# Evaluation of Inappropriate Admission and Hospitalization According to Appropriateness Evaluation Protocol and Estimation of Direct Financial Burden

AUTHORS

Siamak Soltani 1 , Mohamad Hoseini Kasnavieh 2 , Hosein Shaker 2 , Ahmad Abbasian 3 , Alireza Amanollahi 4 , Ali Tahmasebi 5 , *

1 Forensic Medicine Department, Iran University of Medical Sciences, Tehran, Iran

2 Emergency Medicine Department, Emergency Management Research Center, Iran University of Medical Sciences, Tehran, Iran

3 Internal Medicine Department, Tehran University of Medical Sciences, Tehran, Iran

4 Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran

5 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran

How to Cite: Soltani S, Hoseini Kasnavieh M , Shaker H, Abbasian A, Amanollahi A, et al. Evaluation of Inappropriate Admission and Hospitalization According to Appropriateness Evaluation Protocol and Estimation of Direct Financial Burden, Shiraz E-Med J. Online ahead of Print ; 20(12):e87870. doi: 10.5812/semj.87870.

ARTICLE INFORMATION

Shiraz E-Medical Journal: 20 (12); e87870
Published Online: November 3, 2019
Article Type: Research Article
Received: December 18, 2018
Revised: June 3, 2019
Accepted: June 28, 2019
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### Abstract

Background: Appropriate allocation of resources is an important issue in the delivery of services that can reduce the health system costs. The inappropriateness of healthcare services is one of the problems that increase the pressure on hospitals and patients.

Methods: In this study, the data were collected using the appropriateness evaluation protocol by a medicine specialist at Rasoul Akram Hospital. In total, 248 participants were selected through systematic sampling. To calculate the financial burden simultaneously with the evaluation of inappropriate hospitalization days, the medicine and facility costs along with the cost of bed-day were estimated. Data were analyzed by SPSS software.

Results: The type of treatment was surgery in 56.8% of the patients and 43.2% of them were admitted to the hospital for internal medicine. The mean length of stay was 4 ± 6 days. The inappropriate admission rate was estimated at about 6% and the rate of inappropriate hospital stays was 21.5%. The most important factors influencing the inappropriateness of hospitalization were delayed medical consultations, delayed surgery, conservative practitioner, and the follow-up of clinical test results. The sum of the direct financial burden of inappropriate hospitalization for the patients was estimated at around 1060 dollars.

Conclusions: The findings of this study indicated that inappropriate hospitalization and admission imposed a huge financial burden on the health system and community. Hospital authorities by considering issues such as delayed medical consultations and delayed surgery can decrease the financial burden of inappropriate hospitalization to a large extent.

Keywords

### 1. Background

The increasing costs of the health system have led to worries about the appropriate management of resource consumption (1). Hospital bed management is one of the issues that contribute to controlling the increasing costs of the health system. The increases in health care costs and patients’ age, as well as the presence of acute diseases, duplicate the needs for effective management of hospital beds (2). Inappropriate healthcare services are one of the problems that impose more pressure on hospitals and result in the likelihood of wrong admissions (3). Inappropriate admission is referred to the admission of those patients that may have other potential medical service choices with A lower level of technology than the technology of a hospital. This implies that there is no necessity to admit them in the hospital at the present time (4). In addition, the inappropriate hospitalization day is defined as a day in which the patient receives continuous and active medical-nursing or paramedical services while there is no need for such services for him/his (5). The results of some studies indicate that there is a wide variety of factors effective in inappropriate hospital stay attributed to physicians, demographic, and social characteristics (6-8).

The results of a study by Ghods et al. showed that about 7.4% of admissions and 22.1% of hospital stays were inappropriate (9). The cost of inappropriate admissions and hospitalizations as unnecessary services has considerable importance. In another study by Gupta et al., inappropriate admission cost was estimated to be 384.45 dollars on average (10). This cost was equal to 202.82 euros in Soria-Aledo et al. study (1). A decline in the length of patients’ hospitalization for four hours will increase the capacity of hospital beds by 30 (11). Decreasing inappropriate stays will improve hospital efficiency and shorten the waiting list with no decrease in quality. However, unnecessary hospitalization days increase the cost of hospital stays and expose the hospital to nosocomial infections (12-14). Gardiner et al. in their study demonstrated that the lack of inappropriate admissions and stays could lead to a total saving of 47.5 million pounds for two hospitals per year (15).

### 2. Objectives

The present study was conducted aiming at evaluating the rate, reasons, and direct financial burden of inappropriate admission and hospitalization to patients in a hospital.

### 3. Methods

This study was carried out in the first half of the year 2017 at the Iran University of Medical Sciences. The research population included patients admitted to all wards of a hospital (e.g., emergency, internal medicine, surgery, etc.) who were hospitalized for more than one day. This was used as a criterion for patient inclusion in this study. Also, children patients and psychiatric ward patients were excluded from the study. A total of 248 participants were selected for the study through systematic sampling. Data were collected using appropriateness evaluation protocol (AEP), the reliability and validity of which were confirmed by Strumwasser et al. (16). The AEP has four parts. The first part is for gathering the demographic information of patients and their physicians, the second part is a table of appropriate evaluation based on admission and hospitalization protocol criteria, the third one is about the reasons for inappropriate hospitalization and admission, and the fourth part is an appendix of appropriate hospitalization and admission criteria. The AEP considers the appropriateness of the hospitalized patient’s conditions with at least one protocol criterion as the appropriateness condition for admission. For calculating the financial burden simultaneously with evaluating the inappropriate hospitalization days, the medicine and facility costs along with the cost of bed-day according to the tariff and cost of medicine and facilities were extracted from the medical records. Direct cost means the patient’s out-of-pocket payment at the time of discharge. It includes all hospital costs billed at the discharge time for a patient. Following the extraction of costs, the sum of the above-mentioned costs was divided by the number of inappropriate hospitalization days, and thus the direct cost of each inappropriate day of stay was obtained per capita to express the imposed direct financial burden of each inappropriate day of stay for each patient.

The appropriateness of the patient’s hospitalization was collected by an emergency medicine specialist from the medical records of patients. The sample was determined according to the six-month period of the study and considering the proportion of hospitalized patients in each ward. Regarding the inappropriate hospitalization rate of 18% in a previous study (Z = 1.96, d = 0.05), the sample size was estimated at 248.

In addition to admission days of a patient, each hospitalization day for him/his was evaluated by the AEP protocol.

Data collection was approved by the Ethics Committee of the university. Besides, the validity and accuracy of the data were observed throughout the processes of data collection and analysis.

### 4. Results

According to the findings in Table 1, the average age of the patients was 49 ± 21 (men, 52.4%; married, 80.8%). In terms of treatment, 56.8% of the patients underwent surgery and 68% stayed at the hospital for less than four days (mean, 4 days; standard deviation, 6 days) (Table 1).

Table 1. Baseline Information of Participants
Variables/SubgroupsFrequency (%)
Gender
Male118 (47.6)
Female130 (52.4)
Marital status
Married185 (80.8)
Single44 (19.2)
Type of treatment
Surgical133 (56.8)
Medical101 (43.2)
Diagnosis of the disease
New160 (66.1)
Old82 (33.9)
Health insurance
No9 (4.1)
Yes211 (95.9)
Residence
Tehran160 (68.4)
Other cities74 (31.6)
Day of hospitalization
Holiday23 (9.5)
Non-holiday220 (90.5)
Type of referral
Other hospitals76 (31)
Urban ambulance114 (46.5)
Hospital clinic55 (22.4)
Medical specialty
Medical37 (15.3)
Cardiology33 (13.6)
Emergency medicine58 (24)
Ophthalmology23 (9.5)
Gynecology18 (7.4)
ENT19 (7.9)
Orthopedic14 (5.8)
General surgery27 (11.2)
Urology6 (2.5)
Neurosurgery7 (2.9)
Age range
≤ 20 y16 (6.7)
21 - 40 y79 (33.1)
41 - 60 y63 (26.4)
≥ 60 y81 (33.9)
One d108 (43.5)
2 - 3 d61 (24.6)
4 - 6 d31 (12.5)
7 - 10 d20 (8.1)
≥ 11 d28 (11.3)

During the study, 5.6% of the patients (14 out of 248 patients) were admitted inappropriately. The total bed-day of hospitalization was estimated at 1065 days. Based on the AEP, 228 days of hospitalization were inappropriate. Therefore, the rate of inappropriate hospitalization days was 21.5%.

Table 2 shows the influential factors on the inappropriate admission of patients in a regression model. The length of stay (OR = 1.13; P value = 0.03) was more effective on admission inappropriateness. The full-time presence of physicians increased the inappropriate admission possibility (64%) but this increase was not significant (P value = 0.62).

Table 2. Logistic Regression of Variables Affecting Inappropriate Admission
Components/GroupsP ValueOR95% Confidence Interval
Lower LimitUpper Limit
Type of referral
Ambulance or other hospitalsa
Hospital clinic0.1480.1320.0092.043
Gender
Malea
Female0.9561.0460.2075.3
Health insurance
Noa
Yes0.990.2-
Marital status
Marrieda
Single0.8610.7890.05511.24
Residence
Tehrana
Other cities0.0560.0720.0051.07
Type of treatment
Surgicala
Medical0.3040.2610.023.38
Day of hospitalization
Holidaya
Non-holiday0.990.60-
Full-time physician
Yesa
No0.6231.6410.2311.8
Age0.520.9850.941.03
Hospitalizationday0.0311.131.011.3

Abbreviation: OR, odds ratio.

aReference group.

Table 3 demonstrates the factors affecting the patient’s length of stay at the hospital. The length of stay (OR = 1.4; P value < 0.001) and insurance status (OR = 0.07; P value = 0.024) were significantly correlated with inappropriate hospitalization on holidays and non-holidays. Considering the test results, the more the patients’ length of stay, the higher the probability of inappropriate hospitalization. With a single-day increase in the length of stay, the risk of inappropriate hospitalization days increased nearly by 1.4 (OR: 1.4; 95% CI: 1.23 - 1.55, P ≤ 0.001). Besides, the insurance status of patients was another significant factor for the odds of inappropriate hospitalization day (Table 3). Individuals who did not have insurance were more exposed (about 7%) to inappropriate hospitalization days than those who were under the insurance cover (OR: 0.07; 95% CI: 0.01 - 0.7, P = 0.0024).

Table 3. Results of Logistic Regression to Determine Variables Affecting Inappropriate Hospitalization
Components/GroupsP ValueOR95% Confidence Interval
Lower LimitUpper Limit
Type of referral
Ambulance or other hospitalsa
Hospital clinic0.851.110.373.31
Gender
Malea
Female0.8021.120.462.71
Health insurance
Noa
Yes0.0240.070.010.7
Marital status
Marrieda
Single0.8820.9080.263.23
Residence
Tehrana
Other cities0.2751.7220.654.57
Type of treatment
Surgicala
Medical0.8010.8680.292.6
Day of hospitalization
Holidaya
Non-holiday0.1515.1440.5548.05
Age0.5460.9920.971.02
Hospitalizationday≤ 0.0011.41.231.55

Abbreviation: OR, odds ratio.

aReference group.

According to evaluations carried out based on available documents, in 83 of 228 days of inappropriate hospitalization, the reason was medical counseling (36%), surgical operation delay (13%), and physician’s conservativeness (13%). In some cases, the evaluation failed to diagnose the main reason for the inappropriateness of the patient’s stay. These cases were classified in the class ‘other cases’ (Table 4).

Table 4. Reasons for Inappropriate Hospitalization
Reasons for InappropriatenessNumber of Days%
Insurance and discharge problems21
Absence of practitioner21
Consultation8336
Delayed surgery3013
Follow-up of the clinical test results146
Conservative practitioner2913
Patient dissatisfaction with surgery31
Others6529
Total228100

According to Table 5, the sum of the direct financial burden of inappropriate hospitalizations on patients was estimated at around 1060 dollars (10% tariff). Besides, this amount was about 9537 dollars for the government (90% tariff). The total financial burden was the sum of the costs, which equaled to 10597 dollars.

Table 5. Financial Burden of Inappropriate Hospital
Type of Cost/HospitalizationCost of PatientsCost of Health SystemTotal
Hoteling
Hospital stay days93083719302
One day43741
Medicine and equipment
Hospital days13011661295
One day156
Total
Hospital days1060953710597
One day54247

The loss due to each inappropriate day of hospitalization could be calculated by applying the per capita method. The patients’ costs per inappropriate hospital stay were 5 dollars; the rate was nearly 42 dollars for the health system (Table 5). Therefore, the cost of per-day hospital stay was estimated at about 47 dollars by adding up these two figures. Table 6 shows the financial burden of inappropriate days of hospitalization for each ward of the hospital. The orthopedic and internal wards (considering the higher rate of inappropriate hospitalization days) with the costs of 2463 and 1999 dollars had the highest financial burden in this regard, respectively.

Table 6. Financial Burden of Inappropriate Hospital Days Based on Specialties
Medical SpecialtiesNumber of Inappropriate Hospital DaysFinancial Burden of Hoteling, $Financial Burden of Equipment,$Total Financial Burden, \$
Medical431754.24244.321998.56
Cardiology124895668.18557.74
Emergency medicine321305.48181.821487.3
Ophthalmology140.85.6846.48
Gynecology12489.5668.18557.74
ENT6244.7834.09278.87
Orthopedic532162.2301.142463.34
General surgery281142.3159.091301.39
Urology4163.1922.73185.91
Neurosurgery281142.3159.091301.39
Other (unspecified)9367.1751.14418.3
Total2289301.561295.4610597.02

### 5. Discussion

This study aimed to investigate the inappropriate admission and hospitalization days based on AEP and their financial burden. Totally, 14 (6%) out of 248 admissions under investigation did not have appropriate conditions and were determined as inappropriate admissions. Some studies carried out in this field using AEP assessed the rates of inappropriate admissions as 7% - 8.5% (1, 8, 9, 13, 16-19), which are somehow similar to the results of the current study. In another study by Soria-Aledo et al. to estimate inappropriate admissions employing AEP, this rate was equal to 7.4% (1). Several other investigations that did not use AEP for inappropriate admission estimation reported higher rates (14% - 24%) than the current study (15, 20-23). For instance, this rate was reported as 22% in a study by Eriksen et al. in Norway (21). The estimated rate of inappropriate admission in the current study was not very different from the rate in similar studies that used AEP as the tool of estimation. This indicates that there is a conformity between our obtained results and the findings of other similar studies.

Investigation of inappropriate hospitalization days in this study revealed that the inappropriate rate of stay in the hospital was 21.5%. In other similar studies, the inappropriate hospitalization days much varied across studies. This rate was 22.7% on average in similar studies that used AEP for the estimation of inappropriate hospitalization days (5, 8, 9, 13, 24-29). In a study in which AEP was the criterion for the rate of appropriateness or inappropriateness of stays, Soria-Aledo et al. found that this rate was 24.6% (8). Conversely, in studies in which the above-mentioned protocol was not the basis of estimation, this rate was reported as 35.3% (2, 20, 30). This may be due to the issue that such a protocol includes stricter criteria for the evaluation of appropriateness. The inappropriateness rate of patients’ hospitalization days in Vincitorio et al. study was equal to 30% according to an Italian pediatric appropriateness evaluation protocol (PRUO) in which, they used the records of children from 30 days to 14 years of age (20) while in the current study, patients of various ages were assessed. The results of the current study on the comparison of medical specialties demonstrated that the maximum and minimum rates of inappropriate admission were observed in the urology ward and orthopedic/ophthalmology ward, respectively. However, for inappropriate days of stay, the maximum and minimum rates were related to orthopedic and Ophthalmology Departments, respectively. Probably, orthopedic patients because of the need for various counseling and tests prior to the surgical operation have more inappropriate hospitalizations. The orthopedic, neurosurgical, and maternity wards showed higher rates of inappropriate hospitalization. No considerable difference was observed in other specialties. In addition, gender had no significant effect on the inappropriateness of admissions.

Among the possible factors affecting the inappropriate stay, an 83-day delay in medical counseling (36%), surgical operation delay and conservative decisions of physicians (13%), the follow-up test results (6%), and other causes (29%) had higher effects on inappropriate stays of the patients. Tavakoli et al. reported factors such as the time for operation (30%), other factors (27%), the physician’s conservativeness (21%), and medical counseling (11%) (4). Similarly, Meidani et al. (29)mentioned the lack of the physician’s presence (17%) and delay in counseling (12%), as well as insurance problems, discharge, and clearance (8%), as the most important factors. Due to the generality of the hospital, the presence of various specialties, and the inter-ward relationships, problems with medical counseling and delays are common. In another study by Barisonzo et al. conservative performance (39%), results of diagnostic tests (21%), and counseling services (18%) were the contributory factors in inappropriateness of admissions or hospital days (2). The results of the study showed that the likelihood of inappropriateness of hospitalization days increased with the prolonged patients’ length of hospital stay. According to some studies, a single-day increase in the length of hospital stay would increase the risk of inappropriateness of hospitalization days by about 1.4%. Besides, the more the patients stay in the hospital, the more the likelihood of inappropriateness of the stay (9, 31-33). This implies that the probability of inappropriate stay was more in patients with more length of hospital stay. In addition, the results of the study indicated that gender had no effect on the rate of inappropriate admission and days of hospital stay. Some studies also showed similar results (23, 31); however, some other studies reported opposite results in this respect (25, 32). The insurance state of patients had no effect on the probability of inappropriate admission but had effects on inappropriate hospitalization. It is possible that the hospital’s interest in gaining cash form patients rather than gaining from insurance has effects on this matter because insurance payments to the hospital have several months of delay. However, in some studies, insurance and inappropriateness of the stay were found to be significantly related (29, 31, 32). It seems that physicians in the hospital under investigation prescribed medical procedures regardless of the insurance state of the patient and that no demand was induced due to the insurance coverage. Similar to the results of the present study, the findings of a study by Masoompour et al. showed no relationship between insurance and inappropriateness of hospitalization days (23). Several studies have found a direct association between the higher age of the patients and the likelihood of inappropriate hospitalization day (25, 29, 33, 34) while in the present study, this relationship was not approved. The results of a study by Masoompour et al. indicated the lack of any statistically significant correlation between the age and inappropriate hospitalization (23).

Inappropriate admission or stay caused the waste of health system resources and decreased the efficiency of the hospital. Various costs are wasted for each inappropriate admission or stay. This rate in a hospital results in a massive financial loss to the health system per year. Obtaining information on contributing factors in inappropriate admission or stay can save money in the health system and community (1, 8, 10, 35). In the current study, 228 days of stay were inappropriate which caused a cost equal to 10597 dollars. The generalization of this rate to a year and all the admitted patients revealed that many financial resources were lost due to these issues, which could be reduced with appropriate plans in the above-mentioned areas.

#### 5.1. Conclusions

In general, the findings of this study indicated that 6% of the admissions and 21.5% of the stays were inappropriate, indicating a huge financial burden imposed on the health system and community. Through appropriate identification of influential factors on inappropriateness of admissions and hospital stays, a considerable rate of these costs could be prevented annually. The most significant predictors of inappropriate hospitalization in the present study included delay in medical counseling and surgical operation, medical practitioner’s conservativeness, and the follow-up test results. As a result, hospital authorities by considering these areas can decrease the financial burden of inappropriate costs to a large extent.

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