A study on the appropriateness of admission
Date Issued
2002-07-31
Date
2002-07-31
Author(s)
楊志良
DOI
902416H002040
Abstract
Although National Health Insurance (NHI) has been implemented for many years, most of the
hospitals are still unsatisfied with the medical review. At the same time, there are few clinical
guidelines and references available in Taiwan. Therefore, the importance of the study on
appropriateness of admission is self-evident.
Appropriateness Evaluation Protocol (AEP) and Intensity Severity Discharge(ISD) are two
most recommended admission review instruments which the reliability and validity were proved
in United States and Europe countries. We adapted these two tools and the modified AEP(mAEP)
and Severity of illness/Intensity of service (SI/IS) were used in this study. First of all, the
physician and nurse reviewers who were well trained to review the emergency room (ER) and
outpatient (OPD) medical records to judge admission appropriateness by blind technique. Then
the gastrologists and general surgeons justified the validity of tools and clinical experts discussed
the result. Finally, the data was analyzed by statistical methods. The findings are as follows:
General speaking, the consistency of mAEP is better than SI/IS. In reliability test, the
reviewers’ Cohen’s kappa are between 0.4 and 0.7 which met the guideline of good reproducible by
Landis and Koch. If we recalculate the consistency after the reviewers revised their discordant
decision, the kappa would be significantly higher. In validity test, the OPD’s sensitivity of mAEP
and SI/IS are over 91%. The ER’s sensitivity and specificity are over 87% and 91% . Due to the
difficulty of finding the gold standard, it has to be much careful if the mAEP was used for
utilization review in the future. The mean time for admission review was about 3 minutes. To
compare with western countries’ 7-10 minutes, our study took less time. This also suggested that
mAEP was a fast, easy and time saving utilization review instrument. The override of mAEP in our
study is 4%, which is closed to the 5% in US, and it showed that the completeness of mAEP is good.
The number one reason of both outpatient and ER inappropriate admission are ”Any needed
diagnostic procedures and/or treatment can be done on an outpatient basis”. It is as same as western
countries’ studies. To analyze the related factors of admission appropriateness, when the specialists’
decision is the dependent variable, we found only the physician’s specialty was significant in OPD,
but sex, age (demographic variables), major casualty, major examinations before admission (disease
variables) were significant in ER. Due to these findings are only the preliminarily result, so it is
required more studies to prove the power of explanation.
We found the original AEP has to be modified in order to meet the native needs. Although the
sensitivity and specificity of mAEP were proved in Taiwan, it has to be revised periodically due to
the new medical technologies and changed environment. From the experience of western studies,
we knew that invent a utilization review tool needs lots of manpower, budgets, materials and also
time consuming, so it could not be developed in a short time. Therefore, we expect that the mAEP
can be computerized for efficient medical review in short times. We also believe that our study is
just a beginning, and we hope more researches will join in together in the near future.
Publisher
臺北市：國立臺灣大學公共衛生學院醫療機構管理研究所
Type
report
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