Agreement between two expert panels in assessing gain in life expectancy and quality of life from unselected stays in a department of internal medicine was investigated. Weighted kappa statistics of 0.45 for gain in life expectancy and 0.63 for gain in quality of life were found.
OBJECTIVES: Inappropriate hospital admissions are commonly believed to represent a potential for significant cost reductions. However, this presumes that these patients can be identified before the hospital stay. The present study aimed to investigate to what extent this is possible. METHODS: Consecutive admissions to a department of internal medicine were assessed by two expert panels. One panel predicted the appropriateness of the stays from the information available at admission, while final judgments of appropriateness were made after discharge by the other. RESULTS: The panels correctly classified 88% of the appropriate and 27% of the inappropriate admissions. If the elective admissions predicted to be inappropriate had been excluded, 9% of the costs would have been saved, and 5% of the gain in quality-adjusted life-years lost. The corresponding results for emergency admissions were 14% and 18%. CONCLUSIONS: The savings obtained by excluding admissions predicted to be inappropriate were small relative to the health losses. Programs for reducing inappropriate health care should not be implemented without investigating their effects on both health outcomes and costs.
The Tromsø Medical Department Health Benefit Study was designed to estimate health gains from admissions to a department of internal medicine. We have previously reported that the hospital stays had no effect on the life expectancy of 61% of the patients. However, it has been claimed that modern medicine has a greater effect on quality of life (QoL) than on life expectancy. The aim of the present study was to investigate this issue by estimating gains in QoL for patients admitted to a department of internal medicine.
The time trade-off method (TTO) was used for assessing QoL gain from consecutive admissions during a 6-week period. The assessments were made by one of two expert panels, each consisting of an internist, a surgeon and a general practitioner, on the basis of summaries of all relevant clinical information about the patients. Short-term improvements in QoL during the stay or shortly after discharge were scored on an ordinal scale.
Of the admitted patients, 41% had gains in QoL measured with the TTO (mean gain = 0.06; 95% confidence interval = 0.05-0.07; n = 422), and eight of these had gains equal to or greater than 0.50. Another 40% had gains in health-related short-term QoL measured with the ordinal scale. In a multivariate linear regression analysis, emergency admissions, high age and the disease categories 'endocrinological diseases' and 'pneumonia and influenza', were associated with higher gain, and 'undiagnosed symptoms' and 'cerebrovascular diseases' with lower gain.
As judged by the expert panels, the investigated department of internal medicine was effective in improving the QoL of 81% of the admitted patients. Whilst most of the patients achieved small gains, a minority had gains in QoL corresponding to the treatment of life-threatening diseases.
Doubts about the effectiveness of medical care in improving patient health have been raised by epidemiological studies and by studies of geographical variation and inappropriate use of health care. To investigate this problem, the life expectancy gain (LEG) from consecutive admissions to a department of internal medicine during a six-week period was assessed by two expert panels, each consisting of an internist, a surgeon, and a general practitioner. The mean LEG for all admissions was 2.25 years (n = 422). Sixty-one percent had a LEG of 0.10 years or less, while 5% had a LEG of more than 9.98 years. In a probabilistic sensitivity analysis, the mean LEG remained greater than zero under assumptions of overestimated positive LEG and underestimated negative LEG. We conclude that the life expectancy of the majority of the patients was not influenced by the admission, but that a minority had substantial gains, resulting in a high overall mean LEG.
In Norway, as in other countries, questions regarding medical leadership in hospital departments are much discussed. The purpose of this study was to determine how much time medical heads of hospital departments spend on various leadership tasks.
Information was collected by a questionnaire survey in 1996.
567 out of 657 (86%) completed the questionnaire. 71% shared the departmental leadership with a nurse, and 48% of these were content with such co-leadership. Nearly all the respondents were clinically active. 49% of heads of large departments used more than half their working hours on administration, compared with 7% of heads of small departments.
Selection criteria for heads of hospital departments should be adjusted to the work they actually do. Clinical competence is of importance for all heads of clinical departments; the importance of administrative competence varies with the size of the department.
Norwegian hospitals and their leaders are required by law to engage in quality assurance. We wanted to study to what extent the heads of hospital departments were actually engaged in such activities.
Data were collected by questionnaires sent to heads of hospital departments in Norway (n = 657), of whom 567 (86%) responded.
Only 23% of those interviewed prior to their appointment had been asked about experience in quality assurance, less than 30% had written instructions for their work, and only about 40% received regular follow-up from the hospital administration. The majority registered complaints and mistakes, and was engaged in teaching quality assurance. 58% of the heads of small departments and 73% of those of large departments reported that quality in general suffered because of the demands for higher clinical productivity.
Most heads of hospital departments in Norway are engaged in quality assurance work, but the study indicates that hospital administration attaches little importance to this type of work.