Effect of inappropriate admissions on hospitalization performance in county hospitals: a cross-sectional study in rural China

Excessive use of health services leads to waste of health resources and unreasonable increase in medical costs. It is an issue of widespread concern across the globe. Inappropriate admission is one of the most severe problems in the excessive use of health services [1]. Inappropriate admission refers to a condition that the utilization of hospitalization services is not conducted on the basis of clinical needs [2], and physicians act as patients’ agents and therefore can influence the choice of patients to use hospitalization services compared to outpatient services. Therefore, patients tend to choose the hospitalization services according to the physicians’ advice. Admission appropriateness can be assessed by appropriateness evaluation protocol (AEP), which is an objective, effective and reliable tool used to evaluate the appropriateness of the admissions on the basis of inpatient’s medical records [3–6]. AEP criteria can be divided into two parts: medical service intensity and disease severity.

Some studies have pointed out that compared with outpatient services, inappropriate admissions cause excessive use of health services, including human resources, beds, medicines and health care funds [7]. However, it is not clear whether inappropriate admissions cause excessive use of health services compared with appropriate admissions. Though previous studies have indicated that patients with less severe diseases tend to have shorter length of stay (LOS) in hospital, and therefore, consume less health resources [8, 9], this does not mean that the relatively small amount of health resources are consumed by inappropriately admitted patients. The reasons are as follows.

First of all, patients’ actual utilization of hospitalization services will be affected by policies that related to inpatient service delivery in the hospital such as standardized inpatient service provision policy and clinical pathway management and so on. No matter admission is appropriate or not, the patient will receive health care services in accordance with the standards of hospitalization service process. In other words, medical treatments, nursing and examination are strictly implemented in accordance with the clinical pathway form [10], where the timing of diagnosis and treatment measures is clarified, the clinical process is programmed, and the inspection, treatment and nursing that should be done every day are clearly specified. The patient would receive corresponding clinical biochemistry inspection, for instance blood test, urine test [11], and they would spend a standard period in hospital, and receive the prescribed dosage. In this way, it may result in a condition that inappropriately admitted patients have the similar utilization of hospital services compared to those who are admitted appropriately. Second, the patient’s condition is in constant change with uncertainty. The change of the patient’s condition will affect the subsequent series of health services [12]. For instance, the symptoms of the appropriately admitted inpatients may relieve rapidly after hospitalization and require less treatment methods, and accordingly, the length of stay may be shortened. Patients who are admitted inappropriately may get worse, when the utilization of medical services will be more intense. In this case, the length of stay may be extended and the expenditure of hospitalization will increase. Thirdly, the utilization of health services is greatly influenced by doctor’s behaviors. On the one hand, according to the prospect theory proposed by Kahneman [13], most people are risk-averse when facing gain and risk preference when facing loss. People are more sensitive to loss than to gain. As a result, people are often wary of taking risks in the face of gains. In other words, irrespective of the appropriateness of admission, doctors may tend to adopt the most conservative treatment methods when they are not sure of the situation in the process of diagnosis and treatment. This leads patients to do more clinical inspections, extend length of stay for observation and so on, all of which will increase the use of health services. On the other hand, doctor’s behaviors will also be affected by the hospital internal management system and salary system. This generates behaviors that induces consumption or reduces service, etc. Thus, the relationship between the appropriateness of admission and the utilization of health services is unclear, which calls for further exploration.

A study of Bianco A has revealed that doctors adopt a conservative management mode due to their risk aversion, which led to inappropriate admission and inappropriate follow-up hospitalization services [14]. This increased the length of stay, resulting in unnecessary waste of resource. It is more common in surgery departments. Velasco’s [15] study illustrated that patients who were not properly admitted had three times the length of hospital stay compared to those admitted appropriately. Eriksen [16] has measured the proportion of inappropriate admission of internal medicine and the cost, and the findings suggested that not accepting inappropriate admission did not bring the hospital the same percentage of cost reduction.

Although some studies have explored the relationship between admission appropriateness and hospitalization services utilization, these studies also have some limitations. First, some of studies were based on the comparison of an inpatient case itself. These studies were the evaluation of appropriateness of admission and services utilization after hospitalization. They were not compared with other similar or opposite cases. Second, although length of stay and hospitalization expenses were studied in the evaluation of health services utilization, there were little detailed studies on the utilization of clinical inspection. Third, and most importantly, insufficient consideration of the severity of disease made the comparison of service utilization lack of accuracy. The difference in disease severity and the change of disease condition will affect the utilization, and therefore, the performance of hospitalization services. Inappropriate admission and those with appropriate admission both have patients with mild and serious severity. Whether there is a difference in the utilization of services, and if so, what are the differences in the efficiency of hospitalization service are still unknown, and await further study. In addition, matching patients with similar disease characteristics is of great practical significance for accurate evaluation of medical quality, utilization of health services and rational allocation of health resources.

Based on AEP, the appropriateness of admission is evaluated from two aspects of medical service intensity and disease severity. The admissions rated as “inappropriate” indicate that the patients have a mild illness, and the required medical service intensity for them is not large. Thus, in theory, the consumption of health resources for inpatients admitted inappropriately is smaller than those admitted appropriately. Thus, this study hypothesized that inappropriate inpatients have shorter length of stay (LOS), fewer number of clinical inspection (NCI), and lower expenditure of hospitalization (EOH) than those who are admitted appropriately and with similar characteristics, and to verify it. The main contribution of this study relative to other similar studies is the adoption of propensity score matching (PSM) methodology. The PSM was used to match patients in appropriate and inappropriate admissions with similar characteristics, and to examine the differences in the utilization of hospitalization services among them. This would enrich more contribution relative to other methods.

This study is expected to provide reference for the policy makers when adjusting and improving relevant medical policies in order to promote the appropriateness of health resources utilization and control unreasonable increase in hospitalization expenses.

Propensity score matching has been widely used in the field of health economics since the 1990s [27]. It eliminates the selective bias and the mixed bias by matching the individuals in the treatment group with the appropriate comparable objects in the control group [28]. In this study, the resource consumption between appropriate admission and inappropriate admission groups was compared by controlling the factors influencing the utilization of services. This method balances the problems caused by incomplete and inaccurate pairings [29]. Meanwhile, the results of multiple covariates acting together can be expressed [30]. This makes the results accurate and comparable.

For the whole sample, with the similar basic characteristics, the patients admitted inappropriately had shorter LOS and lower EOH than those admitted appropriately. As a whole, the study indicates that the health service utilization of patients admitted inappropriately was less than that of patients admitted appropriately. This is basically in line with expectations. No difference in NCI was observed between them. This indicates that inappropriate admission may result in overuse of clinical inspection services. In different disease groups, there were some specific differences. Diseases were classified into internal and surgical diseases. Among surgical diseases, the EOH of inappropriate admission group was less than the appropriate admission group. As long as the patient needs surgery, he/she is easy to accord with the AEP (A1, A4,) and be evaluated as an appropriate admission. The cost of surgery, drug exchange and infusion, etc., will make the EOH of the appropriate admission higher than that of the inappropriate admission. Thus, in terms of surgical diseases, inpatients admitted inappropriately will not consume more health resources than those admitted appropriately.

The circulatory diseases, digestive diseases and respiratory diseases are internal diseases. There was no statistically significant difference in internal disease in the EOH, LOS and NCI between the two groups. This is different from the comparison results of the surgical diseases. There are two possible explanations.

First, as organic disease, the cause of the internal diseases is complex and difficult to be identified and diagnosed [31]. It has hidden features, and the features of the disease may gradually become apparent after admission. In this case, the means of diagnosis and treatment may increase after hospitalization among the inappropriately admitted patients. Second, the symptoms of patients admitted inappropriately did not change after admission, but the consumption of resources was as much as that of patients admitted appropriately, which indirectly indicates that there exists avoidable consumption of health resources. It may be related to the salary system of public hospitals in China. For years, under the condition of market economy [32], doctors in public hospitals have been required to earn their own salary through business income. At the same time, the pricing of technical services is seriously low, and the human capital value of doctors is not fully reflected. The inappropriate salary structure and distribution factors has led to further distortion of incentive mechanism [33]. Most obviously, “subsidizing medical services with medicine” has distorted the behaviors of medical staff, making them prescribe “big prescriptions” to pursue the maximization of economic benefits to protect their vital interests. They prefer to use expensive drugs, let patients do more clinical inspections and extend the LOS of patients, resulting in increased hospitalization expenditures [34, 35]. Meanwhile, intense doctor–patient relationship at present has led to a condition that some medical staff conduct unnecessary clinical inspections and treatments on patients in order to avoid risks [36]. Besides, it is related to doctors’ own treatment habits and lack of grasp of disease severity [37]. It is possible that after the patient admitted to hospital, doctors provide the services that they are accustomed to, or treat patients according to the specified clinical pathways. Due to the lack of judgment on the severity of the disease, some services are unnecessary, especially for patients who are not appropriately admitted to the hospital.

To solve these problems, it is necessary to reform the salary distribution system of public hospitals [38]. Public hospitals should improve the incentive mechanism of internal allocation by making doctors earnings more on the value of their labor than the quantity of their services. The combination of effective motivation and supervision to the hospitals can promote the hospitals to improve efficiency, reduce service cost, shorten the LOS and reduce the induced expenditure. In addition, optimizing the clinical pathway management is necessary. The clinical pathway aims to optimize the service process, reduce the delay in disease treatment and waste of resources, and provide patients with efficient and high-quality medical and nursing services [39]. Even so, it does not indicate that there is no overconsumption of resources. Studies have shown that the effect of reducing hospital costs through clinical pathway management is limited [40, 41]. Clinical pathways can improve the treatment effectiveness, but it does not reduce the length of stay or hospital costs [42]. Therefore, when implementing clinical pathway, it is necessary to consider the same disease with different severity and make clinical pathway more elaborate.

Inappropriate admissions have generated excessive health service utilization compared with appropriate admissions, especially for internal diseases. On the one hand, the NCI of inappropriately admitted inpatients had no significant difference compared with appropriately admitted inpatients on the whole. On the other hand, when it comes to the disease systems, no significant differences existed between the two groups among EOH, LOS and NCI, except that the EOH was lower among the inappropriate group than the appropriate group in surgical disease. Policy makers need to pay more attention to the utilization of health resources of inappropriately admitted inpatients. Relevant medical policies should be optimized to promote medical service providers’ appropriateness of health service provision, and the clinical pathway management should be more precise. At the same time, patients should be guided to utilize health services appropriately.