Developing of the Appropriateness Evaluation Protocol for Public Hospitals in Iran

Abstract

Background:Employment of utilization review instruments is a method for managing costs and efficiency in the healthcare systems.Objectives:This study developed an instrument for measuring the level of inappropriate acute hospital admissions and days of care in Iran.Patients and Methods:The American version of the Appropriateness Evaluation Protocol (AEP) was modified, using the agreement method, by a multidisciplinary group of physicians. We conducted a retrospective descriptive study of 273 randomly selected patients admitted to Imam Khomeini Hospital of Tehran University of Medical Sciences in Tehran, Iran. For the reliability study, two nurses were asked to review patients’ medical records using the instrument. Validity was appraised by pairs of clinicians, including two general surgeons, two internists and two gynecologists. The degree of consensus between the three pairs of clinicians was compared with that of the nurses.Results:Inter-rater and intra-rater reliability testing revealed an excellent level of consensus between the two nurses employing the AEP in all the studied departments. Overall agreement was > 92%, while the specific appropriate agreement and specific inappropriate agreement were > 88% and > 83%, respectively. External validity testing of the instrument yielded a sensitivity > 0.785, specificity > 0.55, and positive and negative predictive values > 0.775 and > 0.555, respectively. The kappa statistic for the nurses who applied the AEP and clinicians using personal judgment were perfect (k > 0.85) and substantial (k > 0.68), respectively.Conclusions:The results illustrate that the Iranian version of the AEP (IR-AEP) could be a reliable and valid instrument for assessing the level of inappropriate acute hospital admissions and days of care in the Iranian context.

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

“…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 prob-ability of inappropriate admission but had effects on inappropriate hospitalization.…”

“…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)(32)(33). This implies that the probability of inappropriate stay was more in patients with more length of hospital stay.…”

“…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.…”

Investigating inappropriate admissions and hospitalizations in Yasuj educational hospitals based on appropriateness evaluation protocol (AEP): A case study in the internal and surgical wards

“…Hospital costs have a growing trend. For example, they increased over three times from 2002 to 2007 . Although various economic incentives have been used to reduce hospital costs, these incentives have not yielded satisfactory results in terms of patients' access to hospital services and the quality of services provided to the patients.…”

“…For example, they increased over three times from 2002 to 2007. 5,6 Although various economic incentives have been used to reduce hospital costs, these incentives have not yielded satisfactory results in terms of patients' access to hospital services and the quality of services provided to the patients. To maintain quality and accessibility, focusing on cost-limiting indicators with regard to the appropriateness or inappropriateness of the healthcare services provided is necessary.…”