Factors associated with inappropriate hospitalization days in internal medicine wards in Israel: a cross-national survey

Background. The high costs of health care mandate a quality control system that ensures efficient utilization of hospitalization days. Objectives. To obtain a national estimate of the rate of inappropriate hospitalization days in medical wards and to identify the variables associated with inappropriateness. Design. A 1-day cross-national survey. Setting. A sample of internal medicine wards in all public hospitals in Israel. Survey population. The survey population included all patients hospitalized in the ward for at least 24 hours on the survey day. Instruments. We used an adapted version of the appropriateness evaluation protocol (AEP) (Gertman and Restuccia). Reviewers were final year medical students trained to work with the AEP. Final classification of inappropriate days was done by one of the senior investigators. Outcome measure. Utilization of hospitalization days according to the AEP. Results. A total of 1003 hospitalization days in 33 medical wards in 24 hospitals was surveyed. Of this, 182 (18.1%) of the days were found to be inappropriate. In multiple logistic regression analysis, variables significantly associated with inappropriate days were government versus other hospital ownership (OR, 1.51; CI, 1.15-1.96), diagnosis on admission of acute cardiac event versus other diagnosis (OR, 0.46; CI, 0.27-0.77), and period (first, second or final third) of the stay (OR, 1.61; CI, 1.29-2.03). In 62.6% of the 'inappropriate days', continuation of hospitalization was justified (72% were patients awaiting tests or consultation). In 6.7% of the total days surveyed, no justification for continuation of hospitalization was found. Conclusion. The percentage of inappropriate days found in this study is similar to the means found in studies that were conducted in other countries. Awaiting procedures and consultation is a major cause of inappropriate days and may be an important target for intervention.