence interval [CI]: 8%–14%). Moreover, the most important determinant for inappropriate hospitalizations was attributed to physicians.
Another Egyptian study conducted at the internal medicine departments of three general hospitals also reported an average of 18.6% inappropriate admissions. In addition, at four departments in the Zagazig University Hospital, including general surgery, internal medicine, chest, and orthopedic departments, 19% of hospital admissions were inappropriate. Similarly, a different study that was conducted at Monufia University Hospital to measure the inappropriate hospital admission rate found that the inappropriate admission rate among 350 admitted patients ranged from 18.3% to 32.8%.
Hence, as a large portion of health expenditure is due to hospital services, reducing inappropriate admissions and hospital stay is the principal strategy for reducing health-care expenses, thereby ensuring appropriate allocation of resources and health-care quality promotion in addition to improving the accessibility to health-care facilities.
Furthermore, in developing countries, inappropriate admission is a critical issue whose importance has been ignored. Many countries also lack information about its severity and depth. Hence, this study measured the rate of inappropriate admissions at the Internal Medicine Hospital, Ain Shams University, using the appropriateness evaluation protocol (AEP). The factors associated with inappropriate hospital admissions at the selected departments were also identified.
| Materials and Methods|| |
This research is the preintervention phase of an experimental study comprising three phases, namely, preintervention, intervention, and postintervention.
Study setting and time
The study was conducted in the Ain Shams University Hospital from September 2018 to January 2019. The hospital has 606 beds distributed in 13 departments and units, comprising mainly medical departments in addition to ophthalmology. The hospital also admits roughly 43,000 patients annually. The average bed occupancy rate in this hospital is approximately 64%, and the average hospital stay is 3 days. Patients are admitted through the emergency department or the outpatient's clinics. Furthermore, all departments and units of the hospital were included in this study, except the dermatology, geriatrics, physical medicine, and bone marrow transplantation units, as admission at all these departments is <500 patients yearly, which lower the probability of having enough sample patients for comparison.
All medical records of admitted cases during the study time were qualified to be included in the study, except those admitted in the excluded departments.
Sample size: The sample size for inappropriate admission was calculated on the assumption that if the rate of inappropriate admission was 18%, and intervention measures were adopted, a reduction of 30% would be expected (i.e., to be 12%), with an alpha error = 0.05 and a power of 80%. Therefore, we calculated that a minimum of 1106 subjects (553 in the prephase and 553 in the postphase) would be required to detect the estimated difference. Thus, this prephase sample included 576 hospital admissions.
The medical records of patients were stratified following the route of admission into two strata: the emergency admission route and the outpatient admission. Systematic random sampling was then taken from each stratum based on the admission list obtained from the previous day.
A data abstraction sheet divided into three sections was then designed and used to collect the following information after reviewing patients' medical records:
- Section 1: Sociodemographic characteristics of patients (age, gender, marital status, educational level, job, and residence)
- Section 2: Admission data (time, day, date, route, reason and ward of admission, and provisional diagnosis)
- Section 3: AEP criteria compliance to assess the appropriateness of admitting internal medicine cases (15 criteria) based on patient condition at admission (ten criteria) and intensity of care needed (5 criteria). In addition, we assessed admitted elective surgery cases (26 criteria) based on risk (14 criteria) and timelines of admission (12 criteria). If only one criterion was present, hospital admission was regarded as appropriate.,
Inappropriate admission rates represent the proportion of inappropriate admissions in the studied admissions.
The primary outcome is the rate of inappropriate hospital admissions, whereas secondary outcome is the predictor of inappropriate hospital admissions.
Data management and analysis
The collected data were revised, coded, and entered a PC using IBM SPSS Statistics for Windows.Trial version from IBM Corp. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY, USA: IBM Corp. Data were also analyzed according to the type of data obtained for each parameter. Furthermore, the mean and standard deviation were used to describe the obtained quantitative data. However, qualitative data were presented in frequencies and percentages. The proportion of inappropriately admitted cases was also calculated, and a binary response model was used to determine the factors that were significantly associated with it, using chi-square test and t-test. P ≤ 0.05 was considered statistically significant. In addition, multivariate logistic regression using the enter method was used to identify differences in the model's fitness. The model then used independent variables with P < 0.1 to enter the model, which comprised any of gender, shift, route of admission, and body system affected. Adjusted odds ratios (AOR) were also calculated.
Administrative approval was obtained from the Ain Shams University Hospital. Ethical approval was also obtained from the ethical committee of the faculty of Medicine, Ain Shams University, and confidentiality of data was assured.
| Results|| |
This study assessed the appropriateness of hospital admissions in a sample of 576 patients admitted during a 100-day period, including emergency and outpatient admissions. The mean age of included patients was 49.65 ± 17.3, of which 51.9% were females, majorly married (67.7%), and approximately 10% had high educational levels. Regarding patient's occupation, 69.3% were not working (students, retired, homemakers, and unemployed persons) and 16.7% were skilled workers (occupations involving simple or routine physical or manual tasks).
Furthermore, most of the cases were admitted on normal days (60.3%), whereas the majority was admitted during emergencies at the emergency room (ER) (93.2%). Moreover, the most common observed time for patients' admission was during shift A (8:00 am–2:00 pm) (39.6%) [Table 1].
|Table 1: Sociodemographic characteristics of admitted patients included in the study|
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Results also showed that the inappropriate hospital admission rate was 20.5%. This percentage ranged from 19.5% at the internal medicine departments to 40.7% at the ophthalmology department where elective surgeries were conducted.
The most met AEP criteria for internal medicine cases were IV medication, fluid replacement, or both (excluding tube feeding), including surgeries or invasive procedures scheduled within 24 h (33.9% and 22.4% respectively). Moreover, the most adhered to of the risk criteria for elective ophthalmologic surgery cases were the presence of comorbidities, especially cardiac diseases (20%) [Table 2].
|Table 2: Appropriateness of admission using the appropriateness evaluation protocol criteria and criteria met in appropriate cases|
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Furthermore, appropriately and inappropriately admitted cases differed significantly in their gender and shift of admission. Therefore, inappropriately admitted cases were more among females and cases that were admitted during shift A (8:00 am–2:00 pm). However, no difference was observed regarding the other factors, including the route and day of admission. The few vital cases of inappropriate admissions, where gastro intestinal tract (GIT), cardiovascular, respiratory, and immune system cases represented about 80% of the body systems affected among the inappropriately admitted cases [Table 3].
|Table 3: Personal and hospital system factors that affect the appropriateness of admissions|
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Multivariate logistic regression was then conducted to identify predictors that affected the inappropriateness of admission among included cases. From the results, gender, admission shift, and body systems affected were found to affect the inappropriateness of admission significantly. Gender (AOR: 1.8; 95% CI: 1.2–2.9) and shift A admission (AOR: 3.3; 95% CI: 1.8–6.2), including some body systems (immune, endocrine, and GIT) showed variable ORs, whereas respiratory system cases had the highest AORs [Table 4].
|Table 4: Predictors of inappropriate admissions using multiple logistic regression (total=576)|
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| Discussion|| |
Inappropriate hospital admission and stay are important challenges faced by all health systems. AEP criteria are the tools that help identify inappropriate admission cases and build quality improvement interventions aiming for better clinical outcomes at appropriate costs. Therefore, this study assessed the appropriateness of admissions using the AEP in one of the Ain Shams University hospitals, including mainly medical departments in addition to ophthalmology, as a preintervention research.
From our study, the overall inappropriateness rate was 20.5%, and the rates varied from 19.5% in internal medicine departments to 40.7% in departments where elective ophthalmological surgeries were conducted. Alternatively, at the national level, these rates were approximately similar to the previously calculated rates in Egypt. Thus, a report by Al-Tehewy et al., who conducted a study to measure the rate of inappropriate admissions at three government hospitals located in three governorates of Egypt (Cairo, Giza, and Alexandria), found that the rates at the department of internal medicine were 17.4%, 17%, and 21.3%, respectively. Another study conducted at the Zagazig University Hospital in 2013, investigating the appropriateness of admitting close to 200 patients, showed the following rates for inappropriate admission: Internal medicine, 20.5%; chest department, 14.3%; and general surgery, 35.3%. Besides, a study at Monufia University Hospital on 350 patients (1637 days) had variable results. From their study, admissions in various departments in this hospital ranged from 18.3% in some departments to 32.8% at the general surgery department. In contrast, all admissions to internal medicine and chest departments were appropriate. Rates of inappropriate admission in all previously mentioned studies were higher in surgical departments compared to internal medicine. Therefore, the inappropriateness of elective surgery admission is proposed to a be result of delays in conducting surgeries after admission without any significant cause or premature admission to conduct preoperative investigations that would have to be done as an outpatient without necessarily occupying a hospital bed. Moreover, as reported by Al-Tehewy et al., inappropriate admissions at surgery departments of two hospitals (66.3% and 78.9%), compared with that at the third hospital (1.9%), followed a specific admission protocol for elective surgery.
However, at the international level, countries showed variable rates of inappropriate hospital admissions. Thus, some were lower, and others were higher than that of our study results. In township hospitals in China, the average rate of inappropriate admission in medical wards was 26.5%. Contradictorily, different studies in Iran have reported lower rates of inappropriate admission cases, ranging from 7.4% to 13.4%.,,,
Moreover, lower rates of inappropriate admissions have been reported in Europe. Therefore, a study conducted in Spain found that 7.4% of admissions were inappropriate, and this rate further reduced to 3.2% after applying corrective measures. In addition, a study of this form at a teaching hospital in Denmark showed that 14% of acute admissions can be prevented. Hence, we attribute the variation in the rates between countries to the fact that health systems in different counties varied in admission indications and policies. Added to that, the type of studied hospital, whether the hospital was a university, educational, or governmental hospital, including the type of studied department (internal medicine, surgery, or emergency department), in addition to the patient's characteristics, affected the results of admission appropriateness.
A comprehensive review of the predictor factors related to avoidable admissions in patients diagnosed with chronic diseases highlighted that hospitalization was the result of a complex interplay of factors at all levels (person-related factors, physician factors, health system, and geographical and environmental factors). It was also interesting to note that the most studied predictors were age, gender, and race, which were the least modifiable yet continue to be the focus in prognostic health research. Furthermore, these traditional person-related factors (age, gender, marital status, and socioeconomic status) were also significantly associated with hospitalization, and their significance depended on a combination of other factors, such as disease type and disease duration, in addition to the number and nature of comorbidities.
In addition, concerning sociodemographic factors that the affected admission of patients in this study, gender was a significant risk factor. Hence, inappropriately admitted cases were more among females. Similarly, the influence of gender on hospital admission was observed in numerous literature studies.,,,,
Female gender was a determinant for increased inappropriate hospitalization, which was explained by the assumption that men had less tendency to be hospitalized to prevent job absenteeism, while women were more psychologically fragile. On the basis of these factors, the condition of women can become complicated, delaying recovery. However, gender interacts with multiple other predictors. For instance, in several studies, the influence of gender increased when associated with the effects of age, race, disease type, or all.,
Wassif et al. found that age, marital status, and residence were associated with inappropriate hospital admissions. In addition, inappropriately admitted patients were found to be older in age, more among the divorced, and were capital dwellers compared to appropriately admitted ones. Another study found that age was among the main factors associated with inappropriate admissions at township hospitals in China. However, this study failed to highlight these characteristics as risk factors, which is attributable to the effect of confounders.
In addition, this study showed that the shift of admission significantly affected its appropriateness, as inappropriately admitted cases were more among those admitted during the morning shift A (8:00 am–2:00 pm). The finding of Gupta and Potthoff also supported that of our study, which found that admission activities rose in the morning and were steady throughout the day. However, this increased number of admissions in the morning caused overcrowding in the ER.
In this study, the majority of the admitted patients were at the ER (93.2%), but this finding disagreed with a study comparing the appropriateness of admission between Egypt and the Sultanate of Oman. Their results indicated that in both countries, those admitted through the outpatient clinics had more inappropriate admissions. Moreover, Al-Tehewy et al. highlighted that system factors within a hospital are the main contributors to inappropriate admissions. Therefore, the proportion of inappropriate admissions ranged from 1.2% to 8.0% among cases admitted through the ER compared to 30.0%−68.9% among patients admitted through outpatient clinics. Furthermore, the hospital department, severity of illness on admission, and disease categories were the main factors associated with inappropriate admissions at township hospitals in China. However, a study by Aledo et al. found that no significant relationship existed between the route and appropriateness of admission.
Regarding AEP criteria, results from our study agreed with the results of a study that was conducted using the AEP criteria at a teaching hospital in Denmark. They reported that intravenous medications and intravenous fluid replacements represented approximately 45% of admitted patients.
Therefore, the results of this study highlight the importance of adopting measures to optimize hospital utilization to ensure that more patients can be managed at minimal costs and that workload can be moderated.
| Conclusion|| |
Conclusively, the rate of inappropriate hospital admissions at the ASU hospital varied from 19.5% at the internal medicine department to 40.7% in departments where elective surgeries are conducted. However, predictors of inappropriate admissions as observed included female cases presenting with GIT or cardiovascular complaints in addition to those admitted in morning shifts (8:00 am–2:00 pm).
The study results highlight the importance of adopting measures to optimize hospital utilization, thereby ensuring that more patients can be managed at minimal costs and that workload can be moderated. Therefore, the use of preset criteria for hospitalization and training physicians on using the adopted criteria for admission, in addition to routine reviewing of the appropriateness of admissions would help to prevent inappropriate hospital admissions and pave the way for better hospital utilization.
The authors wish to thank the hospital administration who agreed to collect data for this study, healthcare quality team and all participating physicians at internal medicine hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sarkar MK, Botz CM, Laposata M. An assessment of overutilization and underutilization of laboratory tests by expert physicians in the evaluation of patients for bleeding and thrombotic disorders in clinical context and in real time. Diagnosis (Berl) 2017;4:21-6.
Roifman I, Austin PC, Qiu F, Wijeysundera HC. Impact of the publication of appropriate use criteria on utilization rates of myocardial perfusion imaging studies in Ontario, Canada: A population-based study. J Am Heart Assoc 2017;6:e005961.
Solayappan A, Jayakrishnan J, Velmani S. Quality measurement for hospital services. Int Conf Inf Financ Eng 2011;12:246-50.
Moghadam MN, Amiresmaili M, Goudarzi R, Amini S, Khosravi S. Investigating the appropriateness of admission and hospitaliza-tion at a teaching hospital: A case of a developing country. Iran J Public Health 2017;46:1720-5.
Tavakoli N, Kasnavieh SH, Yasinzadeh M, Amini M, Nejad MM. Evaluation of appropriate and inappropriate admission and hospitalization days according to appropriateness evaluation protocol (AEP). Arch Iran Med 2015;18:430-4.
Al-Omar B, Al-Ghanim S. Utilization of hospital resources: A survey-based study of Saudi hospitals in Riyadh City. Clin Gov 2010;15:134-41.
Kouhestan SM, Hashempour R, Raei B, Chivaee D, Safari H. Prevalence and determinants of inappropriate admission and hospitalization in Iran: A systematic review and meta-analysis. Med J Islam Repub Iran 2020;34:2.
Al-Tehewy M, Shehad E, Al Gaafary M, Al-Houssiny M, Nabih D, Salem B. Appropriateness of hospital admissions in general hospitals in Egypt. East Mediterr Health J 2009;15:1126-34.
Wassif SM, Ali AS, Elsharkawy GF, Elwan A. Bed Utilization Pattern At Zagazig University Hospitals. Zagazig University Medical Journal 2013;19:1-14.
Sharfeldin A. Inappropriateness of hospital admission hospital stay and bed utilization at Monufia University Hospitals, Egypt. Egypt Fam Med J 2019;3:113-28.
Ain Shams University Hospitals Activity Report. Information and Technology Center, Ain Shams University Hospitals; 2017.
Gertman PM, Restuccia JD. The appropriateness evaluation protocol: A technique for assessing unnecessary days of hospital care. Med Care 1981;19:855-71.
Chakravarty A, Parmar NK, Bhalwar R. Inappropriate use of hospital beds in a tertiary care service hospital. Med J Armed Forces India 2005;61:121-4.
Zhang Y, Chen Y, Zhang X, Zhang L. Current level and determinants of inappropriate admissions to township hospitals under the new rural cooperative medical system in China: A cross-sectional study. BMC Health Serv Res 2014;14:649.
Ghods AA, Khabiri R, Raeisdana N, Ansari M, Motlagh NH, Sadeghi M, et al
. Predictors of inappropriate hospital stay: Experience from Iran. Glob J Health Sci 2015;7:82-9.
Ashkevari N, Mahfoozpour S, Zarei E, Mehrabi Y. Evaluation of unnecessary admissions and hospital stays and estimation of its financial burden: A study at internal wards of selected hospitals of Alborz University of medical sciences. J Heal Promot Manag 2017;7:51-8.
Jeddian A, Afzali A, Jafari N. Evaluation of appropriateness of admission and hospital stay at educational hospital. Arch Iran Med 2017;20:16-21.
Aledo VS, Alcaraz AC, Pastor BF, Egea AM, Prats MC, Albasini JLA, et al
. Reduction in inappropriate hospital use based on analysis of the causes. BMC Health Serv Res 2012;12:361.
Jepsen HK, Hendriksen C, Nielsen H, Nybo B, Perrild H. Every seventh acute medical admission is preventable. Dan Med J 2013;60:A4595.
Muenchberger H. Kendall E. Determinants of avoidable hospitalization in chronic disease: Development of a predictor matrix. Centre for National Research on Disability and Rehabilitation, Griffith Institute of Health and Medical Research, Griffith University, 2008.
Diette GB, Krishnan JA, Dominici F, Haponik E, Skinner EA, Steinwachs D, et al
. Asthma in older patients: Factors associated with hospitalization. Arch Intern Med 2002;162:1123-32.
Robbins JM, Webb DA. Hospital admission rates for a racially diverse low-income cohort of patients with diabetes: The urban diabetes study. Am J Public Health 2006;96:1260-4.
Al-Amri B, Gadallah H, Awady E, Al Shafee M. Appropriateness of Admission and Days of Stay; Cost and Underlying Factors; Comparative Study between Oman and Egypt. PhD Thesis, Ain Shams University, Egypt; 2011.
Barouni M, Amini S, Khosravi S. Appropriateness of Delivered Services in Educational Hospitals: A Case Study in Kerman University of Medical Sciences. Sadra Medical Journal 2016;4:185-94.
Celik Y, Celik SS, Bulut HD, Khan M, Kisa A. Inappropriate use of hospital beds: A case study of university hospitals in Turkey. World Hosp Health Serv 2001;37:6-13, 33.
Trawick DR, Holm C, Wirth J. Influence of gender on rates of hospitalization, hospital course, and hypercapnea in high-risk patients admitted for asthma: A 10-year retrospective study at Yale-New Haven Hospital. Chest 2001;119:115-9.
Rizza P, Bianco A, Pavia M, Angelillo IF. Preventable hospitalization and access to primary health care in an area of Southern Italy. BMC Health Serv Res 2007;7:134.
Gupta D, Potthoff SJ. Matching supply and demand for hospital services. Found Trends Technol Inf Oper Manag 2016;8:131-274.
[Table 1], [Table 2], [Table 3], [Table 4]