A measuring stick for health care
CMAJ 1998;158:302
The article "Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review" (CMAJ 1997;157 [7]:889-96 [full text / résumé]), by Carolyn DeCoster and colleagues, and the accompanying editorial, "Measuring the appropriateness of hospital use" (CMAJ 1997;157 [7]:901-2 [full text / résumé]), by Dr. Duncan J.W. Hunter, confirm many of the trends and practice patterns we have uncovered at our acute care facility.
Concurrent review of every patient admitted to hospital can be resource intensive when using previously described tools such as the appropriateness evaluation protocol1 or the ISD-A review system.2 At our hospital, a multidisciplinary team developed objective, accurate, easy-to-use criteria that were based on intensity of service and that could be applied quickly by the bedside nurse. Our "ACTIV index" allows concurrent assessment of the need for days of care in the hospital and barriers to care or discharge.3,4 The database that has evolved over the past 4 years represents patient-specific data focusing on the patients' condition, not their diagnosis, acknowledges nonphysician elements and identifies interruptions to care plans.
We suggest that patients who have been "inactive" for 2 hospital days should be targeted for attention. Over 2 years, our own 2-day non-ACTIV project has reduced the number of never-ACTIV hospital days from 17.2% to 5.3% of total hospital days, for a saving in resources of $2.43 million. We have linked our review data to records from the Canadian Institute for Health Information, which allows us to analyse the practice patterns of specific diagnostic groups as well as physician characteristics related to those groups. This information shows variations in care delivery and can be used for physician education.
We too experienced the unexpected phenomenon of reduced nonacute admissions on weekends and evenings. We feel that the emergency department screens these patients well and makes good use of our on-call home care.
The health care process can be measured and managed. Identifying inpatients who are receiving inappropriate levels of care has given us an opportunity to direct patient care processes in a manner that has improved quality and resource use. With the bedside nurse as the reviewer who identifies every patient, every day, many of the barriers to care are identified immediately and broken down almost as fast. We believe that our CONTINUUM project, which uses the "ACTIV index," is a simple, objective, reliable and inexpensive tool for utilization review and could be adapted to suit the needs of hospitals of any size.
David I. Atkinson, MD
St. Thomas-Elgin General Hospital
St. Thomas, Ont.
References
- Gertman PM, Restuccia JD. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med Care 1981;19:855-71.
- The ISD-A review system with adult criteria. Westborough (MA): Inter Qual Inc; 1978.
- Atkinson DI, Collins P, Skafel JR. Concurrent review in a community hospital: the "ACTIV" index. Ont Med Rev 1994;61(12):23-8.
- Collins PE, Skafel JR, Atkinson DI, Jenkins S. CONTINUUM: measuring and managing the patient care process. Healthc Manage Forum 1994;7(3):27-40.
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