Eventos adversos y adecuación sanitaria en el ámbito hospitalariofrecuencia, causas e impacto

Zusammenfassung

Introduction: The Quality of Health Care is affected by the level of inappropriateness of health care, either due to underuse —insufficient care for patients who need it—, or overuse — provision of unnecessary health services with possible damage in the form of adverse events for the patient. Overuse in the hospital setting can present itself in various ways, with inappropriate hospital admission being one of the main ones. Both for the measurement of inappropriate hospital admission and adverse events, strategies based on medical record review have been used, such as the AEP and the HMPS methodology. It is globally accepted that inappropriate health implies a greater risk for the patient. However, this hypothesis has never been corroborated for inappropriate hospital admission by direct estimates. This Doctoral Thesis analyzes the association between inappropriate hospital admissions and the subsequent development of adverse events in a tertiary hospital, combining, in a pioneering way, the AEP and HMPS methodologies (both validated), delving into their initial epidemiological analysis and estimating a measure of direct association from the same sample. This project is framed within the ESHMAD. Objectives The objectives were divided into three phases: 1) To estimate the prevalence of adverse events, their association with the patient’s death at the end of the episode, the factors related to avoidable adverse events, and their economic impact. 2) Estimate the prevalence of inappropriate hospital admissions associated factors, causes and economic impact. 3) To analyze the association between inappropriate hospital admissions and the subsequent development of adverse events and whether inappropriate hospital admission acted as a predictor variable for adverse events. Methodology: The methodology of each phase of the study was: 1) Descriptive observational study carried out within the ESHMAD, based on the HMPS methodology. It was developed in a high complexity hospital, in May 2019, by reviewing the electronic medical record in two phases: 1) Adverse events screening and collection of epidemiological and clinical data from patients; 2) Review and characterization of the adverse events and analysis of its impact, avoidability and associated costs. Two multivariate logistic regression models were performed: 1) An explanatory model to study the association between adverse events and death; 2) A predictive model to analyze the factors associated with avoidable adverse events. 2) An observational cross-sectional study was performed on the total number of patients hospitalized in a high complexity hospital. From the application of the AEP, the prevalence of inappropriate admission, its causes, the association of inappropriateness with intrinsic risk factors of the patient (in a multivariate model), and the economic cost associated with avoidable days of hospitalization derived from the cause of inappropriate admission were analyzed. A multivariate logistic regression model was developed to analyze the variables associated with inappropriate hospital admissions. 3) Observational study with a cross-sectional design conducted on hospitalized patients in May 2019. Inappropriate hospital admissions were measured with the AEP, and adverse events were detected and characterized with the HMPS. The association between inappropriate hospital admissions and adverse events were analyzed using multivariate explanatory models of logistic and linear regression adjusted for confounding variables. The behaviour of inappropriate hospital admission as a contributing factor in predictive models for detecting adverse events and the mean adverse events per patient was evaluated. Finally, the characteristics and economic impact of adverse events associated with inappropriate admissions were compared with those adverse events with appropriate ones. Results: The main results by phase were: 1) A total of 636 patients were studied. The prevalence of adverse events was 12.4%. Death during the stay was associated with the presence of adverse events (OR [95% Confidence Interval (95%CI)]: 2.15 [1.07 to 4.52]), vs absence, and with urgent admission (OR [95%CI]: 17.11 [6.63 to 46.26]), vs programmed. The avoidability of adverse events was 70.2%, associated with a stay in the intensive care unit (OR [95%CI]: 2.75 [1.07 to 7.06]), vs medical service, with the presence of pressure ulcers (OR [95% CI]: 2.77 [1.39 to 5.51]), a central venous catheter (OR [95%CI]: 2.58 [1.33 to 5.00]), and mobility disorders (OR [95%CI]: 2.24 [1.35 to 3.71]), vs absences. The adverse events entailed an increase in the economic cost of €909,716.8 for additional days of hospital stay and €12,461.9 per patient. 2) A total of 611 patients who met the inclusion criteria of the AEP were studied. A total of 73 patients had an inappropriate hospital admission, finding a prevalence of 11.9% (95% CI: 9.5 to 14.8). The increase in the number of intrinsic risk factors for developing care-related complications was associated with inappropriateness, being higher in patients with 1 intrinsic risk factor (OR [95%CI]: 11.27 [3.4 to 37.1]), vs absence, and in admissions to the surgical field (OR [95%CI]: 1.92 [1.1 to 3.4]), vs medical field. Presenting a prognosis of terminal illness reduced the risk of inappropriate hospital admissions (OR [95%CI]: 0.27 [0.1 to 0.9]), vs prognosis of complete recovery at baseline. Inappropriate hospital admissions generated 562 days of avoidable stay, equivalent to €140,463.6, mainly corresponding to urgent inappropriate admissions (€97,730.1). The daily cost of inappropriate hospital admissions per patient was €249.4/day. This is equivalent to a daily loss of €18,265.75 for the centre, considering the total number of patients with inappropriate hospital admissions. 3) A total of 558 patients were studied. Inappropriate hospital admissions increased the risk of adverse events (OR [95%CI]: 3.54 [1.87 to 6.69]), compared to appropriate, and doubled the mean number of adverse events per patient (Coefficient [95%CI]: 0.19 [0.08 to 0.30]) of increase versus appropriate, adjusting for confounders. Inappropriate hospital admission was a predictor variable for the presence of adverse events and the number of adverse events per patient. The adverse events produced after inappropriate hospital admissions added 2.4 days of stay in the intensive care unit compared to appropriate admissions, representing an extra cost of €166,324.9 for the sample studied. Conclusions: The main conclusions of each phase are: 1) The prevalence of adverse events is similar to that found in other studies. Adverse events favour a worse evolution of patients. Although avoidable adverse events are less severe, their higher frequency means a more significant overall impact on the patient and the healthcare system. 2) The prevalence of inappropriate hospital admissions is similar to the frequency found in other studies. Patients with an intermediate number of comorbidities had a higher prevalence of inappropriate hospital admission. The inappropriate hospital admission entailed a significant avoidable economic impact. 3) Patients with inappropriate hospital admissions were associated with a higher risk of suffering adverse events. Due to the multifactorial nature of adverse events, inappropriate hospital admissions are positioned as a possible contributing factor, establishing an association between Appropriateness and Patient Safety. Adverse events that occur after inappropriate admissions prolong the stay in the intensive care unit by more days and represent a higher economic extra cost than adverse events that occur after appropriate admissions.