Quick Diagnosis Units: avoiding referral”>American Journal of Emergency Medicine (2013) 31, 114-123

Original Contribution

Quick diagnosis units: avoiding referrals from primary care to the ED and hospitalizations^?

Xavier Bosch MD, PhD?, Anna Jordan NP, Alfonso Lopez-Soto MD, PhD

Department of Internal Medicine, Hospital Clinic, Institut d’Investigacio Biomedica August Pi i Sunyer (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain

Received 22 April 2012; revised 15 June 2012; accepted 16 June 2012

Abstract

Purpose: The aim of the present study was to determine whether Quick Diagnosis Units can safely and efficiently avoid emergency department (ED) visits and hospitalizations.

Patients and Methods: We included a prospective cohort of 4170 consecutive patients and a retrospective cohort of 3030 hospitalized patients. Medical records of hospitalized patients were reviewed to determine whether patients were stable enough for outpatient diagnostic workup. We studied primary care (PC) and ED referral patterns in two 25-month periods. Hospital and QDU costs were analyzed by microcosting techniques, and a survey was evaluated using care preferences.

Results: From December 2007 to December 2009, 66% QDU patients were referred from PC to ED and 25% from PC to QDU. From January 2010 to January 2012, 35% QDU patients were referred from PC to ED and 53% from PC to QDU (P b .0001). During the first period, 36% ED patients were referred to QDU and 65% (retrospective cohort) were hospitalized, compared with 64% and 35%, respectively, during the second period (P b .0001). Between 84% and 91% of hospitalized patients were stable for QDU workup, and their hospitalization might have been avoided. Cost per process was EUR3241.11 in hospitalized patients and EUR726.47 in QDU patients. Most patients preferred the QDU model and were reluctant to first being transferred to ED.

Conclusions: An increasing number of PC and ED patients were referred to the QDU. Hospitalizations might have been avoided in at least 84% of patients. Although QDU and hospitalization are similarly effective in reaching a diagnosis, the QDU model incurs fewer costs.

(C) 2013

Introduction

Although National Health Systems in Spain and other countries (eg, UK or New Zealand) provide universal coverage and free primary care (PC) access, about half of hospital admissions occur through the emergency depart- ment (ED) [1,2]. In Spain, PC referrals for diagnostic

^? Funding: None.

* Corresponding author. Tel.: +34 93 2275539; fax: +34 93 2279236.

E-mail address: [email protected] (X. Bosch).

procedures, even in patients with suspected cancer, are subject to long waiting times, and physicians and patients often use the ED as a short cut [1-3]. However, optimal coordination of health care could result in many admissions being elective or “direct” (eg, via outpatients), especially in cancer. The normally progressive nature of the onset of cancer symptoms means that patients should normally access PC first, and well-ordered referral procedures should make EDs unnecessary in most cases [4]. Moreover, hospitalizing patients with suspected cancer for full diagnostic workups may be illogical, especially if the health status is good.

0735-6757/$ - see front matter (C) 2013 http://dx.doi.org/10.1016/j.ajem.2012.06.013

Although some Spanish-language studies published in the 1990s suggested that, in Spain, about 20% of hospitalizations in internal medicine services are inappropriate and patients could be studied on an outpatient basis [5-7]; the delays involved in outpatient diagnostic tests mean that this is often impractical, especially when rapid tests for suspected cancer are required. This has resulted in alternatives being sought, including, among others, short-stay Observation Units (often located adjacent to EDs and accommodating patients requiring brief periods of observation or therapy) [8-10], and, more recently, quick diagnosis units (QDUs), hospital outpatient diagnostic units for patients with suspected Serious disease, especially cancer [11-14].

Quick diagnosis units allow patients to avoid hospitali- zation during diagnosis and permit diagnostic tests to be speeded up and coordinated [15]. The QDUs implemented in Spain in recent years are mainly led by general internists and aim to provide patients with serious disease with the prompt and effective diagnosis and treatment they deserve and require [11,12,14,15].

Quick diagnosis units can be a useful destination for patients first attended in the ED or PC because rapid and easy access to diagnostic tests is ensured, much as if the patient were hospitalized to undergo a diagnostic workup [11,14]. These units may thus overcome the problems inherent to the challenges in coordination between primary and hospital care or between EDs and hospital outpatients to achieve a Prompt diagnosis. Ultimately, referral decisions from PC may facilitate ED overloading, hindering the quality of care.

The primary aim of this study was to determine how QDU can be used safely and efficiently to avoid ED visits and hospitalizations. In particular, we compared over time the referral trends of patients with suspected serious disease, chiefty cancer, from PC and ED to the QDU, and evaluated how many hospitalizations could have been avoided. We also compared the value and cost of QDU and conventional hospitalization during a 65-month study period and analyzed patient preferences for the services provided.

Methods

Study design, study setting, and population

Between December 2007 and January 2012, a longitudinal study was conducted in a prospective cohort of 4170 patients consecutively attended by the QDU of a tertiary university public hospital in Barcelona, Spain, which has 855 acute beds and a reference population of 540 000. The 4170 patients include 2000 patients whose results are already reported [14] and 2170 new patients who were evaluated for 20 additional months. Much of the data used for this analysis was collected at QDU evaluation, and our study hypothesis was formulated before December 2007. Institutional review board approval was obtained before the beginning of patient enrollment.

We also retrospectively analyzed 3030 patients with anemia (n = 851), cachexia-anorexia syndrome (n = 717), febrile syndrome (n = 485), adenopathies and/or palpable masses (n = 428), lung and/or pleural abnormalities (n = 278), and chronic diarrhea (n = 271) admitted to the internal medicine service between September 2006 and January 2012. These patients were chosen randomly (using a computer-generated numbers table) from the 3996 consec- utive patients with these disorders during this time and were compared, without matching, with the 3127 QDU patients with the same conditions (Fig.). Selected patients were identified by both admitting and discharge diagnosis, and each medical record was independently reviewed by 2 authors to determine whether the hospitalized patient was stable enough for outpatient diagnostic workup (ie, whether admission could have been avoided by referring these patients to the QDU). To objectively support clinical judgment, they tabulated physiologic variables including temperature, blood pressure, heart rate, and respiratory rate as well as organ system insufficiency (some variables were in fact used to calculate the Charlson score: see later), and, when available or applicable, the inspired oxygen fraction, partial pressure of oxygen, arterial pH, and the Glasgow coma score. In addition, serum levels of sodium, potassium and creatinine, hematocrit, and white blood cell count were recorded.

The QDU evaluates stable patients with suspected serious

disease who require expeditious workup and who, in many instances, would be admitted to hospital for diagnostic testing. Thus, patients must be physically and mentally capable of attending several outpatient appointments. Serious disease had been identified by us (before QDU implementation) as clinical entities whose constellation of signs and symptoms made a rapid diagnostic workup (and treatment) advisable. Patients with some lung abnormalities such as Pulmonary nodules, receive rapid evaluation by the 1-day unit of the respiratory disease service. However, this does not preclude assessment by the QDU.

All conditions evaluated were chosen according to previously established referral criteria (Table 1). Referring agencies, including the ED; outpatient clinics; and other sources received information on these criteria [14,15].

For each patient, a full diagnostic workup was conducted according to the established protocols for each type of disease process. Definitive diagnoses were made according to the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems [16] by the QDU physician before referral to another service and normally at the last QDU visit.

Patients who required hospitalization or routine outpatient study before the initial QDU evaluation according to the judgment of the QDU or ED physician were excluded. Only clinically stable patients with a relatively good physical status were judged suitable for initial QDU evaluation. To aid objective determination of clinical stability, the QDU physician also took into account the same physiologic and severity data used by the authors who reviewed the medical

4603 patients initially evaluated

433 excluded

4170 patients with a First visit at QDU

43 excluded from furher evaluation:

• Death (12)
• Hospitalization (15)
• Lost (16)

4127 patients with complete QDU evaluation

Hospitalized patients

Anemia (n = 867) Cac-Anor synd (n = 782) Febrile synd (n = 488)

Adenop/masses (n = 429) Lung/pleural abnorm (n = 288) Chronic diarrhea (n = 273)

Anemia (n = 851) Cac-Anor synd (n = 717)

Febrile synd (n = 485) Adenop/masses (n = 428) Lung/pleural abnorm (n = 278) Chronic diarrhea (n = 271)

Fig. Flow diagram of QDU patients’ enrollment and comparison groups. Cac-Anor, cachexia-anorexia syndrome; Febrile synd, febrile syndrome; Adenop/masses, adenopathies and/or palpable masses; Lung/pleural abnorm, lung and/or pleural abnormalities.

records of hospitalized patients (see previous discussion). If a patient was referred from ED to the QDU on the basis of the ED physician’s criterion but the QDU physician judged that an initial QDU evaluation was not appropriate, the QDU physician’s criterion prevailed. Furthermore, if patients’ clinical status deteriorated during the QDU evaluation period, they were referred to the ED and/or hospitalized to continue the study.

Measurements

In addition to the previously mentioned variables, we prospectively recorded the following: reason for consulta-

tion, referral source, waiting time for initial visit, date and number of visits, waiting time between appointments, time to diagnosis (time from the first visit to ultimate diagnosis), date, type and number of complementary examinations, definitive diagnosis, and destination. We also evaluated the Charlson Comorbidity Index, which is reliable and valid for use with our study population [17].

The same factors were recorded for hospitalized patients (retrospective cohort), except for waiting time to the first visit, number and date of visits, waiting times between visits, and time to diagnosis. In addition, we recorded the mean hospital stay for each patient.

Before setting up the QDU, PC providers were educated about the existence and capabilities of the QDU and

The referral patterns from ED to the QDU (n = 1876) vs hospitalization (n = 2031) according to the 6 main reasons for consultation detailed previously were also quantified and compared using the same periods.

Table 1 QDU referral criteria

Criteria Considerations

Anemia Hemoglobin level b8 g/L, with or without symptoms

Cachexia-anorexia syndrome

Febrile syndrome

Adenopathies and/or palpable masses Unexplained severe abdominal pain

Chronic diarrhea Severe constipation

(recent onset) Rectorrhagia Jaundice

Lung and/or pleural abnormalities

Unexplained anorexia, asthenia, and loss of >=10% of body weight during at least

6 wk

Fever of unknown origin with a temperature >=38?C for at least 2 wk

-

-

Loose stools for at least 4 wk

-

Unexplained dyspnea Dysphagia

Ascites and/or anasarca Bone pain with suspicion

of bone malignancy Arthritis

-

-

Mainly suggestive of neoplasm. After excluding obvious causes such as community-acquired pneumonia or residual lesions -

-

-

-

Hemogram abnormalities suggestive of primary hematologic disorder

Splenomegaly and/or hepatomegaly

Other than degenerative osteoarthritis

-

Monoclonal paraprotein band with or without suspicion of multiple myeloma

neurologic disorders (central, spinal, and Peripheral nervous system)

Absence of previously known liver disease or hematologic disorder (eg, chronic myelogenous leukemia)

-

Other than cerebrovascular disease, delirium and dementia, Movement disorders, sleep disorders, dizziness and vertigo, and Neuropathic pain

Includes Horner syndrome

Both QDU and hospital costs were analyzed using a basic microcosting study, in which resource use and unit costs of direct and indirect cost elements were identified for the 6 main reasons for consultation (Table 2). The microcosting method is commonly regarded as a benchmark scheme for pricing hospital services because it determines all applicable cost components at a meticulous level [18-20]. The approach allows costs per patient to be determined and provides insight into patient subgroups that might account for a large portion of the total allocation. Microcosting has been used in other areas for diverse intentions such as the comparison of 2 surgical procedures within a particular center [21] and, worldwide [22], in-depth cost estimations of screening techniques for ensuing application in Cost-effectiveness analyses [23]. In our analysis, direct cost fractions comprised diagnostic tests (eg, imaging and laboratory services), consumables (medications and disposables), QDU visits, and inpatient stay. This information was available per individual patient, obtained from hospital information systems (bottom-up microcosting). Indirect cost parts mainly referred to overheads (eg, maintenance and general expenses). We calculated the number of QDU visits and the cost per visit and per process (from admission to discharge). Likewise, the length of stay and cost per day of hospitalization and per process were calculated for all inpatients admitted to our 2 internal medicine wards.

The QDU has a dedicated consulting room and patient/ family waiting room. It is open for 5 hours from Monday to Friday and is staffed by a consultant in internal medicine and a full-time nurse, with part-time support from 2 secretaries. In addition, consultations are provided by specialists from other services as required. The internal medicine wards have 25 beds each, which are staffed by 2 consultants and 4 resident physicians, a nurse supervisor and 3 teams of 3 full-time

received training on the referral criteria. To determine whether our QDU had an impact on PC referrals over time, we studied the referral patterns in two 25-month periods: December 2007 to December 2009 (n = 1963 patients) and January 2010 to January 2012 (n = 2207 patients). We quantified the number of patients referred directly to the QDU and those who, after PC referral to the ED, were transferred to the QDU.

Table 2 Main reasons for consultation of QDU patients

Other Total

120 (2.9%)

4170

Reasons for consultation	n
Anemia	878 (21.1%)
Cachexia-anorexia syndrome	732 (17.6%)
Febrile syndrome	489 (11.7%)
Adenopathies and/or palpable masses	466 (11.2%)
Lung and/or pleural abnormalities	282 (6.8%)
Chronic diarrhea	280 (6.7%)
Abdominal pain	255 (6.1%)
Ascites	189 (4.5%)
Rectorrhagia	130 (3.1%)
Jaundice	127 (3.0%)
Dysphagia Arthritis	123 (2.9%) 99 (2.4%)

registered nurses plus 2 nursing assistants, and a full-time secretary. All staff salaries were included in the cost analysis. Costs were assessed using our hospital costs and not overall Spanish National Health Service costs. We included only costs generated during QDU evaluation or hospital admission; the costs of the referring agency, such as PC or the ED, were excluded. Costs were adjusted for inftation into 2012 Euros, the last year of data collection, using the

standard Consumer Price Index.

One month after QDU evaluation, we conducted a telephone survey in 300 randomly selected QDU patients evaluated between December 2010 and December 2011, based on a questionnaire previously used by our service [14]. Randomization was made using a computer-generated num- bers table. Verbal consent was sought by telephone and the conversation recorded to ensure privacy. The hospital ethics committee approved the survey. The survey consisted of various multiple-choice questions and evaluated care prefer- ences (QDU vs hospitalization) and type of referral (QDU vs ED) in the future. One month after discharge, we also surveyed a random sample of 200 patients (also selected using a computer-generated numbers table) from the retrospective cohort, admitted between August 2010 and December 2011, and asked about care preferences (hospitalization vs QDU) and preferred type of referral (ED vs QDU and PC) in the future.

Statistical analyses

We calculated the mean, SD, median, and 25% and 75% percentiles for normally distributed and skewed continuous variables, respectively. The ?2 test or Fisher exact test were used to compare categorical variables as required. The Student t test was used to assess normally distributed continuous variables, and the Mann-Whitney U nonpara- metric test was used for nonnormally distributed variables. A level of P = .05 was established as statistically significant. The statistical analysis used the SAS v.9.1 statistical package (SAS, Cary, North Carolina).

Results

We initially evaluated 4603 patients; of these, 433 were excluded due to associated conditions, severity indicators, or physiologic indicators that made QDU management inap- propriate. Of the 4170 patients finally evaluated, 48% (n = 2001) were male, and the mean age (SD) was 61 (17.93) years. All patients were judged stable enough for an initial QDU assessment. Sixteen patients were lost to follow-up, 15 were hospitalized, and 12 died during the QDU evaluation before reaching a diagnosis (Fig.).

With regard to the 3030 hospitalized patients, the medical record review by the authors concluded that 94 (11%) of 851 patients with anemia, 72 (10%) of 717 with cachexia-

anorexia syndrome, 68 (14%) of 485 with febrile syndrome,

39 (9.1%) of 428 with adenopathies and/or palpable masses,

45 (16.2%) of 278 with lung and/or pleural abnormalities, and 35 (13%) of 271 with chronic diarrhea were not suitable for initial QDU evaluation, thus requiring hospitalization. In other words, hospitalization might have been avoided in between 84% and 91% of hospitalized patients.

Table 2 shows the primary reasons for consultation in QDU patients. The referral sources of QDU and hospitalized patients and the waiting times for the first visit or admission, respectively, are shown in Table 3.

From December 2007 to December 2009, 1304 (66%) of 1963 QDU patients were referred from PC to the ED and 496 (25%) of 1963 QDU patients from PC to the QDU. In contrast, from January 2010 to January 2012, 774 (35%) of 2207 QDU patients were referred from PC to the ED and 1172 (53%) of 2207 QDU patients from PC to the QDU (P b .0001).

Analysis of the referral patterns from the ED over time for the 6 main reasons for consultation showed significant differences in the number of patients referred to the QDU vs hospitalization. From December 2007 to December 2009, 683 (36%) of 1876 patients were referred from the ED to the QDU, and 1320 (65%) of 2031 patients (retrospective cohort) were directly hospitalized from the ED. In contrast, from January 2010 to January 2012, 1193 (64%) patients were referred from the ED to the QDU and 711 (35%) patients were hospitalized from the ED (P b .0001).

The most common diagnoses were cancer in 1264 (30.3%) of 4170 patients and iron-deficiency anemia not related to malignancy in 792 of (19%) 4170 patients. The most frequent malignancies were Colorectal cancer and lymphoma: the main reason for iron-deficiency anemia was chronic gastrointestinal bleeding (325/4170 [7.8%] patients; Table 4).

Each QDU patient had a mean of 3.13 visits and a mean (SD) time to diagnosis of 8.9 (2.35) days. The mean (SD)

Table 3 Referral sources and waiting times of QDU and hospitalized patients

time ^b (days) (1.3)

PHC, primary health care center.

^a Of the 2335 patients referred by the ED, 89% (n = 2078) were first referred to the ED from PHC, and the remaining patients attended the ED voluntarily.

^b Waiting time for the first QDU visit or admission. Data expressed as range and mean.

(4.9) (2.8)

	ED	PHC	Other hospital services	Other sources
QDU n (%)	2335	1668	84 (2)	84 (2)
	(56) a	(40)
Waiting	0-3.5	1-7
time b (d)	(1.9)	(3.6)
Hospitalized n (%)	2666	91 (3)	212 (7)	61 (2)

patients		(88)
	Waiting	0-2	3-7	2-4

Diagnosis	n
Malignant neoplasm	1264	(30.3%)
Colorectal	317	(7.60%)
Lymphoma	312	(7.48%)
Gastric	95	(2.28%)
Lung	133	(3.19%)
Pancreatic	198	(4.75%)
Other hematologic a	66	(1.58%)
Breast	40	(0.96%)
Head and neck	4	(0.09%)
Gynecologic	12	(0.29%)
Prostate	8	(0.19%)
Esophageal	4	(0.09%)
Renal cell	38	(0.91%)
Hepatocellular carcinoma	16	(0.38%)
Soft tissue sarcomas	8	(0.19%)
Pleural mesothelioma	2	(0.05%)
Seminoma	1	(0.02%)
UPM b	10	(0.25%)
Iron-deficiency anemia	792	(19%)
Digestive	325	(7.79%)
Unknown cause	182	(4.36%)
Heavy menstrual bleeding	132	(3.17%)
Multifactorial anemia	153	(3.67%)
Megaloblastic anemia	77	(1.85%)
Chronic liver disease	131	(3.14%)
Irritable bowel syndrome	177	(4.24%)
Inftammatory bowel disease	38	(0.91%)
Benign gastroduodenal disorder	157	(3.76%)
Esophagitis	83	(1.99%)
Gallbladder disease	47	(1.13%)
Acute Viral illness	80	(4%)
Depressive disorder	277	(6.64%)
Reactive adenitis	158	(3.79%)
Autoimmune rheumatic disease	56	(1.34%)
Nonmalignant lung and/or pleural disease	147	(3.53%)
Undiagnosed	219	(5.25%)
a Leukemia, myelodysplastic syndrome, and multiple myeloma. b Unknown primary-site malignancy.

hospital stay of the retrospective cohort of hospitalized patients was 8.76 (2.18) days.

Table 4 Main diagnoses of QDU patients

Table 5 shows the destinations of QDU and hospitalized patients, after diagnosis and hospital discharge, respectively. During the QDU evaluation, 125 (3%) patients were referred to the ED due to complications of the process under

Table 5 Destinations of QDU and hospitalized patients

PHC

QDU

Outpatients Admission Palliative

care

n 2559 1444 (35) 124 (3)

(%) (62)

Hospitalized patients

n 1697

939 (31)

394 (13)

(%) (56)

PHC, primary health care center.

evaluation (eg, worsening of anemia). Overall, 15 patients were hospitalized and 12 died. In the remaining cases, the situation was resolved and the QDU evaluation proceeded. Hospitalization in those 15 patients was due to rapid worsening of their condition in 11 and unrelated factors in

1. Death was due to unexpected sudden death in 8 and acute severe conditions (pulmonary embolism in 2, probable Aspiration pneumonia in 1, and shock of unknown origin in 1) occurring shortly after ED transfer. Review of these 27 cases showed that, at least initially, they were stable enough to start QDU evaluation.

The main characteristics of QDU and hospitalized patients according to the 6 main motives for consultation are shown in Table 6. Patients with anemia and chronic diarrhea who were referred to QDUs had a significantly lower ager than did hospitalized patients with the same diagnoses (65.3 vs 76. 3 and 50.1 vs 62.3, respectively; P b .0001 in both cases). No other parameters were significantly different.

Table 7 shows the cost per stay, per visit, and per process for hospitalized and QDU patients with the 6 principal reasons for consultation. The mean cost per process was EUR3241.11 in hospitalized patients and EUR726.47 in QDU patients.

The response rate to the survey was 96% among QDU patients. If further diagnostic tests were required, 88% of these patients would prefer the QDU care model to hospitalization. In addition, 97% would prefer direct PC referral to the QDU without the need to attend the ED first. Finally, 182 (96%) of the 190 patients from the retrospective cohort who responded to the survey would prefer the QDU care model to hospitalization should the diagnostic workup be performed again, and 98% would prefer direct hospitalization from the QDU or PC without attending the ED first.

Discussion

We describe a novel system of expedited outpatient care to help alleviate crowding in EDs and Inpatient units. Transferring patients requiring acute access to emergency diagnostics to the ED is a common practice in the United States and other countries [2,4]. Emergency department visits frequently culminate in hospitalization after laboratory tests, radiographic studies, and ED consults from a variety of services. Emergency department visits for patients with complex medical conditions are time consuming, lead to Prolonged ED stays, and contribute to ED overcrowding. The establishment of rapid admission units and observation units is commonplace and well reported [8-10,24-26]. However, QDUs are unique in that they are specifically aimed at providing care for patients perceived to require a well-orchestrated setup of diagnostic tests and specialist consults, mainly related to cancer.

Table 6 Main characteristics of QDU and hospitalized patients

Anemia	QDU (n = 867)	Hospitalized (n = 851)	P
Age (y)	65.25 (16.44), 73 [61-78]	76.33 (14.25), 78.34 [73-84]	b.0001
Female	441 (51%)	435 (51.1%)
Male	426 (49%)	416 (48.9%)
Time to diagnosis/HS (d)	7.88 (1.45), 8 [6.5-9.5]	8.88 (3.26), 8.3 [8-11]	NS
Hemoglobin	76.25 (21.3), 75 [53-82]	75.24 (19.8), 77 [63-77]	NS
Anemic syndrome	811 (93.5%)	813 (95.5%)	NS
Transfusion	601 (69.3%)	604 (71%)	NS
Charlson Com In.	1.4 (2.2), 1.6 [1-1.4]	1.6 (2.3), 1.7 [1-2.1]	NS
Main diagnosis	Iron-deficiency anemia/colon cancer	Iron-deficiency anemia/colon cancer
Cachexia-anorexia syndrome	QDU (n = 782)	Hospitalized (n = 717)	P
Age (y)	67.42 (17.47), 68 [61-76]	69.73 (16.34), 72.5 [68-78]	NS
Female	390 (49.9%)	356 (49.7%)
Male	392 (50.1%)	361 (50.3%)
Time to diagnosis/HS (d)	10.19 (3.28), 10 [9-12]	10.62 (3.55), 11 [10-12]	NS
Weight loss (kg)	9.9 (2.31), 10 [9-11]	9.7 (1.84), 10 [9-10.5]	NS
Charlson Com In.	1.2 (2.0), 1.2 [1-1.3]	1.3 (2.2), 1.3 [1-1.5]	NS
Main diagnosis	Pancreatic cancer	Pancreatic cancer
Febrile syndrome	QDU (n = 488)	Hospitalized (n = 485)	P
Age (y)	48.38 (14.67), 51 [43-56]	49.15 (15.07), 52 [47-57]	NS
Female	249 (51%)	246 (50.7%)
Male	239 (49%)	239 (49.3%)
Time to diagnosis/HS (d)	8.56 (2.31), 9 [8-10.3]	9.07 (3.62), 10.1 [9-11.2]	NS
Mean duration of fever (d)	20.97 (12.10), 23 [20-25.5]	19.88 (11.12), 22 [19-26]	NS
Charlson Com In.	1.1 (1.4), 1.3 [1.0-1.5]	1.2 (1.7), 1.4 [0.8-1.6]	NS
Main diagnosis	Lymphoma	Lymphoma
Adenopathies and/or palpable masses	QDU (n = 429)	Hospitalized (n = 428)	P
Age (y)	59.25 (18.74), 60.11 [56-61.5]	60.28 (14.55), 63 [57-64]	NS
Female	219 (51%)	215 (50.2%)
Male	210 (49%)	213 (49.8%)
Time to diagnosis/HS (d)	8.03 (2.62), 8 [7-8.5]	7.99 (3.44), 9 [7-10]	NS
Charlson Com In.	1.2 (1.2), 1.3 [0.9-1.3]	1.3 (1.9), 1.7 [1.3-1.8]	NS
Main diagnosis	Lymphoma	Lymphoma
Lung and/or pleural abnormalities	QDU (n = 288)	Hospitalized (n = 278)	P
Age (y)	61.24 (19.27), 61.76 [58-62.5]	61.76 (16.64), 62.5 [59-63]	NS
Female	101 (35.1%)	103 (37.1%)
Male	187 (64.9%)	175 (62.9%)
Time to diagnosis/HS	7.93 (2.83), 8 [7.5-8.7]	7.96 (4.14), 9 [8-9.5]	NS
Charlson Com In.	1.0 (1.1), 1.2 [0.7-1.2]	1.1 (1.8), 1.6 [1.2-1.7]	NS
Main diagnosis	Lung cancer	Lung cancer
Chronic diarrhea	QDU (n = 273)	Hospitalized (n = 271)	P
Age (y)	50.11 (15.77), 52 [44-57]	62.31 (16.43), 71 [60-74]	b.0001
Female	138 (50.5%)	136 (50.2%)
Male	135 (49.5%)	135 (49.8%)
Time to diagnosis/HS (d)	9.21 (2.78), 10 [9-10.8]	9.37 (3.55), 10.4 [9-11.1]	NS
Charlson Com In.	1.2 (1.3), 1.4 [1.1-1.6]	1.3 (1.7), 1.5 [0.9-1.5]	NS
Main diagnoses	IBS/IBD	IBS/IBD
Data expressed as mean (SD) and median [25th-75th percentiles]. HS, length of stay; Charlson Com In., Charlson comorbidity index; NS, nonsignificant; IBS, irritable bowel syndrome; IBD, inftammatory bowel disease.

Staff salary b	263.26 c	61.38	2306.16	192.12
Complementary tests b	55.47	161.31	485.92	504.90
Stock b	17.18	0.88	150.50	2.75
Consumables b,d	1.19	0.17	10.42	0.53
Medical gases	0.03	NA	0.26	NA
Catering	15.84	NA	138.76	NA
Cleaning	8.68	4.52	76.03	14.15
Laundry	5.15	0.27	45.11	0.85
Maintenance	0.49	0.32	4.29	1.00
Communications	0.29	0.24	2.54	0.75
Mail	0.00	0.00	0.00	0.00
Depreciation	2.41	1.31	21.11	4.10
Travel e	NA	1.7	NA	5.32
Total	369.99	232.1	3241.11 (SD, 915)	726.47 (SD, 617)
Mean stay: hospitalization, 8.76 days; QDU, 3.13 visits. NA, applicable, a Admission to discharge episode. b Direct costs. c Salary of all the staff for a single stay of 12.5 patients. d Includes blood transfusions. e Includes costs of Patient transportation to and from the QDU and costs of accompanying personnel.

We have observed a change in the PC referral pattern over time, with an increasing number of patients being directly referred to the QDU rather than the ED. The referral patterns from the ED also changed during the two 25-month periods for the 6 main reasons for consultation, with an increasing number of patients being directly referred to the QDU rather than being admitted. In addition, most QDU and hospitalized patients were reluctant to be transferred to the ED as an intermediate step between the primary referral source and the ultimate destination.

Table 7 Costs (EUR) of QDU and hospitalization

Hospitalization 1-d stay

QDU i

visit

Cost per process ^a

Hospitalization

QDU

The increase over time in referrals to the QDUs from both PC and ED physicians was mainly driven, in our opinion, by education and serial presentation (at least once a year) of results to these physicians. Our extended results also confirm previous data that QDU and hospitalization are similarly effective in reaching a definitive diagnosis in patients with potentially serious diseases, especially cancer, but that the QDU model seems to incur fewer costs [14,15]. The wide cost disparity between QDU and hospitalized patients shown by our results can be ascribed mostly to staff costs and the hours worked and to the fixed costs of hospitalization.

Hospitalization might have been avoided in between 84% and 91% of hospitalized patients, which also has obvious economic repercussions. These patients could have been safely and more inexpensively evaluated in the QDU setting, suggesting that admissions should be principally reserved for patients with Acute conditions such as, for example, those with pneumonia or acute exacerbations of chronic obstruc- tive pulmonary disease. However, QDU patients must be sufficiently “healthy” to attend outpatient visits, whatever the disease studied and however serious it may be. In addition,

for the QDU to function satisfactorily, excellent coordination with PC is necessary.

Although the Spanish PC system is universal and seen positively by users, health care costs are ever-increasing, due to aging, an increasing population (including immigrants), and increasingly costly health technologies. Both the central government and the regions (which control the health system) are searching for ways to reduce deficit spending, whereas customer dissatisfaction is growing, especially with respect to waiting times and user information. Furthermore, health care professionals have criticized staffing levels, organization, and payment levels for PC physicians, as related to European standards [1,27]. Spain has almost twice as many specialist physicians as PC physicians, although specialist access is mainly through PC or the ED [27-29]. The increasing number of patients attending the ED directly rather than accessing PC clearly shows that the system is not functioning correctly [30]. Among the many reasons for this, Borkan et al [27] suggested a failure of the health care system itself, including patient education, which must be resolved to bring down costs and improve performance. In addition to ED overcrowding, using EDs for inappropriate conditions may hamper the value of care that severely and/or acutely ill patients merit (ie, those needing hospitalization) [1,3,4].

Overall, the waiting times to the first QDU visit were

significantly longer for PC referrals compared with ED referrals (3.6 days vs 1.9 days; Table 3). Patients are referred directly by the ED for the first QDU visit. However, for PC referrals, to date, PC physicians must first send a formal written request via fax or e-mail, which is read and approved by the QDU physician, thus resulting in a slight delay in the

first visit. Our preliminary data show that, in general, PC referrals are less likely to fulfill QDU criteria compared with ED referrals. Although we are currently analyzing how to speed up PC referrals so that patients can be referred directly from PC centers without intermediate filters, we are also working on methods of improving awareness of referral criteria among PC physicians. Improving PC referrals to the QDU will probably depend mainly on the design, develop- ment, and introduction of electronic health records. In the last

15 years, all Spanish regions have worked to introduce computerized health records and unified databases [31]. By 2007, 97% of PC consultations used electronic records and 64% of PC centers had online patient referral tools [27]. Regions such as Andalusia and Catalonia are well advanced in the integration of all health and administrative records including appointments into one system accessible to both health professionals and patients [27].

One limitation of our study that makes it difficult to judge

whether the use of QDUs alleviates ED crowding is the heterogeneity of patients included. Although a more compelling argument in favor of the QDU model might be made by selecting a single clearly defined entity, when analyzing the main reasons for consultation and correspond- ing final diagnoses, no significant differences other than age in patients with anemia and chronic diarrhea were observed between QDU and hospitalized patients (Table 6). These variations may be a sign of the ED and/or QDU physicians’ resolution to leave out 93 and 32 patients, respectively, from the first assessment. A separate evaluation of these patients revealed an older age (73.7 and 59.8 years, respectively) and more comorbidities (Charlson index, 2.1 and 1.8, respec- tively; data not shown). Another limitation is the lack of randomization between the QDU and inpatient arms, which might be sidestepped by a randomized study assessing 2 prospective cohorts; however, admission and exclusion from QDU assessment would likely be needed for some patients with an impaired clinical situation and/or significant comorbidities. That our 2 cohorts were not individually matched 1:1 is another limitation. However, we primarily intended to compare all consecutive QDU patients with patients hospitalized for the same reasons in the same period. Most hospitalized patients had essentially similar physio- logic and severity variables to QDU patients, with our review showing that between 84% and 91% of hospitalized patients were stable for outpatient workup and that hospitalization might have been avoided. Likewise, all QDU patients were stable enough for an initial QDU evaluation according to the QDU physician’s evaluation. In addition, as mentioned, except for age in patients with anemia and chronic diarrhea, no differences were found when comparing the main characteristics of QDU and hospitalized patients according to the 6 main reasons for consultation. On the other hand, although the review of cases was conducted according to clinical parameters, we cannot exclude the possibility of some subjectivity when determining which hospitalized patients could have been worked up safely in the QDU.

Finally, because we did not describe the course of patients after an Initial diagnosis was reached, we do not have an accurate picture of the overall costs involved.

Conclusions

In conclusion, patterns of PC referrals are changing over time, with more direct referrals to the QDU and less to the ED. Similarly, ED physicians are increasingly using the QDU as an alternative to hospitalization, which may provide a more rational use of Hospital beds, which is vital at a time of economic constraint. Our results suggest that hospitalization might have been avoided in at least 84% of patients who were suitable for QDU study. A strong Referral program that uses a QDU may contribute to cost savings, enhance patient satisfaction, decrease hospital admissions, and lead to more timely treatment for patients with defined symptoms. Surveys of Representative samples of PC and ED physicians about their perceptions of QDU performance may provide useful insights into its strengths and limitations.

References

1. Martin-Moreno JM, Alonso P, Claveria A, Gorgojo L, Peiro S. Spain: a decentralised health system in constant flux. BMJ 2009;338:b1170.
2. Beatty S, Stevens W, Stevens G, Kolbe J, Cox B. Lung cancer patients in New Zealand initially present to secondary care through the emergency department rather than by referral to a respiratory specialist. N Z Med J 2009;122:33-41.
3. Porta M, Fernandez E, Belloc J, Malats N, Gallen M, Alonso J. Emergency admission for cancer: a matter of survival? Br J Cancer 1998;77:477-84.
4. Sikka V, Ornato JP. Cancer diagnosis and outcomes in Michigan EDs vs. other settings. Am J Emerg Med 2012;30:283-92.
5. Matorras P, de Pablo M, Otero L, Alonso F, Daroca R, Diaz-Caneja N. Adecuacion de los ingresos en un servicio de Medicina Interna de un hospital de tercer nivel. Med Clin (Barc) 1990;94:290-3.
6. Gonzalez-Montalvo JI, Baztan JJ, Rodriguez-Manas L, San Cristobal E, Gato A, Ballesteros P, et al. Ingreso hospitalario urgente en servicios medicos: causas, justificacion, factores sociales y sus diferencias en funcion de la edad. Med Clin (Barc) 1994;103:441-4.
7. Rodriguez-Vera FJ, Alcoucer MR, Rodriguez FJ, Camacho T, Colchero J, Pujol E. Adecuacion de los ingresos en un servicio de Medicina Interna de un hospital de segundo nivel. An Med Interna (Madrid) 1999;16:277-80.
8. Daly S, Campbell DA, Cameron PA. Short-stay units and observation medicine: a systematic review. Med J Aust 2003;178:559-63.
9. Scott I, Vaughan L, Bell D. Effectiveness of acute medical units in hospitals: a systematic review. Int J Qual Health Care 2009;21:397-407.
10. Lucas BP, Kumapley R, Mba B, Nisar I, Lee K, Ofori-Ntow S, et al. A hospitalist-run short-stay unit: features that predict length-of-stay and eventual admission to traditional inpatient services. J Hosp Med 2009;4:276-84.
11. Capell S, Comas P, Piella T, Rigau J, Pruna X, Martinez F, et al. Quick and early diagnostic outpatient unit: an effective and efficient model of care. Five years experience. Med Clin (Barc) 2004;123:247-50.
12. Rubio-Rivas M, Vidaller A, Pujol I Rarriols R, Mast R. Rapid diagnosis unit in a third level hospital. Descriptive study of the first year and a half. Rev Clin Esp 2008;208:561-3.
13. Kendall MJ, Toescu V, Wallace DMA. QED: quick and early diagnosis. Lancet 1996;348:528-9.
14. Bosch X, Jordan A, Coca A, Lopez-Soto A. Quick diagnosis units versus hospitalization for the diagnosis of potentially severe diseases in Spain. J Hosp Med 2012;7:41-7.
15. Bosch X, Aibar J, Capell S, Coca A, Lopez-Soto A. Quick diagnosis units: a potentially useful alternative to conventional hospitalisation. Med J Aust 2009;191:496-8.
16. World Health Organization. International Classification of Diseases (ICD). 10th revision (ICD-10). http://www.who.int/classifications/ icd/en/2012 Accessed 3 June.
17. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: develop- ment and validation. J Chronic Dis 1987;40:373-83.
18. Drummond MF, Sculpher MJ, Torrance GW, et al, editors. Methods for the economic evaluation of health care programmes. New York (N.Y.): Oxford University Press; 2005.
19. Tan SS, Rutten FF, van Ineveld BM, Redekop WK, Hakkaart-van Roijen L. Comparing methodologies for the cost estimation of hospital services. Eur J Health Econ 2009;10:39-45.
20. Finkler SA, Ward DM, Baker JJ, editors. Essentials of cost accounting for health care organisations. 3rd edition. New York (N.Y.): Aspen Publishers; 2007.
21. Long KH, Bannon MP, Zietlow SP, Helgeson ER, Harmsen WS, Smith CD, et al. A prospective randomized comparison of laparo- scopic appendectomy with open appendectomy: clinical and economic analyses. Surgery 2001;129:390-400.
22. Schreyogg J. A micro-costing approach to estimating hospital costs for appendectomy in a cross-European context. Health Econ 2008;17(1 Suppl):S59-69.
23. Henry SG, Ness RM, Stiles RA, Shintani AK, Dittus RS. A cost analysis of colonoscopy using microcosting and time-and-motion techniques. J Gen Intern Med 2007;22:1415-21.
24. Basic D, Khoo A. Admission variables predicting short lengths of stay of acutely unwell older patients: relevance to emergency and medical short-stay units. Aust Health Rev 2009;33:502-12.
25. Peacock 4th WF, Young J, Collins S, Diercks D, Emerman C. Heart failure observation units: optimizing care. Ann Emerg Med 2006;47: 22-33.
26. McD Taylor D, Bennett DM, Cameron PA. A paradigm shift in the nature of care provision in emergency departments. Emerg Med J 2004;21:681-4.
27. Borkan J, Eaton CB, Novillo-Ortiz D, Rivero Corte P, Jadad AR. Renewing primary care: lessons learned from the Spanish health care system. Health Aff (Millwood) 2010;29:1432-41.
28. Duran A, Lara JL, van Waveren M. Spain: health system review. Copenhagen: European Observatory on Health Systems and Policies. Health Syst Transit 2006;8(4).
29. Ministry of Health and Social Policy, Health Information Institute. National health system of Spain. Madrid: The Ministry; 2012. http:// www.msps.es/en/organizacion/sns/libroSNS.htm. Accessed 3 June.
30. Ministry of Health and Consumer Affairs. Spanish National Health System. Madrid: The Ministry; 2012. http://www.msc.es/en/ estadEstudios/estadisticas/docs/FOLLETO-BAJA-INGLES.PDF. Accessed 3 June.
31. Red.es, Health Departments of all Autonomous Regions, INGESA (Ceuta and Melilla), Ministry of Health and Consumer Affairs. ICT in the national health system: the Healthcare Online Programme. Madrid: Red.es; 2012. http://www.epractice.eu/files/media/media2623.pdf.

Accessed 3 June.