The Role of Feedback in Reducing Medically Unnecessary Hospital Use

A controlled trial to test the effect of informational feedback on the appropriateness of hospital use is described. The feedback was derived from utilization reviewers' retrospective application of the Appropriateness Evaluation Protocol (AEP) to a sample of Medicare hospital admissions and days of care in six New England hospitals. During the study period (January 1984 to June 1985), hospitals faced economic incentives to reduce both admissions and length of stay under the state all-payer hospital reimbursement system. The effect of the feedback on inappropriate admissions and days of care was quantitatively evaluated through appropriateness assessments of 8,049 medical records. The dissemination and usefulness of the feedback in each hospital were evaluated qualitatively by a questionnaire sent to hospital utilization review coordinators. Only three hospitals distributed the feedback to the key decisionmakers - attending physicians. Rates of inappropriate admissions decreased during the study period in both the treatment and control groups, suggesting a secular trend independent of the intervention. The feedback, where applied, was effective in decreasing the rate of inappropriate days of care in the treatment group; in contrast, there was a slight increase in the control group in inappropriate days of care. The study emphasizes the need for hospitals to take deliberate and active steps to strengthen utilization review and feedback to physicians if they are to transfer the economic incentives they face under prospective payment systems to physicians.