Diseño de una herramienta para valorar la adecuación de la estancia hospitalaria en pacientes quirúrgicos (VAEQ)

Abstract

Among appropriateness studies in the sanitary environment, hospital stay is an element of great interest, not only because of his economic impact (with an estimated cost of 1.051,51 euros per day in surgical services and 573,13 in medical ones), but also because of its clinical implications. Inappropriateness in hospital stay is linked to an increase of hospital acquired infections and other adverse events. Furthermore, it decreases the patient and his family’s satisfaction with the healthcare process. Inappropriate hospital stay is estimated at 30% approximately, varying from 24% to 76%, depending on the author. Among the existing tools for measuring appropriateness hospital stay (AEP, OBSI, AdeQhos, ISD, etc.), AEP is considered as the standard. Designed in 1981 and updated for the last time in 1987, it has good sensibility although its specificity is low, and it is not specific for surgical patients. The objective of this work is to develop an actualized tool for assessing hospital appropriateness in a General Surgery department. For assessing hospital appropriateness in surgical patients, a new tool (VAEQ) was designed as part of this study. Delphi methodology was used to improve its validity. Hospital stay appropriateness was compared in a sample of 566 stays corresponding to 99 patients using AEP and VAEQ. An expert panel was formed to analyze individually the stays that showed discrepancies between both tools. A cost analysis was performed to assess the impact of inappropriate hospital stay. As results, inappropriate hospital stay rate was 9,9% when measured with AEP and 36, 04% with VAEQ. Both tools showed the same results (agreement in appropriateness and inappropriateness) in 73,85% of the stays while they offered different results in 26,15% of the cases. Kappa index among them was 0,3199. Among the stays where the tools showed disagreement, 100% of them were considered inappropriate by VAEQ and appropriate by AEP. The panel of experts considered 4,06% of them appropriate and 95,94% inappropriate. The Gold Standard was defined by the panel of expert’s result in the stays that showed disagreement between both tools, and the result of the tools in the stays that showed agreement. Kappa index between Gold Standard and AEP was 0,3390, and 0,9769 between Gold Standard and VAEQ. Inappropriate hospital stay was higher in males than in females according to AEP (13,04% vs 6.09%, p = 0,0144) and smaller according to VAEQ (26,81% vs 45,86% p < 0,0001). It was higher among patients not receiving surgery during their stay than patients with a surgery performed according to AEP (13,94% vs 8,23% p = 0,0387), and without statistical difference according to VAEQ. Higher among patients without any reintervention than the ones who needed a reintervention according to AEP (11,07% vs 1,45% p = 0,0122), and smaller according to VAEQ (1,59% vs 72,46% p < 0,0001). Higher in patients discharged to their previous residence than in patients requiring admission to a care facility, according to AEP (11,86% vs 0% p = 0,0021) and smaller according to VAEQ (30,72% vs 70,24% p < 0,0001), these last results were confirmed in a multivariate analysis. Regarding comorbidity, according to VAEQ, inappropriateness was higher in patients with high severity index (according to APR-GRD) vs low (47,86% vs 32,86% p= 0,0014) and in those with high mortality index (according to APR-GRD) vs low (54,62% vs 31,77% p= 0,0001). Multivariant analysis only showed correlation with mortality index, being more likely to present an appropriate hospital stay when the mortality index is low (OR 4,210, IC: 1,115-15,896). During the break down analysis of the items conforming each tool, 6 AEP items (3, 6, 7, 8, 9 y 21) were found negative in all the stays analyzed. In VAEQ, only one item (3) was negative for all the stays analyzed and it was suppressed. There were 7 AEP items (11, 12, 13, 15, 16, 17 y 19) positive (justifying the stay), when it was considered inappropriate by the experts panel. 4 of these items (13,15, 16 y 17), were also single positives. 56 hospitalization days, with an associated cost of 50.989,4 euros were considered inappropriate in our sample by AEP. VAEQ found 204 inappropriate hospitalization days, with a cost of 184.415,6 euros. By extrapolating these values to all hospital stays throughout a year at the General Surgery department, AEP esteemed 2943 days as inappropriate, with a 2.476.921,84 euros cost, and VAEQ 10.714 days, with a cost of 9.016.996,27 euros. As a conclusion of this job, inappropriateness of hospital stay was noticeably inferior with AEP compared to VAEQ. The only factors associated to inappropriate hospital stay in the multifactorial analysis were a high risk of mortality and the need of a facility care after discharge. Of the 26 items conforming AEP, 6 were always negative and 4 were positive when the stay was considered inappropriate by the experts panel. VAEQ perceived and elevated number of inappropriate hospital stays in the sample, with an important cost. According to the results, we consider VAEQ a useful and adjusted tool for measuring appropriateness of hospital stay in surgical patients, adapted to the current healthcare situation.