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Determining appropriateness for rehabilitation or other subacute care: is there a role for utilisation review?

Determining appropriateness for rehabilitation or other subacute care: is there a role for... Background: Rehabilitation and other forms of subacute care play an important role in the Australian health care system, yet there is ambiguity around clinical definitions of subacute care, how it differs from acute care, where it is best done and what resources are required. This leads to inconsistent and often poorly defined patient selection criteria as well as a lack of research into efficient models of care. Methods: A literature review on the potential role of utilisation review in defining levels of care and in facilitating appropriate care, with a focus on the interface between acute care and rehabilitation. Results: In studies using standardised utilisation review tools there is consistent reporting of high levels of 'inappropriate' bed days in acute care settings. These inappropriate bed days include both inappropriate admissions to acute care and inappropriate continuing days of stay. While predominantly an instrument of payers in the United States, concurrent utilisation review programs have also been used outside of the US, where they help in the facilitation of appropriate care. Some utilisation review tools also have specific criteria for determining patient appropriateness for rehabilitation and other subacute care. Conclusion: The high levels of 'inappropriate' care demonstrated repeatedly in international studies using formal programs of utilisation review should not be ignored in Australia. Utilisation review tools, while predominantly developed in the US, may complement other Australian patient flow initiatives to improve efficiency while maintaining patient safety. They could also play a role in the identification of patients who may benefit from transfer from acute care to another type of care and thus be an adjunct to physician assessment. Testing of the available utilisation review tools in the Australian context is now required. uable contribution to patient outcomes and being essen- Background Introduction tial for the flow of patients from acute care. Yet there is Rehabilitation and other subacute care plays a significant ambiguity around what subacute care is, how it differs role in the Australian health care system, providing a val- from acute care or other longer term care such as 'transi- Page 1 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 tion care', where it is best done and what resources are one that is: 'provided for a person with an impairment, required. While rehabilitation is perhaps the most readily disability or handicap' and; 'for whom the primary treat- recognised type of subacute care, with well-accepted serv- ment goal is improvement in functional status' and; ice models, there still remains inconsistency when it 'which is evidenced by an individualised and documented comes to patient selection for rehabilitation. initial and periodic assessment of functional ability by the use of a recognised functional assessment measure' and This paper briefly considers the concept of subacute care, 'an individualised multidisciplinary rehabilitation plan but with a particular emphasis on patient selection for which includes negotiated rehabilitation goals and indic- rehabilitation and on the interface between acute care and ative time frames' [9]. rehabilitation. It then examines the role that formal utili- sation review may have in an acute hospital in the identi- While the current Australian definitions that exist for sub- fication of patients who may be more appropriately acute care, including rehabilitation, may be useful for classified as requiring a subacute level of care, including casemix purposes and to describe the general characteris- rehabilitation. If utilisation review can be shown to offer tics of this patient population, they are not as helpful assistance in clinically defining the boundary between when trying to prospectively identify patients who may be acute and subacute care, then research into models of sub- appropriate for such care or for determining when it acute care, including optimising the interface between should commence. This, in turn, leads to an inability to acute and subacute care, may be facilitated. Utilisation examine different models of care for such patients. Eagar review could also provide a mechanism for improving the (1999) notes that the boundary between acute care and transit of patients within acute care, by assisting in the rehabilitation needs to be more clearly defined now that identification of inefficiencies in the processes of care. there is a classification system for rehabilitation and sub- These issues are relevant to clinicians, hospital adminis- acute care [7]. trators and policy makers. A 2001 Victorian Department of Human Services report Subacute care and rehabilitation into the interface between subacute and acute care [10] Eagar and Innes introduced the term 'subacute' into Aus- noted that there was a 'lack of focus and coordination in tralia in 1992 to describe patients whose need for health referral to, and provision of, subacute services, which care is predicted by their functional status, rather than affects throughput and efficiency'. The report raised the their principal medical diagnosis [1]. Other definitions of issue of the timing of patient transfer between acute and subacute care also exist. Common to all is that there is a subacute services, and the impact that may have on both group of patients who no longer meet criteria for classifi- the acute and subacute episode. While the report details cation as 'acute', but who still require care in a hospital strategies to address some of these issues, the use of more setting, with the care required being more clinically transparent and validated patient selection criteria for intense and goal directed than is long term care [2-5]. The rehabilitation and other subacute care was not men- issue becomes more difficult when trying to define the tioned. actual boundary between acute care and subacute care, with the situation in Australia being one where, according The interface between acute care and rehabilitation to Eagar and Innes, our 'acute' hospitals "treat a diverse Rehabilitation medicine services within Australia gener- ally have guidelines, either implicit or explicit, that population of patients, many of whom would not meet criteria for classification as acute" [1]. In a later paper, broadly define the types of patients that they will accept Eagar then discusses the boundaries between acute care for an inpatient rehabilitation program. These guidelines and other forms of care, and the development of the sub- will usually include clinical factors, such as the potential acute and non-acute patient casemix classification system for the patient to functionally improve with rehabilitative [6]. therapy, the capacity of the patient to participate in a reha- bilitation program and the degree to which the patient is In Australia, rehabilitation is classified, for casemix pur- medically stable. Other factors may include specific goals poses, as a distinct form of subacute care [7]. The AN- of the patient and/or carers and the patient's premorbid SNAP (Australian National Sub-acute and Non-Acute level of functioning. Patient) classification system, developed in 1997, defined four types of subacute care (Rehabilitation, Geriatric Eval- In practice, while the decision about if, and when, to uation and Management, Psychogeriatric and Palliative transfer a patient to a rehabilitation bed is largely based Care), as well as non-acute (Maintenance) care, with these on the clinical judgement of the assessing rehabilitation definitions being subsequently incorporated into the physician or registrar, the threshold for accepting a patient National Minimum Data Set for Admitted Patient Care for rehabilitation is often influenced by a number of sys- [8]. Within AN-SNAP, a rehabilitation episode of care is tem factors. These may include the degree of 'bed pressure' Page 2 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 in acute care, the availability of the rehabilitation bed, selection. These returns were screened by title, initially for access to diagnostic investigations and/or ongoing medi- relevance to "rehabilitation" or "sub-acute care" and "uti- cal or surgical care or review in the rehabilitation facility, lization review" or "patient selection". Those not evident and the availability of substitutable ambulatory rehabili- from the title were reviewed at abstract level for relevance. tation programs. The references from each of the chosen papers were then reviewed to find other contributory papers. A general Transferring patients from acute care to rehabilitation or Internet search was also conducted, in addition to use of other subacute level of care at the optimal time may have unpublished data from the Australian Rehabilitation Out- significant benefits, both for the patient, as well as for the comes Centre (AROC), University of Wollongong, Aus- health system [10]. Outcomes for patients may be tralia. improved if they are able to commence formal rehabilita- tion earlier and there may also be improvements in over- Results all hospital length of stay and cost of care. In addition, the Selection Criteria for Rehabilitation problem of 'access block' may be helped by the more There is a growing literature on the predictors of rehabili- timely transfer of patients from acute care beds to rehabil- tation outcomes, but selection criteria based only on itation. Conversely, there may be adverse outcomes if those for whom a 'good' outcome can be anticipated will patients are transferred too early. For example, patients deny many patients the opportunity to achieve worth- who remain medically unstable may not be able to be while functional recovery. Wade (2003) notes that pur- safely managed in the rehabilitation facility, unstable chasers of health care services often ask service providers medically conditions could render the rehabilitation to produce selection criteria. These are meant to ensure process less effective, and undue time could be wasted if that only patients likely to benefit from an intervention the patient has to be transferred back to the acute care are referred and accepted, and that all applicable patients facility, or other centre, for diagnostic or medical evalua- are referred. However, in the rehabilitation context, Wade tion. argues that the question of potential benefit is not always clear cut, with the situation being more a case of patients Selection for a formal rehabilitation program is relatively varying along two continua – the likelihood of benefit clear-cut when patients have the new onset of defined and the extent of benefit. He cautions against the use of impairments that are likely to be responsive to rehabilita- public selection criteria, due to the lack of good evidence tion. The situation is less clear when patients have multi- on who is responsive to rehabilitation and the danger of ple morbidities or general debility and this group, which asking untrained staff to apply clinical criteria [11]. is typically older patients, is increasingly occupying acute care wards as the population ages. These patients will Much of the literature on patient factors that predict a often have completed an acute episode, are no longer good rehabilitation outcome centres on specific diagnos- deemed to require acute care by their medical or surgical tic groups, such as stroke or orthopaedic conditions teams, but are not able to be discharged. They often [12,13], but selection for rehabilitation becomes less clear require a period of restorative care and/or complex dis- when patients have multiple morbidities or general debil- charging planning, with the question often becoming ity [14]. This would seem to be an increasing trend in Aus- whether transfer to a formal rehabilitation or subacute/ tralia, as unpublished AROC data show that up to 25% of post-acute program is the best option, or whether the rehabilitation episodes in public hospitals are now for patient is more efficiently managed by remaining in the patients with more general debility or multiple impair- acute care ward until ready for discharge. ments. But there is also anecdotal evidence to suggest that, even with relatively straightforward conditions such as One way of more clearly defining the boundary between elective joint replacement, the utilisation of formal reha- acute care and rehabilitation or other subacute care is to bilitation programs varies widely between the states and develop specific criteria for the identification of patients between the public and private sectors. If this is the case, who no longer meet criteria for classification as 'acute', as a lack of uniform patient selection criteria may be a factor. well as selection criteria and processes for rehabilitation transfer. This suggests a role for utilisation review. There is very little in the literature on formal criteria or procedures for patient selection for rehabilitation and lit- Methods tle evidence to guide the development of such criteria. A Medline search was conducted via Ovid to examine the This deficit has been recognised, with Unsworth (2001) literature on selection for rehabilitation or other subacute [12] noting that objective criteria for the selection of care and the role of utilisation review in these situations. patients for rehabilitation may help acute care clinicians Key words searched included utilization review, rehabili- make more informed discharge planning decisions. tation, physical medicine, subacute care, and patient Page 3 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 Alternatives to physician assessment alone for selection 60%, while between 18% and 48% of admissions to acute for rehabilitation have been explored. For example, mem- care have been reported as inappropriate [5]. Causes of bers of the multidisciplinary rehabilitation team could be inappropriate days of stay include delays in the discharge involved in the selection process. One US study showed process, lack of appropriate post acute care services, delays that rehabilitation outcomes for stroke patients were the in diagnostic tests, and delays in medical and other spe- same if patients were selected by a physiatrist (rehabilita- cialised consultations [22]. Utilisation review tools may tion physician) alone, or by the physiatrist basing their also highlight situations when the patient remains in decision to accept a patient on a nurse practitioner's acute care when the need is for rehabilitation or other sub- assessment [15]. However, the reliability of the clinical acute level of care. judgement of different members of the multidisciplinary rehabilitation team in determining the rehabilitation There can also be significant rates of under-utilisation of potential of patients has been questioned, with the sug- acute care, although there are fewer studies available that gestion that, in the case of older patients, it may be prefer- specifically examine under-utilisation. The amount of able to use a standardised assessment in the initial inappropriate under-utilisation is reported as being much decision regarding patient selection [14]. Other sugges- smaller (less than 4 %) than that for inappropriate over- tions include scoring systems to determine the site of utilisation [23]. Detecting under-utilisation may assist in rehabilitation (home versus post-acute facility) for maintaining clinical quality by the monitoring of prema- patients following total hip replacement [16], or nurse to ture discharge, or care in a sub-optimal setting (for exam- nurse referral for rehabilitation in community hospitals in ple, when patients should be in critical care rather than on the United Kingdom [17]. a general ward, or the premature transfer to rehabilitation of patients who are medically unstable). The issue of selection criteria for other 'subacute' care is less clear than for rehabilitation, probably because defini- Utilisation review became widespread in the United States tions of what constitutes subacute care vary [18]. following the introduction of Medicare and Medicaid [19]. Utilisation review programs have since been Utilisation Review – a brief description adopted in Canada, the United Kingdom, and Europe, but Utilisation review is a method that assesses the appropri- less so in Australia [24,25]. In the US, formal utilisation ateness of the medical or clinical care provided to a review programs have primarily become a tool of payers patient, including the appropriateness of the care setting of health care services to better manage costs. However, and the duration of care [19]. Inappropriate hospital uti- another cited reason for detecting over-utilisation is to lisation includes both over- and under-utilisation. Over- help reduce the iatrogenic risk associated with hospitalisa- utilisation includes the admission to hospital of patients tion [19]. Done concurrently, utilisation review in the who could have been managed, from a clinical perspec- United States is regarded by managed care organisations tive, in a less intensive care setting, or patients who remain as being both a cost containment strategy and a quality in a more acute setting for longer than required [20]. improvement tool [26]. However, outside of the United Under-utilisation occurs when patients do not receive the States, utilisation review tools are seen more as an aid to intensity of care required. facilitate appropriate care, rather than a mechanism for approving or denying care, or the payment for care, for Utilisation review information is derived from the individual patients [27]. patient's medical record, their treating clinical team, or a combination of these sources. Concurrent utilisation When utilisation review was introduced, appropriateness review is the most common, as well as the most useful, as was based primarily on the reviewer's judgement. How- it allows for corrective action to be taken, such as dis- ever, when inter-rater reliability was found to be inade- charge planning or finding a more appropriate care setting quate, even when using physicians who had been selected for the patient. Retrospective reviews are likely to reveal based on their expertise, attention was placed on the higher rates of inappropriate utilisation than concurrent development of specific criteria. The Appropriateness reviews, but this is usually due to information justifying a Evaluation Protocol (AEP) by Gertman and Restuccia [28] level of care being missing or unavailable [21]. was the most widely used tool initially developed. The AEP contained a list of medical and nursing/life services The utilisation review literature consistently demonstrates that were judged to be only available at an acute hospital high levels of inappropriate hospital bed days for patients and a list of patient condition factors that were thought to in acute care, with a large percentage of these days being require the resources of an acute hospital. A patient day for patients who should, according to the review criteria, was considered appropriate if any one of the services or be in a lower level of care. The reported rate of inappropri- conditions was present [19]. ate days of stay in acute care ranges from around 19% to Page 4 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 While utilisation review may be able to detect 'inappropri- care is not just to move patients from one setting to ate' days of stay in acute care, it remains only an assump- another, but to provide more appropriate care. tion that patients will be more appropriately managed in a less acute setting [29]. Further, there is evidence that Published papers outside of the United States indicate only about 50% of unnecessary days in acute care can be that the InterQual Criteria have been predominantly used avoided without additional resources being required, and in Canada and the United Kingdom that the 'inappropriate' days are less resource intensive [5,23,29,32,33,39,40,42,46,47]. DeCoster et al (1997), in and thus less costly [30]. This needs to be considered a retrospective chart review of 3,904 patients in Canada, when determining the cost effectiveness and clinical found that, after one week, 53.2% of patients assessed as appropriateness of utilisation review interventions. In needing acute care on admission no longer required acute addition, because overall hospital length of stay in acute care. Patients 75 years of age accounted for more than care has fallen, it is possible that there may not be as many 50% of bed days, but 74.8% of these bed days were inappropriate days of stay now, compared to the findings regarded as being inappropriate for acute care. The of earlier studies. authors noted that the InterQual Criteria have the advan- tage of being diagnosis independent (thus being unaf- Utilisation review has not been widely reported as a tool fected by diagnostic errors), they are broadly accepted by to assist in the determination of the appropriateness for, physicians as being a reasonable measure of the need for and timing of, transfer to rehabilitation or subacute care. acute care, and they have been externally validated[33]. While a number of utilisation review tools are reported in the literature, very few tools report specific criteria for In another large Canadian study involving 189 acute care determining appropriateness for rehabilitation and suba- hospitals and 13,242 patient discharges, Flintoff et al cute care. The three tools reported to include selection cri- (1998) used the InterQual (Adult Acute) criteria to deter- teria for rehabilitation or sub-acute care are all proprietary mine the level of care most appropriate for admission and products. These are the InterQual Criteria (McKesson Cor- subsequent days of stay [5]. They found that, for all poration), the Managed Care Appropriateness Protocol – admissions, 62.2% were judged by the criteria to be acute, MCAP – which is based on the AEP (The Oak Group), and 19.7% subacute and 18.1% non-acute. Following admis- the Milliman Care Guidelines (Milliman USA). Being pro- sion, acute care was needed on only 27.5% of subsequent prietary, access is not freely available, and there is only days, subacute care on 40.2% of days and non-acute care limited information available on them in the peer on 32.3% of days. Inter-rater reliability in this study was reviewed literature. Of these three, the InterQual Criteria found to be high (kappa ranged from 0.71 to 1.00). is the most widely reported, with about 25 papers or cita- tions in Medline. When used in the United Kingdom, the InterQual Criteria were found to have high reliability and to be valid when The InterQual Criteria – a utilisation review tool there was a presumption that the full range of alternative The InterQual Criteria is a proprietary utilisation review levels of care was available. There were limits to their tool developed in the United States. It has been cited in validity in the UK National Health Service when the alter- published work originating from both the US and outside natives were not available [40], leading to the criticism the US [5,23,24,27,29,31-46]. For example, one US study that, if the alternatives are not available, then utilisation (a retrospective chart review of 858 admissions) used the review is not achieving its aims [48]. However, it is also InterQual subacute criteria to determine the prevalence of suggested that health services planners could use the subacute patients in acute care beds in 43 Veterans Affairs information supplied by the utilisation review process to Hospitals in the US. This study showed that over one third then evaluate the benefits of developing those services of patients (38%) had at least one subacute day during which are not available [47]. their acute admission, with subacute days occurring more frequently for medical (42%) than for surgical admissions Utilisation review, and the various review tools, are not (33%). For those admissions which had any subacute without their critics, with concerns raised about the valid- days, 54% of the days in acute care were classified as sub- ity of the criteria being used [29,36,37,49,50]. The Inter- acute by the InterQual Criteria [31]. This was equivalent Qual tool, along with the AEP, was shown to have to almost 7 bed days per admission. This study also found moderate validity and reliability in the United States in a that patients experiencing subacute days were likely to be study done by Straumwasser in 1990, leading the authors older and sicker. The authors suggest that future studies to conclude that payment should not be denied based on focus on developing targeting criteria that enable clini- the instrument alone, but only if the decision is confirmed cians to prospectively identify patients with subacute care by a physician [41]. Even though criteria such as Inter- needs. The authors also note that the purpose of subacute Qual have been validated against expert panels, the ques- tion arises as to how valid they remain with subsequent Page 5 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 revisions and with changes in clinical practice. Also, valid- ciplinary, goal directed, rehabilitation interventions are ity may vary between institutions, depending upon the afforded to all patients likely to benefit. services available [34]. It should be noted, however, that administered concurrently, the InterQual Criteria allow This leads to a possible role for utilisation review. The for physician over-ride to the outcome of the review if high levels of 'inappropriate' care demonstrated repeat- there are clinical reasons for doing so. edly in international studies using a variety of tools, as well as the limited Australian work available, should not Applicability of utilisation review tools in Australia be ignored in Australia, especially as we grapple with While the concept of utilisation review is likely to be as issues of efficiency and patient safety. Yet formal utilisa- applicable in Australia as it is in other developed coun- tion review has not been embraced. Practiced overseas, tries, the applicability of the specific tools requires formal utilisation review has a role in clinically determining the testing. The AEP has been trialled in an Australian study most appropriate level of care for an individual patient, that audited admission appropriateness to an acute hospi- with some tools also having specific criteria for selection tal, finding that it was both efficient and clinically valid for rehabilitation or other subacute level of care. As well for use in Australian hospitals, with only minor modifica- as being potentially useful at the interface between acute tions required [25]. A further study, also using the AEP, care and other types of care, utilisation review has the found that 15.2% of admission days and 28.7% of days of potential to provide a mechanism by which the processes stay were non-acute. The authors concluded that the AEP of acute care could be improved. It could also assist health was a useful tool for assessing non-acute days of stay, but service planners in determining acute and subacute capac- that inpatient treatment in acute care facilities in Australia ity. may not be as rigidly controlled as in the US, where the tool was developed [51]. Despite these studies, adoption In the absence of well-validated, contemporary, public of the AEP in Australia as a utilisation review tool does not domain tools, there appears little choice but to consider appear to have occurred. proprietary utilisation review tools. The companies pro- moting them claim that the tools enhance efficiency and One of the criticisms of the InterQual Criteria is its patient safety through having evidence-based checklists reduced suitability outside of the United States due to the that support the safe transit of patients through different existence of fewer alternatives to acute care available in levels of care and care settings. However, the tools also other health systems [24]. Also, what constitutes 'acute have their critics and need to be tested against current Aus- care' may also differ, with the US appearing to have tighter tralian practice. Their applicability in the Australian con- definitions than in Australia as to what comprises acute text, where there are less alternate care settings than are care, with these definitions both shaping, as well as being available in the US, and where clinical terminology differs shaped by, utilisation review tools. from the US, also needs to be tested. Conclusion Even if the tools are shown to be applicable in Australia, Tools to inform patient selection decisions, and which it would still need to be shown whether the establishment help to validate care within settings, are of relevance to cli- of formal utilisation review programs is cost effective, and nicians, administrators and policy makers. While suba- whether these US-based systems are transferable to Aus- cute care is an accepted and important component of the tralia without major modifications to the criteria and sup- Australian health care system, it remains poorly defined porting software. The degree of physician acceptance is from a clinical perspective. This lack of clinical definition another very important issue. These are important impedes research into models of subacute care, including research questions that need to be tested and which could how it should best interface with acute care and when and have significant health policy implications for Australia. how it should occur outside of the acute care setting. Competing interests Rehabilitation is a type of subacute care with firmly estab- The author(s) declare that they have no competing inter- lished models of clinical practice and good evidence of ests. efficacy in a range of impairments. Yet patient selection for rehabilitation remains variable, relying predominantly Authors' contributions on clinical judgement and being influenced by system fac- CP undertook the literature review. Both authors drafted tors such as rehabilitation bed availability and pressure on the manuscript and approved the final manuscript. acute care. It is the challenge of our health care system to ensure that the potential gains to be made from multidis- Page 6 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 27. Bruce S, DeCoster C, Trumble-Waddell J, Burchill C, De Haney S: References Acuity of Patients Hospitalized for Medical Conditions at 1. Eagar K, Innes K: Creating a Common Language: The Produc- Winnipeg Acute Care Hospitals. Manitoba Centre for Health tion and Use of Patient Data in Australia. 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Santos-Eggimann B, Sidler M, Schopfer D, Blanc T: Comparing 1995, 49(2):194-199. results of concurrent and retrospective designs in a hospital 46. Coast J, Peters TJ, Inglis A: Factors associated with inappropriate utilization review. International Journal for Quality in Health Care emergency hospital admission in the UK. International Journal for 1997, 9:115-120. Quality in Health Care 1996, 8:31-39. 22. Chopard P, Perneger TV, Gaspoz JM, Lovis C, Gousset D, Rouillard C, 47. Wright CJ, Cardiff K: Validity of utilization review tools.[com- Sarasin FP, Unger PF, Waldvogel FA, Junod AF: Predictors of inap- ment]. CMAJ 2000, 163:1235-1236. propriate hospital days in a department of internal medicine. 48. Kalant N, Berlinguet M, Diodati JG, Dragatakis L, Marcotte F: authors' International Journal of Epidemiology 1998, 27:513-519. response. CMAJ 2000, 163:1239 -1242. 23. Trerise B, Dodek P, Leung A, Spinelli JS: Inappropriate underutili- 49. Mitchell WH: Who are "Milliman & Robertson" and how did zation of services in an acute care hospital. Vancouver BC, Cen- they get in my face? Journal of the Kentucky Medical Association 1996, tre for Health Evaluation and Outcome Science; 1999. 94:521-522. 24. McDonagh MS, Smith DH, Goddard M: Measuring appropriate use 50. Anonymous: Milliman & Robertson guidelines under fire again. of acute beds. A systematic review of methods and Hospital Case Management 2000, 8:. results.[erratum appears in Health Policy 2000 Nov 51. South Australian Health Commission: Evaluation of the Appropri- 17;54(2):163]. Health Policy 2000, 53:157-184. ateness Evaluation Protocol (AEP). Adelaide, Clinical Advisory 25. O'Donnell J, Pilla J, Van Gemert L: Which hospital admissions are Committee, South Australian Health Commission; 1991. appropriate? Australian Health Review 1990, 12:19-33. 26. Murray ME, Darmody JV: Clinical and fiscal outcomes of utiliza- tion review. Outcomes Management 2004, 8:19-25. 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Determining appropriateness for rehabilitation or other subacute care: is there a role for utilisation review?

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Springer Journals
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Copyright © 2007 by Poulos and Eagar; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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1743-8462
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10.1186/1743-8462-4-3
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17352832
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Abstract

Background: Rehabilitation and other forms of subacute care play an important role in the Australian health care system, yet there is ambiguity around clinical definitions of subacute care, how it differs from acute care, where it is best done and what resources are required. This leads to inconsistent and often poorly defined patient selection criteria as well as a lack of research into efficient models of care. Methods: A literature review on the potential role of utilisation review in defining levels of care and in facilitating appropriate care, with a focus on the interface between acute care and rehabilitation. Results: In studies using standardised utilisation review tools there is consistent reporting of high levels of 'inappropriate' bed days in acute care settings. These inappropriate bed days include both inappropriate admissions to acute care and inappropriate continuing days of stay. While predominantly an instrument of payers in the United States, concurrent utilisation review programs have also been used outside of the US, where they help in the facilitation of appropriate care. Some utilisation review tools also have specific criteria for determining patient appropriateness for rehabilitation and other subacute care. Conclusion: The high levels of 'inappropriate' care demonstrated repeatedly in international studies using formal programs of utilisation review should not be ignored in Australia. Utilisation review tools, while predominantly developed in the US, may complement other Australian patient flow initiatives to improve efficiency while maintaining patient safety. They could also play a role in the identification of patients who may benefit from transfer from acute care to another type of care and thus be an adjunct to physician assessment. Testing of the available utilisation review tools in the Australian context is now required. uable contribution to patient outcomes and being essen- Background Introduction tial for the flow of patients from acute care. Yet there is Rehabilitation and other subacute care plays a significant ambiguity around what subacute care is, how it differs role in the Australian health care system, providing a val- from acute care or other longer term care such as 'transi- Page 1 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 tion care', where it is best done and what resources are one that is: 'provided for a person with an impairment, required. While rehabilitation is perhaps the most readily disability or handicap' and; 'for whom the primary treat- recognised type of subacute care, with well-accepted serv- ment goal is improvement in functional status' and; ice models, there still remains inconsistency when it 'which is evidenced by an individualised and documented comes to patient selection for rehabilitation. initial and periodic assessment of functional ability by the use of a recognised functional assessment measure' and This paper briefly considers the concept of subacute care, 'an individualised multidisciplinary rehabilitation plan but with a particular emphasis on patient selection for which includes negotiated rehabilitation goals and indic- rehabilitation and on the interface between acute care and ative time frames' [9]. rehabilitation. It then examines the role that formal utili- sation review may have in an acute hospital in the identi- While the current Australian definitions that exist for sub- fication of patients who may be more appropriately acute care, including rehabilitation, may be useful for classified as requiring a subacute level of care, including casemix purposes and to describe the general characteris- rehabilitation. If utilisation review can be shown to offer tics of this patient population, they are not as helpful assistance in clinically defining the boundary between when trying to prospectively identify patients who may be acute and subacute care, then research into models of sub- appropriate for such care or for determining when it acute care, including optimising the interface between should commence. This, in turn, leads to an inability to acute and subacute care, may be facilitated. Utilisation examine different models of care for such patients. Eagar review could also provide a mechanism for improving the (1999) notes that the boundary between acute care and transit of patients within acute care, by assisting in the rehabilitation needs to be more clearly defined now that identification of inefficiencies in the processes of care. there is a classification system for rehabilitation and sub- These issues are relevant to clinicians, hospital adminis- acute care [7]. trators and policy makers. A 2001 Victorian Department of Human Services report Subacute care and rehabilitation into the interface between subacute and acute care [10] Eagar and Innes introduced the term 'subacute' into Aus- noted that there was a 'lack of focus and coordination in tralia in 1992 to describe patients whose need for health referral to, and provision of, subacute services, which care is predicted by their functional status, rather than affects throughput and efficiency'. The report raised the their principal medical diagnosis [1]. Other definitions of issue of the timing of patient transfer between acute and subacute care also exist. Common to all is that there is a subacute services, and the impact that may have on both group of patients who no longer meet criteria for classifi- the acute and subacute episode. While the report details cation as 'acute', but who still require care in a hospital strategies to address some of these issues, the use of more setting, with the care required being more clinically transparent and validated patient selection criteria for intense and goal directed than is long term care [2-5]. The rehabilitation and other subacute care was not men- issue becomes more difficult when trying to define the tioned. actual boundary between acute care and subacute care, with the situation in Australia being one where, according The interface between acute care and rehabilitation to Eagar and Innes, our 'acute' hospitals "treat a diverse Rehabilitation medicine services within Australia gener- ally have guidelines, either implicit or explicit, that population of patients, many of whom would not meet criteria for classification as acute" [1]. In a later paper, broadly define the types of patients that they will accept Eagar then discusses the boundaries between acute care for an inpatient rehabilitation program. These guidelines and other forms of care, and the development of the sub- will usually include clinical factors, such as the potential acute and non-acute patient casemix classification system for the patient to functionally improve with rehabilitative [6]. therapy, the capacity of the patient to participate in a reha- bilitation program and the degree to which the patient is In Australia, rehabilitation is classified, for casemix pur- medically stable. Other factors may include specific goals poses, as a distinct form of subacute care [7]. The AN- of the patient and/or carers and the patient's premorbid SNAP (Australian National Sub-acute and Non-Acute level of functioning. Patient) classification system, developed in 1997, defined four types of subacute care (Rehabilitation, Geriatric Eval- In practice, while the decision about if, and when, to uation and Management, Psychogeriatric and Palliative transfer a patient to a rehabilitation bed is largely based Care), as well as non-acute (Maintenance) care, with these on the clinical judgement of the assessing rehabilitation definitions being subsequently incorporated into the physician or registrar, the threshold for accepting a patient National Minimum Data Set for Admitted Patient Care for rehabilitation is often influenced by a number of sys- [8]. Within AN-SNAP, a rehabilitation episode of care is tem factors. These may include the degree of 'bed pressure' Page 2 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 in acute care, the availability of the rehabilitation bed, selection. These returns were screened by title, initially for access to diagnostic investigations and/or ongoing medi- relevance to "rehabilitation" or "sub-acute care" and "uti- cal or surgical care or review in the rehabilitation facility, lization review" or "patient selection". Those not evident and the availability of substitutable ambulatory rehabili- from the title were reviewed at abstract level for relevance. tation programs. The references from each of the chosen papers were then reviewed to find other contributory papers. A general Transferring patients from acute care to rehabilitation or Internet search was also conducted, in addition to use of other subacute level of care at the optimal time may have unpublished data from the Australian Rehabilitation Out- significant benefits, both for the patient, as well as for the comes Centre (AROC), University of Wollongong, Aus- health system [10]. Outcomes for patients may be tralia. improved if they are able to commence formal rehabilita- tion earlier and there may also be improvements in over- Results all hospital length of stay and cost of care. In addition, the Selection Criteria for Rehabilitation problem of 'access block' may be helped by the more There is a growing literature on the predictors of rehabili- timely transfer of patients from acute care beds to rehabil- tation outcomes, but selection criteria based only on itation. Conversely, there may be adverse outcomes if those for whom a 'good' outcome can be anticipated will patients are transferred too early. For example, patients deny many patients the opportunity to achieve worth- who remain medically unstable may not be able to be while functional recovery. Wade (2003) notes that pur- safely managed in the rehabilitation facility, unstable chasers of health care services often ask service providers medically conditions could render the rehabilitation to produce selection criteria. These are meant to ensure process less effective, and undue time could be wasted if that only patients likely to benefit from an intervention the patient has to be transferred back to the acute care are referred and accepted, and that all applicable patients facility, or other centre, for diagnostic or medical evalua- are referred. However, in the rehabilitation context, Wade tion. argues that the question of potential benefit is not always clear cut, with the situation being more a case of patients Selection for a formal rehabilitation program is relatively varying along two continua – the likelihood of benefit clear-cut when patients have the new onset of defined and the extent of benefit. He cautions against the use of impairments that are likely to be responsive to rehabilita- public selection criteria, due to the lack of good evidence tion. The situation is less clear when patients have multi- on who is responsive to rehabilitation and the danger of ple morbidities or general debility and this group, which asking untrained staff to apply clinical criteria [11]. is typically older patients, is increasingly occupying acute care wards as the population ages. These patients will Much of the literature on patient factors that predict a often have completed an acute episode, are no longer good rehabilitation outcome centres on specific diagnos- deemed to require acute care by their medical or surgical tic groups, such as stroke or orthopaedic conditions teams, but are not able to be discharged. They often [12,13], but selection for rehabilitation becomes less clear require a period of restorative care and/or complex dis- when patients have multiple morbidities or general debil- charging planning, with the question often becoming ity [14]. This would seem to be an increasing trend in Aus- whether transfer to a formal rehabilitation or subacute/ tralia, as unpublished AROC data show that up to 25% of post-acute program is the best option, or whether the rehabilitation episodes in public hospitals are now for patient is more efficiently managed by remaining in the patients with more general debility or multiple impair- acute care ward until ready for discharge. ments. But there is also anecdotal evidence to suggest that, even with relatively straightforward conditions such as One way of more clearly defining the boundary between elective joint replacement, the utilisation of formal reha- acute care and rehabilitation or other subacute care is to bilitation programs varies widely between the states and develop specific criteria for the identification of patients between the public and private sectors. If this is the case, who no longer meet criteria for classification as 'acute', as a lack of uniform patient selection criteria may be a factor. well as selection criteria and processes for rehabilitation transfer. This suggests a role for utilisation review. There is very little in the literature on formal criteria or procedures for patient selection for rehabilitation and lit- Methods tle evidence to guide the development of such criteria. A Medline search was conducted via Ovid to examine the This deficit has been recognised, with Unsworth (2001) literature on selection for rehabilitation or other subacute [12] noting that objective criteria for the selection of care and the role of utilisation review in these situations. patients for rehabilitation may help acute care clinicians Key words searched included utilization review, rehabili- make more informed discharge planning decisions. tation, physical medicine, subacute care, and patient Page 3 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 Alternatives to physician assessment alone for selection 60%, while between 18% and 48% of admissions to acute for rehabilitation have been explored. For example, mem- care have been reported as inappropriate [5]. Causes of bers of the multidisciplinary rehabilitation team could be inappropriate days of stay include delays in the discharge involved in the selection process. One US study showed process, lack of appropriate post acute care services, delays that rehabilitation outcomes for stroke patients were the in diagnostic tests, and delays in medical and other spe- same if patients were selected by a physiatrist (rehabilita- cialised consultations [22]. Utilisation review tools may tion physician) alone, or by the physiatrist basing their also highlight situations when the patient remains in decision to accept a patient on a nurse practitioner's acute care when the need is for rehabilitation or other sub- assessment [15]. However, the reliability of the clinical acute level of care. judgement of different members of the multidisciplinary rehabilitation team in determining the rehabilitation There can also be significant rates of under-utilisation of potential of patients has been questioned, with the sug- acute care, although there are fewer studies available that gestion that, in the case of older patients, it may be prefer- specifically examine under-utilisation. The amount of able to use a standardised assessment in the initial inappropriate under-utilisation is reported as being much decision regarding patient selection [14]. Other sugges- smaller (less than 4 %) than that for inappropriate over- tions include scoring systems to determine the site of utilisation [23]. Detecting under-utilisation may assist in rehabilitation (home versus post-acute facility) for maintaining clinical quality by the monitoring of prema- patients following total hip replacement [16], or nurse to ture discharge, or care in a sub-optimal setting (for exam- nurse referral for rehabilitation in community hospitals in ple, when patients should be in critical care rather than on the United Kingdom [17]. a general ward, or the premature transfer to rehabilitation of patients who are medically unstable). The issue of selection criteria for other 'subacute' care is less clear than for rehabilitation, probably because defini- Utilisation review became widespread in the United States tions of what constitutes subacute care vary [18]. following the introduction of Medicare and Medicaid [19]. Utilisation review programs have since been Utilisation Review – a brief description adopted in Canada, the United Kingdom, and Europe, but Utilisation review is a method that assesses the appropri- less so in Australia [24,25]. In the US, formal utilisation ateness of the medical or clinical care provided to a review programs have primarily become a tool of payers patient, including the appropriateness of the care setting of health care services to better manage costs. However, and the duration of care [19]. Inappropriate hospital uti- another cited reason for detecting over-utilisation is to lisation includes both over- and under-utilisation. Over- help reduce the iatrogenic risk associated with hospitalisa- utilisation includes the admission to hospital of patients tion [19]. Done concurrently, utilisation review in the who could have been managed, from a clinical perspec- United States is regarded by managed care organisations tive, in a less intensive care setting, or patients who remain as being both a cost containment strategy and a quality in a more acute setting for longer than required [20]. improvement tool [26]. However, outside of the United Under-utilisation occurs when patients do not receive the States, utilisation review tools are seen more as an aid to intensity of care required. facilitate appropriate care, rather than a mechanism for approving or denying care, or the payment for care, for Utilisation review information is derived from the individual patients [27]. patient's medical record, their treating clinical team, or a combination of these sources. Concurrent utilisation When utilisation review was introduced, appropriateness review is the most common, as well as the most useful, as was based primarily on the reviewer's judgement. How- it allows for corrective action to be taken, such as dis- ever, when inter-rater reliability was found to be inade- charge planning or finding a more appropriate care setting quate, even when using physicians who had been selected for the patient. Retrospective reviews are likely to reveal based on their expertise, attention was placed on the higher rates of inappropriate utilisation than concurrent development of specific criteria. The Appropriateness reviews, but this is usually due to information justifying a Evaluation Protocol (AEP) by Gertman and Restuccia [28] level of care being missing or unavailable [21]. was the most widely used tool initially developed. The AEP contained a list of medical and nursing/life services The utilisation review literature consistently demonstrates that were judged to be only available at an acute hospital high levels of inappropriate hospital bed days for patients and a list of patient condition factors that were thought to in acute care, with a large percentage of these days being require the resources of an acute hospital. A patient day for patients who should, according to the review criteria, was considered appropriate if any one of the services or be in a lower level of care. The reported rate of inappropri- conditions was present [19]. ate days of stay in acute care ranges from around 19% to Page 4 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 While utilisation review may be able to detect 'inappropri- care is not just to move patients from one setting to ate' days of stay in acute care, it remains only an assump- another, but to provide more appropriate care. tion that patients will be more appropriately managed in a less acute setting [29]. Further, there is evidence that Published papers outside of the United States indicate only about 50% of unnecessary days in acute care can be that the InterQual Criteria have been predominantly used avoided without additional resources being required, and in Canada and the United Kingdom that the 'inappropriate' days are less resource intensive [5,23,29,32,33,39,40,42,46,47]. DeCoster et al (1997), in and thus less costly [30]. This needs to be considered a retrospective chart review of 3,904 patients in Canada, when determining the cost effectiveness and clinical found that, after one week, 53.2% of patients assessed as appropriateness of utilisation review interventions. In needing acute care on admission no longer required acute addition, because overall hospital length of stay in acute care. Patients 75 years of age accounted for more than care has fallen, it is possible that there may not be as many 50% of bed days, but 74.8% of these bed days were inappropriate days of stay now, compared to the findings regarded as being inappropriate for acute care. The of earlier studies. authors noted that the InterQual Criteria have the advan- tage of being diagnosis independent (thus being unaf- Utilisation review has not been widely reported as a tool fected by diagnostic errors), they are broadly accepted by to assist in the determination of the appropriateness for, physicians as being a reasonable measure of the need for and timing of, transfer to rehabilitation or subacute care. acute care, and they have been externally validated[33]. While a number of utilisation review tools are reported in the literature, very few tools report specific criteria for In another large Canadian study involving 189 acute care determining appropriateness for rehabilitation and suba- hospitals and 13,242 patient discharges, Flintoff et al cute care. The three tools reported to include selection cri- (1998) used the InterQual (Adult Acute) criteria to deter- teria for rehabilitation or sub-acute care are all proprietary mine the level of care most appropriate for admission and products. These are the InterQual Criteria (McKesson Cor- subsequent days of stay [5]. They found that, for all poration), the Managed Care Appropriateness Protocol – admissions, 62.2% were judged by the criteria to be acute, MCAP – which is based on the AEP (The Oak Group), and 19.7% subacute and 18.1% non-acute. Following admis- the Milliman Care Guidelines (Milliman USA). Being pro- sion, acute care was needed on only 27.5% of subsequent prietary, access is not freely available, and there is only days, subacute care on 40.2% of days and non-acute care limited information available on them in the peer on 32.3% of days. Inter-rater reliability in this study was reviewed literature. Of these three, the InterQual Criteria found to be high (kappa ranged from 0.71 to 1.00). is the most widely reported, with about 25 papers or cita- tions in Medline. When used in the United Kingdom, the InterQual Criteria were found to have high reliability and to be valid when The InterQual Criteria – a utilisation review tool there was a presumption that the full range of alternative The InterQual Criteria is a proprietary utilisation review levels of care was available. There were limits to their tool developed in the United States. It has been cited in validity in the UK National Health Service when the alter- published work originating from both the US and outside natives were not available [40], leading to the criticism the US [5,23,24,27,29,31-46]. For example, one US study that, if the alternatives are not available, then utilisation (a retrospective chart review of 858 admissions) used the review is not achieving its aims [48]. However, it is also InterQual subacute criteria to determine the prevalence of suggested that health services planners could use the subacute patients in acute care beds in 43 Veterans Affairs information supplied by the utilisation review process to Hospitals in the US. This study showed that over one third then evaluate the benefits of developing those services of patients (38%) had at least one subacute day during which are not available [47]. their acute admission, with subacute days occurring more frequently for medical (42%) than for surgical admissions Utilisation review, and the various review tools, are not (33%). For those admissions which had any subacute without their critics, with concerns raised about the valid- days, 54% of the days in acute care were classified as sub- ity of the criteria being used [29,36,37,49,50]. The Inter- acute by the InterQual Criteria [31]. This was equivalent Qual tool, along with the AEP, was shown to have to almost 7 bed days per admission. This study also found moderate validity and reliability in the United States in a that patients experiencing subacute days were likely to be study done by Straumwasser in 1990, leading the authors older and sicker. The authors suggest that future studies to conclude that payment should not be denied based on focus on developing targeting criteria that enable clini- the instrument alone, but only if the decision is confirmed cians to prospectively identify patients with subacute care by a physician [41]. Even though criteria such as Inter- needs. The authors also note that the purpose of subacute Qual have been validated against expert panels, the ques- tion arises as to how valid they remain with subsequent Page 5 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 revisions and with changes in clinical practice. Also, valid- ciplinary, goal directed, rehabilitation interventions are ity may vary between institutions, depending upon the afforded to all patients likely to benefit. services available [34]. It should be noted, however, that administered concurrently, the InterQual Criteria allow This leads to a possible role for utilisation review. The for physician over-ride to the outcome of the review if high levels of 'inappropriate' care demonstrated repeat- there are clinical reasons for doing so. edly in international studies using a variety of tools, as well as the limited Australian work available, should not Applicability of utilisation review tools in Australia be ignored in Australia, especially as we grapple with While the concept of utilisation review is likely to be as issues of efficiency and patient safety. Yet formal utilisa- applicable in Australia as it is in other developed coun- tion review has not been embraced. Practiced overseas, tries, the applicability of the specific tools requires formal utilisation review has a role in clinically determining the testing. The AEP has been trialled in an Australian study most appropriate level of care for an individual patient, that audited admission appropriateness to an acute hospi- with some tools also having specific criteria for selection tal, finding that it was both efficient and clinically valid for rehabilitation or other subacute level of care. As well for use in Australian hospitals, with only minor modifica- as being potentially useful at the interface between acute tions required [25]. A further study, also using the AEP, care and other types of care, utilisation review has the found that 15.2% of admission days and 28.7% of days of potential to provide a mechanism by which the processes stay were non-acute. The authors concluded that the AEP of acute care could be improved. It could also assist health was a useful tool for assessing non-acute days of stay, but service planners in determining acute and subacute capac- that inpatient treatment in acute care facilities in Australia ity. may not be as rigidly controlled as in the US, where the tool was developed [51]. Despite these studies, adoption In the absence of well-validated, contemporary, public of the AEP in Australia as a utilisation review tool does not domain tools, there appears little choice but to consider appear to have occurred. proprietary utilisation review tools. The companies pro- moting them claim that the tools enhance efficiency and One of the criticisms of the InterQual Criteria is its patient safety through having evidence-based checklists reduced suitability outside of the United States due to the that support the safe transit of patients through different existence of fewer alternatives to acute care available in levels of care and care settings. However, the tools also other health systems [24]. Also, what constitutes 'acute have their critics and need to be tested against current Aus- care' may also differ, with the US appearing to have tighter tralian practice. Their applicability in the Australian con- definitions than in Australia as to what comprises acute text, where there are less alternate care settings than are care, with these definitions both shaping, as well as being available in the US, and where clinical terminology differs shaped by, utilisation review tools. from the US, also needs to be tested. Conclusion Even if the tools are shown to be applicable in Australia, Tools to inform patient selection decisions, and which it would still need to be shown whether the establishment help to validate care within settings, are of relevance to cli- of formal utilisation review programs is cost effective, and nicians, administrators and policy makers. While suba- whether these US-based systems are transferable to Aus- cute care is an accepted and important component of the tralia without major modifications to the criteria and sup- Australian health care system, it remains poorly defined porting software. The degree of physician acceptance is from a clinical perspective. This lack of clinical definition another very important issue. These are important impedes research into models of subacute care, including research questions that need to be tested and which could how it should best interface with acute care and when and have significant health policy implications for Australia. how it should occur outside of the acute care setting. Competing interests Rehabilitation is a type of subacute care with firmly estab- The author(s) declare that they have no competing inter- lished models of clinical practice and good evidence of ests. efficacy in a range of impairments. Yet patient selection for rehabilitation remains variable, relying predominantly Authors' contributions on clinical judgement and being influenced by system fac- CP undertook the literature review. Both authors drafted tors such as rehabilitation bed availability and pressure on the manuscript and approved the final manuscript. acute care. It is the challenge of our health care system to ensure that the potential gains to be made from multidis- Page 6 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:3 http://www.anzhealthpolicy.com/content/4/1/3 27. Bruce S, DeCoster C, Trumble-Waddell J, Burchill C, De Haney S: References Acuity of Patients Hospitalized for Medical Conditions at 1. Eagar K, Innes K: Creating a Common Language: The Produc- Winnipeg Acute Care Hospitals. Manitoba Centre for Health tion and Use of Patient Data in Australia. 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Australia and New Zealand Health PolicySpringer Journals

Published: Mar 13, 2007

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