DETECTION AND CLASSIFICATION OF INAPPROPRIATE HOSPITAL STAY

Objective: To study the reliability and validity of concurrent review of hospital-bed utilization carried out by a trained nurse. Design: An alysis of interrater reliability and validity of utilization review.Se tting: Tertiary care hospital associated with a university. Patients: Eighty patients randomly selected from 203 patients admitted to the ho spital. Interventions: 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 Approp riateness 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. Main outcome measures: Agreement be tween different raters on the number of and reason for inappropriate a dmission days, total number of inappropriate days and of inappropriate days due to delayed discharge, to diagnostic procedures or to ineffic ient medical management. Results: Agreement between the two nurses who used clinical judgement was substantial (kappa or the intraclass corr elation coefficient [R(I)] 0.77 to 0.98) on the number of and reason f or inappropriate admission days, on the total number of inappropriate hospital days and on days due to delayed discharge, diagnostic procedu res or inefficient medical management. Agreement was moderate (R(I) 0. 47) on the number of inappropriate days' stay awaiting surgery. Agreem ent was substantial (kappa or R(I) 0.69 to 0.94) between the two nurse s who used clinical judgement and the panel, except on the total numbe r of inappropriate days; however, for this variable, exclusion of one case increased the R(I) from 0.35 to 0.80. Agreement was substantial b etween the two nurses who used clinical judgement and the nurse who us ed the AEP on appropriateness of admission days and the number of inap propriate 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 t he one outlying case was excluded. Some admissions were classified as premature when the AEP was used, whereas other raters considered the a dmissions 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. Conclusions: Data collecti on and judgement of appropriateness of hospital stay by a trained nurs e 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 t o patient factors that influence the timing of admission.