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PubMed2003

The ineffectiveness of retrospective drug utilization review.

As policymakers debate adding a prescription drug benefit to Medicare, they must also seek ways to promote cost-effective use of drugs and minimize inappropriate prescribing. For more than a decade, all state Medicaid agencies and most private insurers have used computerized drug utilization review (DUR) programs to prevent or rectify potential prescribing errors. DUR can be retrospective, in which claims data are reviewed to identify patterns of drug use, or prospective, in which prescriptions are reviewed before a drug is dispensed. This Issue Brief summarizes a landmark study that suggests that retrospective DUR has had no measurable effects on outpatient drug use or clinical outcomes in the Medicaid program.

Drug Utilization Review↗
PubMedDate not supplied

Advantages of local UR (utilization review).

Physicians recognize that there is a certain amount of waste and inefficiency in the current health care delivery system. They also realize that everyone stands to gain if the areas of waste can be identified and eliminated. Statistics consistently reveal that a small percentage of providers and patients are responsible for a very large percentage of inappropriate care. A properly structured utilization review program is a reasonable way to rid the delivery system of this waste.

Decision Making↗
PubMed1990

Reliability and validity of utilization review criteria. Appropriateness Evaluation Protocol, Standardized Medreview Instrument, and Intensity-Severity-Discharge criteria.

A study was conducted to assess the reliability and validity of the Appropriateness Evaluation Protocol (AEP), the Standardized Medreview Instrument (SMI) and the Intensity-Severity-Discharge criteria set (ISD), three utilization review instruments used to determine whether inpatient care is required. Reliability and validity were assessed for retrospective application of these instruments to charts of a sample of 119 medical cases from 21 hospitals in the state of Michigan. The reliability of each instrument was determined by having the instrument applied by two different nurse reviewers to each hospital record. Results indicated that the AEP and ISD were moderately reliable, while the SMI had low reliability. The validity of each instrument was tested by comparing the judgments of nurse reviewers using the instruments with the judgment of a panel of physicians. The AEP and ISD were found to be moderately valid and the SMI was found to have low validity. Results suggested that the SMI should not be used. The modest level of validity of the other two instruments suggests that payment should never be denied on the basis of the instrument alone. Payment should be denied only if a physician confirms the judgment based on the instrument that inpatient care was not required.

Health Maintenance Organizations↗
PubMed1989

Office quality assurance and utilization review for the beginning oral and maxillofacial surgeon.

For the senior oral and maxillofacial surgery resident, the task of establishing a well functioning private practice is filled with great challenges and opportunities. The purpose of this article is to make the beginning oral and maxillofacial surgeon aware of the concepts of quality assurance and utilization review and their application to private practice. Discussions, methods, and examples of evaluating one's office are presented.

Internship, Nonmedical↗
PubMed1991

Have hospital inpatient cost containment programs contributed to the growth in outpatient expenditures? Analysis of the substitution effect associated with hospital utilization review.

The rapid increase in outpatient expenditures has been the focus of growing attention in recent years. This increase has corresponded with public and private efforts to contain hospital inpatient costs, prompting some analysts to suggest that outpatient expenditure growth is the result of a substitution effect; that is, the substitution of outpatient for inpatient care associated with hospital cost containment programs. Claims data on 43 privately insured groups that adopted utilization review (UR) during the latter part of 1984 or early 1985 were analyzed, comparing outpatient expenditures before and after adoption of hospital inpatient UR to quantify the substitution effect associated with UR. UR was not associated with higher physician office expenditures nor with higher outpatient diagnostic expenditures. UR was related to significantly higher hospital outpatient department expenditures. On average, these expenditures were approximately 20% higher (P = 0.01) after the adoption of UR. However, outpatient department expenditures of the groups analyzed represented a fairly small percentage of total medical expenditures; hence, the absolute expenditure increase was quite modest, on the order of $9 per insured person per year. This analysis, admittedly limited in scope, suggests that UR is associated with a measurable substitution effect. It is likely that inpatient hospital cost containment programs have resulted in some substitution of outpatient for inpatient care and thus have played a role in fostering outpatient expenditure growth during recent years.

Cost Control↗
PubMed1991

Using utilization review information to improve hospital efficiency.

Hospitals are currently under great pressure to improve the efficiency of internal operations without sacrificing quality of care. In the rush to do this, they often overlook an extremely useful source of information that already exists--data routinely collected as part of the utilization review (UR) process. This article describes a system using UR data for management purposes that was developed in a large urban teaching hospital. The components described are: (1) data collected systematically by trained reviewers applying the Appropriateness Evaluation Protocol; (2) software for data collection using inexpensive, highly portable computers; and (3) formats for reporting UR findings to hospital administrators and physicians. Information derived from UR in the study hospital is discussed, as well as factors to be considered in adapting some or all of the system's components in other hospitals.

Data Collection↗
PubMed1993

Drug utilization review in ambulatory settings: state of the science and directions for outcomes research.

There are escalating national pressures to analyze pharmaceutical outcomes and to develop drug-related clinical guidelines. These interests coincide with passage of the Medicaid Rebate Law (OBRA, 1990), which mandates the implementation of prospective and retrospective drug utilization review (DUR) programs by Medicaid in 1993. This report investigates DUR programs that target outpatient drug therapies. The authors present a conceptual framework that identifies the factors influencing drug prescribing and the range of potential patient outcomes. Current types of DUR interventions and their applications are described, in addition to problems that hinder implementation or evaluation of DUR programs. DUR evaluation studies are reviewed, and a critique identifies the limitations of available DUR research. The authors recommend an expanded DUR policy research agenda, strongly suggesting that priority be given to studies in the following areas: DUR criteria development and validation; prevalence of prescribing problems and their association with patient outcomes; efficacy, toxicity and costs of therapeutic alternatives; and DUR program evaluation. The overall conclusion is that the state of the science pertaining to DUR is not well developed. The potential of DUR may not be realized due to the lack of resources needed to design, implement, and evaluate effective programs. Instead, DUR efforts may be limited to cost-containment issues without due consideration of quality-of-care outcomes. The authors call for rigorous evaluation efforts to inform DUR design and implementation, thereby assuring more rational prescribing and enhancing patient outcomes.

Ambulatory Care Facilities↗
PubMed2005

Confronting utilization review in New Mexico's Medicaid mental health system: the critical role of "medical necessity".

The insertion of managed care into Medicaid services for the mentally ill has created contention about clinical decision making. At the center of this debate is the matter of what constitutes a medical necessity. Employing ethnographic methodology, this study examines utilization review (UR), the context in which decisions concerning the authorization of mental health care services are made. Interviews carried out in the study contrast ideological underpinnings of providers and advocates of the mentally ill, on the one hand, with employees and administrators of managed care institutions, on the other. The result is an exploration into the ways discourses surrounding the mental health care needs of New Mexico's Medicaid population are being constructed and are determining the actual care they receive.

Adolescent↗
PubMed1994

Development of clinical methods for utilization review in psychiatric day treatment.

When a time-limited day treatment program was reconfigured to serve individuals with long-standing psychotic disorders, the number of treatment episodes exceeding six months rose to 70%. To justify this concentration of resources, the program needed methods to identify individuals for whom sustained treatment was appropriate. This report describes development of utilization review methods adapted to publicly funded day treatment of individuals with serious mental illness and training of clinicians in new documentation skills. Data from three years of operation suggest that symptom severity is not a reliable indicator of medical necessity in day treatment. As expected with a clinically based system, a composite measure of benefit and medical necessity indicators weighted toward functioning in living, learning, working, and socializing environments predicted physician reviewer denial of continued day treatment, but length of stay did not.

Day Care, Medical↗
PubMed1997

An economic and clinical rationale for changing utilization review practices for outpatient psychotherapy.

The growth of managed care has led to greater cost consciousness in the financing and delivery of mental health and substance abuse services. The authors examine whether pressures to reduce the costs associated with mental health and substance abuse treatment have led to the overapplication of a popular managed care strategy, utilization review (UR), to the management of outpatient psychotherapy benefits. Several arguments are presented highlighting why changing outpatient psychotherapy UR practices would be in the best economic and clinical interests of all involved parties, including payers, managed care organizations (MCOs), mental health consumers, and providers. A number of alternatives to the aggressive management of outpatient psychotherapy benefits are outlined and discussed.

Community Mental Health Services↗
PubMed1985

Hospital usage of parenteral antimicrobial agents: a gradated utilization review and cost containment program.

Forty percent to 60% of antimicrobial agents administered in hospitals without effective antimicrobial review and control programs are not needed. Excessive use of antimicrobial agents in the hospital promotes colonization of patients with resistant organisms, needlessly exposes them to the risk of an adverse drug reaction, and increases the cost of care. A gradated antimicrobial utilization review program is presented that determines hospital usage, develops guidelines for appropriate cost-effective drug administration, provides several options for implementation, and monitors outcome so that measures can be modified for specific situations. The techniques used are basic epidemiologic measures currently used to assess hospital infections.

Anti-Bacterial Agents↗
PubMed1993

Michigan drug utilization review and OBRA 90.

The DUR Board's role in the Medicaid DUR process is significant. With the requirements for membership on the DUR Board and the responsibilities directed by OBRA 90, the standards will ensure that they reflect the accepted medical practice and are clinically relevant to the geographical area represented. The DUR Board has the potential to improve drug utilization review and ultimately improve the quality of care. The approval of criteria for both patient retrospective and prospective DUR and the addition of education intervention will help us to improve the quality of care. DSS encourages your input and participation on the DUR regional committees. There are currently three committees that meet monthly and are located in: Detroit, Ann Arbor, Lansing.

Drug Utilization Review↗
PubMed1976

Utilization review, attempted suicide, and involuntary hospitalization.

A patient's refusal to participate in recommended treatment is a problem faced in all branches of medicine. However, psychiatry faces special problems because of its authority to impose hospitialization of suicide attempters, cases were identified where there was indepdent agreement between both the experts' standards and the treating resident psychiatrists that hospitalization was required. Despite this agreement, the patients were not hospitalized because the patients refused. By most criteria, these patients were a high risk group. They had made repeated suicide attempts, used lethal means which eventuated in serious medical consequences, and were still suicidal when referred for treatment. The emergency room psychiatrists reported feeling confused, anxious, and annoyed in dealing with these patients, and the patients signed out against medical advice. A review of these cases indicated that discussions of social control vs. medical responsibility and clear criteria for hospitalization should be incorporated into residency training programs since the emergency room resident faces these tension-producing issues frequently with several different types of patients. Moreover, utilization review criteria may help to set standards which will assist the psychiatrist in making these difficult decisions.

Adult↗
PubMed1998

Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer.

CONTEXT: Pharmacotherapy is among the most powerful interventions to improve health outcomes in the elderly. However, since some medications are less appropriate for older patients, systems approaches to improving pharmacy care may be an effective way to reduce inappropriate medication use. OBJECTIVE: To determine whether a computerized drug utilization review (DUR) database linked to a telepharmacy intervention can improve suboptimal medication use in the elderly. DESIGN: Population-based cohort design, April 1, 1996, through March 31, 1997. SETTING: Ambulatory care. PATIENTS: A total of 23269 patients aged 65 years and older throughout the United States receiving prescription drug benefits from a large pharmaceutical benefits manager during a 12-month period. INTERVENTION: Evaluation of provider prescribing through a computerized online DUR database using explicit criteria to identify potentially inappropriate drug use in the elderly. Computer alerts triggered telephone calls to physicians by pharmacists with training in geriatrics, whereby principles of geriatric pharmacology were discussed along with therapeutic substitution options. MAIN OUTCOME MEASURES: Contact rate with physicians and change rate to suggested drug regimen. RESULTS: A total of 43007 alerts were triggered. From a total of 43007 telepharmacy calls generated by the alerts, we were able to reach 19368 physicians regarding 24 266 alerts (56%). Rate of change to a more appropriate therapeutic agent was 24% (5860), but ranged from 40% for long half-life benzodiazepines to 2% to 7% for drugs that theoretically were contraindicated by patients' self-reported history. Except for rate of change of beta-blockers in patients with chronic obstructive pulmonary disease, all rates of change were significantly greater than the expected baseline 2% rate of change. CONCLUSIONS: Using a system integrating computers, pharmacists, and physicians, our large-scale intervention improved prescribing patterns and quality of care and thus provides a population-based approach to advance geriatric clinical pharmacology. Future research should focus on the demonstration of improved health outcomes resulting from improved prescribing choices for the elderly.

Aged↗
PubMed1989

Efficiency gains in utilization review.

A study was conducted to determine which Major Diagnostic Categories (MDCs) accounted for most of the nonessential hospital admissions in 73 Michigan hospitals in 1986. The Intensity, Severity, Discharge-Appropriateness (ISD-A) criteria set was used to identify nonessential admissions. Large concentrations of nonessential admissions were found in medical, psychiatric, and substance abuse cases; surgical admissions had low rates of nonessential hospitalization. Focusing utilization review on MDCs with nonessential rates exceeding 15% results in an examination of 44% of admissions, while capturing 77% of nonessential admissions and 73% of potential dollar savings. Implications for UR activities are discussed.

Age Factors↗
PubMed1994

Identification of potentially avoidable pediatric hospital use: admitting physician judgment as a complement to utilization review.

OBJECTIVE: To determine, for acute general pediatric admissions, 1) the proportion of admissions that the admitting physician would identify as potentially avoidable; 2) services that might help reduce avoidable admissions; 3) potential savings in hospital days through eliminating avoidable admissions; 4) the role that social factors play in admission decisions; and 5) if admitting physician judgment provides a valuable complement to Utilization Review (UR) in identifying avoidable admissions. METHODS: A questionnaire was used to determine the proportion of 600 acute general pediatric admissions considered potentially avoidable by the admitting physician and to identify services required to prevent such admissions. Savings through eliminating potentially avoidable admissions and social factors influencing admission decisions were examined. Physicians' and UR assessments of necessity of inpatient care were compared. RESULTS: Admitting physicians judged 28% of admissions as potentially avoidable, citing alternative services for each avoidable admission. Eliminating all avoidable admissions would have reduced hospital days by 7.7%. Physicians identified 6% of admissions as social admissions, most commonly due to an overwhelmed family. UR identified 1% of potentially avoidable admissions as unnecessary. CONCLUSION: Incorporating admitting physician judgment may significantly improve current efforts to identify and reduce avoidable hospital use.

Acute Disease↗