A possible measure to cut expenditure in health care is to reduce the inappropriate use of hospitalisation. The identification of inappropriate urgent admissions is complex as there is no reference model to enable a determination of the validity of admission criteria.
By means of a systematic review, the aim is to determine the tools available to assess the appropriateness of hospital admissions, to perform a qualitative analysis of the degree of appropriateness and the existing alternatives. Observations have been made to quantify the appropriateness of admissions to Osakidetza hospitals and the level of care required in inappropriate cases. The admission criteria used were those contained in the AEP (Appropriateness Evaluation Protocol), which has been validated in one of the hospitals that have taken part n the study.
Review of the bibliographical database and qualitative synthesis of the information. Study of the validity and reliability of the AEP in 90 cases selected from the Aránzazu Hospital. The 'gold standard' was established through the clinical judgement of three experts. Transversal observation study in a stratified random sample per centre and admission date of 900 admissions through the emergency services from May 1 to 15 1999 in Osakidetza hospitals.
The AEP has been identified as the most appropriate tool because of the validity and reliability of the literature. The proportion of inappropriate admissions through the emergency services varies between 5 and 25%. The actions that reduce hospital admissions and/or costs include actions taken in Primary Health Care, the rapid action units in cases of patients with asthma, thorax pain units and home visits in the case of the elderly.
The AEP validation study has shown a sensitivity of 54% and a specificity of 91%; the reliability among reviewers is good with a Kappa of 0.81. The weighted Kappa calculated in order to measure the reliability of the list of required forms of care is 0.7.
The measured inappropriateness of Osakidetza is 4.2% (IC: 3-5.8%) which varies from 1.3 to 6.5% between hospitals. There are no significant differences between medical and surgery admissions. The required levels of care in 65% of inappropriate admissions were hospital out patients consultations and specialised health centres.
Two can be highlighted here: 1) The utility of the AEP in the Review of Hospital Use must be limited to its capacity as a screening tool, not as the sole criterion for decision taking; and 2) 2/3 of the cases of inappropriateness identified would be avoided with an appropriate circuit of specialist consultations and complementary tests.