Barriers to Appropriate Utilization of an Acute Facility

Professional Standards Review Organizations (PSROs) have been mandated to assure appropriate utilization of health resources. In order to meet this objective, PSROs must be able to determine when and why health resources are misutilized so that corrective action may be taken. This paper describes a study designed to identify and measure the significance of factors causing the misutilization of beds at one hospital. Using explicit Medicare levels of care criteria, a utilization review nurse coordinator determined the appropriate location (hospital, skilled nursing facility, home health care, home with outpatient or no care) or a sample of hospital patients. When a patient was judged inappropriately located on a particular day the nurse coordinator identified the barrier(s) to appropriate utilization, i.e., the reason(s) the patient remained in the hospital. Approximately 10 per cent of the 1,902 patient days were judged inappropriate at a hospital level of care. The most significant barriers to appropriate utilization were 1) the unavailability of skilled nursing facilities with the necessary amount of nursing services, and 2) the attending physician's conservative medical management of the patient. The implications for reduction of hospital misutilization are discussed.