International Journal for Quality in Health Care 2002; Volume 14, Number 5: 429–430

Letters to the Editor

The AEP in the assessment of appropriatehospital stay

To the Editor: The Appropriateness Evaluation Protocol Other main causes of inappropriate admission and stay inour service were the need for a test or examination that(AEP) is a useful tool for detecting the overuse of hos-could not be delayed to allow for response from the con-pitalization resources [1,2]. In his article [3], Dr Panis reportedsultation service, and also the wait for test results as the onlyresults for inappropriateness of stay in the Department ofcause of stay. With this service, we created an accurate in-Internal Medicine that were significantly lower than ours [4]hospital consultation service with an average waiting time(14.1% compared with 33%) and other studies [2,5,6]. Thisof 7 days from the time of referral from the Emergencymade us re-read the article in order to find the causes thatDepartment and 2 days from the performance of tests. Thesemight explain the difference. We thought we would find themeasures allowed a decrease in inappropriate admissionsanswer to this question in Appendix 2, after reading aboutfrom 13.4% in 1999 to 9.1% in 2001 [4]. Inappropriatethe modifications made to the US version of the AEP (US-stays remain at 33%, however, probably due to the higherAEP) to create the Dutch AEP (D-AEP). However, thecomorbidity of patients hospitalized after selection of patientscriteria applied to determine whether a stay is appropriate areto be admitted to the hospital.even more restrictive in the D-AEP: cardiac catheterization,

angiography, biopsy of internal organ(s), tests requiring dietaryF. Javier Rodriguez-Vera

control and respiratory care are not considered criteria of Hospital Juan Ramon Jimenez de Huelvaappropriateness of stay in the US-AEP, whereas we consider Sevilla, Spainthese appropriateness criteria. We would like to know whatpercentage of the patients in that subgroup did not fulfillany other criteria of stay, because many of these techniques

Referencesusually require nursing care or intravenous medication thatcould make the stay appropriate. Secondly, another point that

1. Gertman MP, Restuccia JD. The Appropriateness Evaluationmight explain the difference is the use of the override criteria, Protocol: a technique for assessing unnecessary days of hospitalmentioned in the Methods section of Dr Panis’ study, to care. Med Care 1981; 19: 855–871.consider the stay appropriate. It would be useful to know

2. Peiro Moreno S, Portella E. Identification of the inappropriatethe percentage of patients to whom these criteria were applieduse of hospitalization: the search for efficiency (in Spanish).in order to discern whether the clinical criteria were theMed Clin (Barc) 1994; 103: 65–71.determinants of this result. Thirdly, the low percentage of

3. Panis L, Verheggen F, Pop P. To stay or not to stay. Thestays may be an indirect marker of low inappropriateness ofassessment of appropriate hospital stay: a Dutch report. Int Jadmissions, because the inappropriate admissions usuallyQual Health Care 2002; 14: 55–67.generate more inappropriate stays than those that fulfill the

criteria of admission [7,8]. Finally, comorbidity of patients 4. Rodriguez-Vera FJ, Pujol de la Llave E. Inappropriate ad-may prolong the stay [9,10], sometimes inappropriately. It missions. J R Soc Med 2002; 95: 111.would be useful to compare the comorbidity of the patients in

5. Donald IP, Jay T, Linsell J, Foy C. Defining the appropriateour respective Internal Medicine Departments. After making use of community hospital beds. Br J Gen Pract 2001; 51: 95–100.these adjustments, it is possible that the difference between

6. McDonagh MS, Smith DH, Goddard M. Measuring the ap-the inappropriate stays in the two hospitals would be lower.propriate use of acute beds. A systematic review of methodsOn the other hand, we want to mention that we have hadand results. Health Policy 2000; 53: 157–184.similar reasons for inappropriate stays. After an analysis was

7. Matorras P, De Pablo M, Otero L, Alonso F, Daroca R, Dıaz-made in 1999, we carried out an intervention program toCaneja N. Appropriateness of admissions to an internal medicinedecrease inappropriate admissions and stays. A diagnosisservice at a tertiary hospital (in Spanish). Med Clin (Barc) 1990;review and consultation service called the Diagnostic Ori-94: 290–293.entation Consultation service (DOC) was established. The

service consists of two internists at any time who are available 8. Rodrıguez-Vera FJ, Alcoucer Dıaz MR, Rodrıguez Gomez FJ,by telephone or e-mail 24 hours a day for consultation Martınez Garcıa T, Colchero Fernandez J, Pujol de la Llave E.

Appropriateness of admissions to an internal medicinerequests from primary care practitioners. The average timedepartment of a second level hospital (in Spanish). Ann Medfrom consultation request to response is 72 hours, with theInterna 1999; 16: 277–280.possibility of immediate advice by telephone when necessary.

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Letters to the Editor

9. Librero J, Peiro S, Ordinana R. Chronic comorbidity and 10. Librero J, Peiro S, Ordinana R. Chronic comorbidity andhomogeneity in diagnostic related groups (in Spanish). Gac Sanoutcomes of hospital care: length of stay, mortality, and re-

admission at 30 and 365 days. J Clin Epidemiol 1999; 52: 171–179. 1999; 13: 292–302.

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