Elsevier

Health Policy

Volume 53, Issue 3, 1 October 2000, Pages 157-184
Health Policy

Measuring appropriate use of acute beds: A systematic review of methods and results

https://doi.org/10.1016/S0168-8510(00)00092-0Get rights and content

Abstract

A systematic review of the methods used to assess appropriateness of acute bed use and the evidence on the scale of inappropriate use in different patient groups is presented. Issues of generalisability of the findings are also addressed. Criteria based tools are the accepted way of measuring inappropriate days of stay and admissions, although opinion based classification is very common. While a number of tools exist, few have been adequately tested for reliability and validity. The Appropriateness Evaluation Protocol (AEP) is the most commonly used tool, and has been tested more widely. It appears to be both reliable and valid. An estimated 29% of admissions to acute psychiatric may be inappropriate. Regarding days of care after admission, between 24 and 58% of stays were not judged to be appropriate for continued stay on an acute ward. The need for continued acute psychiatric care may become lower as patients experience continued stay in the acute setting. A lack of housing and community support was the most commonly cited reason preventing discharge. Rates of inappropriate use appear to be higher for older patients than for the general population. Wide variation in rates of inappropriate days of stay was found, but it may be safe to assume that inappropriate use is greater than 20% across a wide variety of settings. Reasons for older patients to remain in an acute hospital bed after medically necessary are typically moderate nursing care needs (i.e. long-term care). The estimates of inappropriate use in other groups was found to be highly variable. Before definitive conclusions on the inappropriate use of acute beds can be made, future research needs to take into account the methodological problems discussed here.

Introduction

In all health care systems, the use of acute hospital beds is an issue of concern both to policy-makers and practitioners. In most countries, the acute hospital sector accounts for a substantial share of expenditure on health care services, thus attempts to improve efficiency and reduce costs often begin in this sector. Whilst a number of strategies might be pursued in order to achieve this aim, reducing the number of acute beds is often seen as a key part of such a process [1], [2], [3]. In recent years, this has offered a particularly attractive solution as it is also in accord with the widespread strategy of shifting care out of hospital into the primary care and community sectors. As a result, the number of inpatient beds has declined in almost every country. For example, apart from Turkey and Germany, every other OECD country has fewer beds now than in the late 1970s, with the UK, Ireland, and Sweden having the largest reductions and the Netherlands, Hungary, and Canada, the smallest [4]. However, there has also been some concern that the reduction in beds may have gone too far [3], [5], [6]. Similar concerns have prompted a ‘national beds inquiry’ in the UK in order to investigate the number, range and mix of beds appropriate for future demand [7].

It is not surprising that the debate surrounding over or under-bedding persists as both the demand and supply of beds is influenced by a wide variety of factors. In this paper we consider just one of these factors in terms of its influence on the demand for beds-the extent to which acute hospital beds are used appropriately. The way in which the current supply of beds is used will clearly have an impact on the future demand and supply of beds and this is therefore an important economic and policy issue for health care systems around the world. The objectives of this review are to describe and assess critically the available tools for measuring inappropriate acute bed use and to summarise the findings of research into the extent of inappropriate acute bed use.

There are important issues with respect to how information regarding appropriateness of bed use may be applied. For example if inappropriate bed use is identified, shifting care out of hospitals may not necessarily yield financial savings [1], [3], [8]. However, the aim of this paper is to focus on measurement issues in the appropriate use of acute care beds and specifically does not consider this additional aspect.

Section snippets

Methods

The data for this review were obtained through an English language literature search using MEDLINE, Health Star, HMIC, and the Cochrane Library CD-ROM for the years 1988–1998. Bibliographies from included studies were also searched. Relevant studies were identified from more than 12 000 located. For inclusion, the studies had to assess inappropriate use of acute hospital beds, although all study designs were accepted. Data extraction was performed using a standard form. A formal quality-scoring

Methodological issues in assessing the appropriateness of acute bed use

In an effort to quantify the amount of inappropriate use of hospital beds, research in this area originally included asking various health professionals to classify patients as appropriate or inappropriate for occupying an acute hospital bed. Occasionally a definition of ‘inappropriate’ is provided for guidance. Physician opinion is generally considered the gold standard. However, in such research, the decision of ‘appropriateness’ may largely depend on whose opinion is being asked. For

Intensity-severity-discharge (ISD)

The intensity-severity-discharge review system with adult criteria (ISD-A) was originally developed in the USA by InterQual, in 1978. It is a proprietary product that has been briefly described in the literature [11], [18]. This tool is intended for use with adult medical, surgical, obstetric and gynaecologic patients only. It includes 22 sets of criteria, the first of which is generic and applies to all patients. The subsequent sets of criteria are applied as is necessary for a particular

Estimates of inappropriate bed use

A great deal of research aimed at identifying the extent of inappropriate bed use has been undertaken, using the tools outlined above as well as less objective methods. The following sections summarise the results of this research by patient group. The majority of studies of psychiatric and older patients were from the UK (Table 1, Table 2), but results from other countries are reported as appropriate (Table 3).

Generalisability of research findings

The generalisability of findings from this review is limited by factors relating to the external validity of the studies included. External validity is dependent on several variables, including both patient and health care system factors. Patient factors likely to influence the generalisability include demographic, cultural and disease specific factors. Health system factors of likely importance have to do with the financing and structure of health care delivery especially alternative care

Conclusions

The scale of inappropriate use of acute beds is an important consideration in most health care systems around the world. It is therefore not surprising that a substantial amount of research effort has been directed at estimating the extent of inappropriate admissions or days of stay in acute beds for a variety of patient groups. However, the results of our review suggest that we are still some way from being able to make any definitive statements about the scale of inappropriate use and also,

Acknowledgements

The authors would like to thank Kath Wright for valuable help in organising and carrying out the literature search, Helen Parkinson and Hannah Duckmanton for excellent secretarial assistance, and Peter Smith for valuable comments. The financial support of the Department of Health is gratefully acknowledged but the views expressed are those of the authors and do not necessarily represent those of the Department.

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