الفهرس 
Review of LiteratureOnly 14 pages are availabe for public view
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Abstract
Utilization review (UR) is an essential principle in Utilization management (UM) that can be used to minimize inappropriate hospital utilization and to restrain hospital costs. UR is the assessment of the appropriateness and efficiency of hospital utilization through reviewing hospital records. UM cycles include interventions before, during, and after the clinical encounter (Roifman et al., 2017).
Inappropriate hospital admission rate has proved to be an important indicator for assessing the appropriateness of any health care facility (Jeddian et al., 2017). The quantified values of preventable hospital utilization using Appropriateness Evaluation Protocol (AEP), help in planning for improving efficiency and quality of care (Zhao et al., 2019).
A large portion of health expenditure is due to hospital services. And hence, reducing the inappropriate admissions and hospital stay is the principal strategy for reduction of health care expenses, appropriate allocation of resources, health care quality promotion and improving the accessibility to heath care facilities (Kouhestan et al., 2020).
The study was conducted to:
1. Measure the rate of inappropriate admissions in the internal medicine Hospital of Ain Shams University.
2. Identify causes of inappropriate hospital admissions, at the selected departments.
3. Develop and implement a new admission policy.
4. Evaluate the change in the inappropriate admission rate after implementation of the policy.
A total of 1133 patient medical records were reviewed with the AEP criteria to assess appropriateness of hospital admission (576 in the pre-phase and 557 in the post-phase). During on job training for staff, all the junior staff that were present in the hospital during training period was asked to participate in the study. Ninety-one of them participates in the study and answer the associated questionnaire.
The pre-intervention phase overall inappropriateness admission rate was 20.5% which varies from 19.5% in internal medicine departments to 40.7% in departments where elective surgeries are carried out (ophthalmology department).
While the post-intervention phase overall inappropriateness admission rate was 8.1%. It varies from 7.7% in internal medicine departments to 20% in departments where elective surgeries are carried out (ophthalmology department).
The results of the current study showed that there was a significant reduction in the inappropriateness rate after intervention by 60%.
In the current study the relation between inappropriateness of admission and some personal factors was studied (age, gender, marital status, educational level, occupation and whether the patient lives inside or outside greater Cairo). In the pre-intervention phase, it was observed that inappropriateness differs significantly by gender only and there were more inappropriateness cases among females. While in the post-intervention phase was no significant difference by gender or other factors.
As regards the hospital admission circumstances that are related to inappropriateness of admission, the pre-intervention phase of present study shows that most of cases were admitted during normal weekdays (60.3%), the majority was admitted from Emergency Room (ER) (93.2%) and most of cases were admitted during shift (A) (39.6%). The increase in number of patients admitted during shift (A), for preintervention phase might be attributed to patient referral from the outpatient clinic to be admitted from ER. Also, the body system affected at admission was a significant risk factor. The gastrointestinal systems had the largest percent of inappropriate cases followed by cardiovascular, respiratory, and immune systems respectively. There was no statistically significant difference between appropriately and inappropriately admitted cases as regards other factors including department responsible for admission, route, and day of admission. While in the post-intervention phase; there was statistically significant difference between appropriately and inappropriately admitted cases of post intervention phase as regard route of admission and body system affected at time of admission, however there was no statistically significant difference as regards day, type of day, department, and shift. The cardiovascular systems had the largest percent of inappropriate cases followed by gastrointestinal, respiratory and immune systems respectively.
As regards AEP criteria, the result of current study shows that most of met criteria in pre-and post-intervention phases were of the intensity of care needed criteria with 76.2% and 88.0% respectively. For the intensity of care needed criteria; IV medication, fluid replacement, or both (does not include tube feeding) beside the Surgery or invasive procedure scheduled within 24 hours requiring general or regional anesthesia or an equipment available only in hospital were the two most common criteria of the intensity of care needed criteria in studied cases in both phases (47.3%, 31.2%in pre- phase & 97.4%, 47.2%in post-phase respectively). While the most met criteria for elective surgery other than performing the procedure on the same day of admission was the presence of co-morbidities especially cardiac diseases (30%) in the pre-intervention phase and cardiac co-morbidities / Special preoperative or treatment available only on an inpatient basis (16.7%) in the post-intervention phase.
The participating physicians reported the most common causes for inappropriateness of admission as that the patient lives far away from hospital that makes follow up difficult, followed by large number of cases to be followed up in emergency room and patients’ co-morbidities or mental status or immobility with 54.6%, 53.8% and 46.2% respectively.
About 36% of physicians in the current study also reported that (Lag in obtaining results of laboratory investigations or radiology results) is a cause for inappropriate admission.
Recommendations include revising the policy of IV medications, physician should be requested to clarify the need of the patient to have IV medications in presence of alternatives, update and enforce the new admission policy that include AEP criteria that could help physicians in admission decision, revise and standardize the admission process from Outpatient clinics and ER. And also, establishing a monitoring mechanism for inappropriate admission using the AEP criteria is a primary and key measure to help tracing causes of inappropriate admissions, also giving physicians’ regular feedback of the monitoring to keep them motivated to maintain optimal use of hospital beds.