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PubMed1982

Periodic medical review: the impact in Pennsylvania.

Periodic Medical Review (PMR) of all Medicaid beneficiaries in skilled nursing facilities (SNFs) in Pennsylvania was implemented in fiscal year 1973-74. In this study, the authors explored the impact of PMR through its first four annual review periods. Because over two thirds of all SNF patients who were determined (over the four-year period) to require lower levels of care were identified during the first year of the program, the study was focused on the impact of first-year reviews on patient placements and nursing home industry characteristics in the subsequent years. Although the results did not strongly show that PMR had significant long-term effects, the general conclusions reached were that: 1) first year PMR decisions altered (in the intended direction) SNF patient placements and structural characteristics of the nursing home industry in Pennsylvania; 2) the initial impact of PMR was still apparent by the fourth year, but much weaker; and 3) the PMR review team may have been more lenient in their decisions concerning appropriate levels of care for reviewed SNF patients after the first year.

Aged↗
PubMed1988

Medicare patients and alternatives to the acute care hospital.

There are many instances where hospitalized elderly patients no longer need intensive hospital care but are not ready to be discharged. One solution to this dilemma is the use of a skilled nursing facility (SNF) or some type of step-down bed, where patients can continue to receive managed care at a less intense and costly level. A major concern with using step-down beds is that while costs may be controlled, quality of care may suffer and patient outcomes may be jeopardized. From an efficiency perspective, the step-down bed can provide an excellent alternative to hospital care for the less acutely-ill patient. For alternative managed care environments to be satisfactorily received by patients and physicians, however, they must produce outcomes equal or better than those in the hospital. Some patients and diagnoses are more appropriate than others for treatment in alternative managed care environments. The judgement of appropriateness must take into account patient and physician satisfaction with the efficiency and effectiveness of the care. This paper describes how the Fallon Community Health Plan, Worcester, Mass., which regularly uses a step-down facility for patient care, assessed outcomes in terms of efficiency and effectiveness. An overview of this alternative managed care facility and its relationship to the HMO is discussed below. Several studies examining outcomes and patient and physician satisfaction are presented. Finally, the ways in which these studies represent a merger of quality assurance (QA) and utilization review (UR) methodologies are discussed.

Aged↗
PubMed2005

A methodology for timing reviews of inpatient hospital stay.

OBJECTIVE: This paper aims to describe a methodology to inform decisions about the optimal time to schedule reviews of a patient's hospital stay and to provide an example of its implementation. METHOD: Length of hospital stay was assessed in 1227 consecutive inpatient admissions. Data were transformed to reflect the probability of discharge from hospital in the following 7 days. RESULTS: The resulting data reflected the points at which the conditional probability of being discharged were declining, revealing the potentially efficient times to conduct reviews of inpatient admissions. CONCLUSIONS: The methodology outlined appears useful in assisting psychiatrists responsible for inpatient care to decide upon optimal times to review a patient's stay in hospital.

Adult↗
PubMed2000

The impact of utilization management on readmissions among patients with cardiovascular disease.

OBJECTIVE: To determine if prospective utilization reviews that lead to reduced hospital length of stay (LOS) relative to days requested by an attending physician affect the likelihood of readmission for privately insured patients with cardiovascular disease. DATA SOURCES: Data obtained from a private insurance company on utilization management decisions from 1989 through 1993. During this five-year period, 39,117 inpatient reviews were conducted, 4,326 (11.1 percent) on patients with cardiovascular disease. We selected for analysis all 4,326 reviews performed on patients with cardiovascular disease. STUDY DESIGN: We used proportional hazard analysis (Cox regression) to investigate the relationship between LOS reductions relative to days requested by a patient's attending physician and the likelihood of readmission within 60 days of discharge. Separate analyses were performed for medical and procedural admissions. PRINCIPAL FINDINGS: There were 2,813 requests for medical admission, and 1,513 requests for procedural admission. Requests for admission were rarely denied. Length of stay was reduced relative to that requested by the treating physician for 17 percent and 19 percent of medical and procedural admissions, respectively. Cumulative 60-day readmission rates were 9.5 percent for medical admissions and 12.3 percent for procedural admissions. We found no relationship between LOS reduction and the likelihood of readmission for medical admissions. However, patients admitted for procedures who had their length of stay reduced by two or more days were 2.6 times as likely to be readmitted within 60 days as those who had no reduction in their length of stay (95% CI: 1.3-5.1; p < .005). CONCLUSIONS: Utilization management (UM) rarely denies requests for inpatient treatment of cardiovascular disease. The association between LOS reduction and the likelihood of readmission for patients admitted for cardiovascular procedures raises concern that UM may adversely affect clinical outcome for some patients. Further research is needed to definitively elucidate any relationship that might exist between utilization review decisions and quality of care.

Adult↗
PubMedDate not supplied

Health care cost containment: how Pittsburgh is addressing the challenge.

Rapidly escalating health care costs have the public and private sectors searching for methods to provide health care benefits in a more efficient manner. Efforts have also been underway at the community level with the development of health care coalitions created to build consensus toward a fair solution for all parties affected. With the assistance of the Robert Wood Johnson Foundation and many local co-sponsors, the Pittsburgh Program for Affordable Health Care (PPAHC) was organized to address health care cost containment issues in the greater Pittsburgh area. One of the means by which PPAHC chose to achieve this was through the development of a Model Utilization Management Program. This is a document containing community-sanctioned administrative and clinical standards for utilization review which take into consideration the needs and concerns of providers, purchasers, and consumers, and which have a goal of reducing medically unnecessary inpatient hospitalization while concurrently maintaining quality of and access to care. This article describes both the process and the product of PPAHC's efforts toward health care cost containment in Pittsburgh, specifically focusing on its utilization management component.

Community Participation↗
PubMedDate not supplied

A system that works: managing managed care in psychiatry.

The Carrier Foundation, a not-for-profit psychiatric facility in Belle Mead, NJ, has been working with managed care for the past 5 years. As managed care began to affect patients' access to care, the quality improvement department at The Carrier Foundation became involved in case management. Through case management, the quality improvement department began to provide guidance to private review organizations to preserve and protect patients' rights and to ensure accurate reporting of clinical data.

Concurrent Review↗
PubMed1993

Pre-billing DRG reviews set new standard.

When and how you do DRG review is critical. This piece offers tips on hiring consultants who can help you provide this financially important service.

Abstracting and Indexing↗
PubMed1977

Evaluation of a new strategy for continued stay review in hospitals.

A classification of in-patients by "reason for admission" (RFA) is described and compared with the classification by diagnosis. The RFA classification assigns length of stay on the basis of twenty-five reasons for admission for adult medical-surgical cases. Length of stay norms for the RFA method were developed and compared to diagnosis specific norms (dx norms). A group of 500 charts was subjected to simulated continued stay review using both RFA and dx norms as screening methods. Although the dx norms screened out for individual review 76% more cases than the RFA norms, the number of screened out cases in which length of stay could have been reduced without affecting the quality of care was the same. The RFA strategy may provide a more efficient method of continued stay review that is also more relevant to hospital medical care than the standard method based on diagnosis.

Adult↗
PubMed1998

Designing an internal audit process for physician billing compliance.

An internal audit process is central to an effective compliance program. When based on pertinent Federal regulatory guidelines and executed by staff with appropriate technical expertise, an internal audit limits opportunities for noncompliant physician billing and reduces the risk of incurring financial penalties. The design of an effective internal audit process will incorporate uniform internal audit procedures, communication mechanisms, and educational initiatives to correct any deficiencies that are identified. For healthcare organizations that are involved with physician group practices, review of physician documentation is particularly important. This review provides essential information on potential areas of risk and offers a focus for future education of physicians regarding appropriate billing and documentation.

Communication↗
PubMed2001

Contraindicated medications dispensed with cisapride: temporal trends in relation to the sending of 'Dear Doctor' letters.

PURPOSE: 'Dear Doctor' letters alert the prescribing community of drug labeling changes that contain new contraindications, warnings, adverse reactions, and precautions. There has been little assessment of the impact of these letters. We quantified the impact of two 'Dear Doctor' letters concerning interactions between cisapride and a series of drugs. A letter in 1995 described a risk of prolonged QT intervals and serious ventricular arrhythmia in patients who received macrolide antibiotics and imidazole antifungals in conjunction with cisapride. A June 1998 letter that expanded the list of contraindicated comedications had wider distribution than an earlier one, was accompanied by substantial Internet and media coverage, and was complemented by an effort to inform large pharmacy dispensing information organizations of the warnings against concurrent use of the named drugs. METHODS: Health plan members with one or more outpatient pharmacy claims for cisapride during the period 1 January 1995 through 31 May 1999 were identified among members of a large New England health insurer. A retrospective review of concurrent and nearly concurrent dispensings of cisapride and contraindicated comedications was undertaken in the automated pharmacy claims data using both graphical and statistical time-series analysis. We tabulated by month the fraction of cisapride dispensings that occurred in close temporal relation to dispensings of contraindicated comedications. Codispensings that occurred on the same day were taken as the most direct measure of prescriber responsiveness to the letters. Codispensings that occurred in windows of plus or minus 2 weeks (29 day window) and plus or minus 4 weeks (57 day window) were taken as measures of possible simultaneous consumption. Among overlapping dispensings, we counted the proportion dispensed by the same pharmacy. Time series regression analysis of secular, seasonal, and step-effects was conducted. RESULTS: There was a steady decline in codispensing of cisapride and contraindicated medicines, and a pronounced seasonal effect, arising principally from the seasonal use of macrolide antibiotics. Against this background, the isolated Dear Doctor letter of October 1995 had no discernible effect on prescribing practices. The 1998 letter and surrounding activity, by contrast, were followed by a 66% decline in same-day dispensings and a smaller, but still pronounced decline in dispensings in the wider time windows. For most codispensings of contraindicated medications with cisapride, both medications came from the same pharmacy. CONCLUSIONS: Publicity and direct intervention with dispensing pharmacies may be an important supplement to Dear Doctor letters when the goal is to eliminate the codispensing of drugs that should not be taken together.

Adolescent↗
PubMed2006

Effect of drug utilization reviews on the quality of in-hospital prescribing: a quasi-experimental study.

BACKGROUND: Drug utilization review (DUR) programs are being conducted in Canadian hospitals with the aim of improving the appropriateness of prescriptions. However, there is little evidence of their effectiveness. The objective of this study was to assess the impact of both a retrospective and a concurrent DUR programs on the quality of in-hospital prescribing. METHODS: We conducted an interrupted time series quasi-experimental study. Using explicit criteria for quality of prescribing, the natural history of cisapride prescription was established retrospectively in three university-affiliated hospitals. A retrospective DUR was implemented in one of the hospitals, a concurrent DUR in another, whereas the third hospital served as a control. An archivist abstracted records of all patients who were prescribed cisapride during the observation period. The effect of DURs relative to the control hospital was determined by comparing estimated regression coefficients from the time series models and by testing the statistical significance using a 2-tailed Student's t test. RESULTS: The concurrent DUR program significantly improved the appropriateness of prescriptions for the indication for use whereas the retrospective DUR brought about no significant effect on the quality of prescribing. CONCLUSION: Results suggest a retrospective DUR approach may not be sufficient to improve the quality of prescribing. However, a concurrent DUR strategy, with direct feedback to prescribers seems effective and should be tested in other settings with other drugs.

Cisapride↗
PubMed2000

Assessing managed care's role in promoting preventive care.

The current trend of managed health care systems opens the door to more effective control of chronic diseases through preventive care. The goal of this study was to assess managed care's role in promoting preventive care. A mail survey was conducted of a national sample of 1,200 directors, associated with preventive care, in managed care organizations (MCOs) in the U.S. Data was obtained on perceived effectiveness, degree of importance, and likelihood of support for implementation of strategies recommended (case management, utilization review programs, selective contracting, and cost sharing) for ensuring appropriate utilization of preventive services. Also, information was collected on interventions perceived effective in encouraging plan members to utilize and providers to offer preventive services. Response rate was 17.3%. Case management and prospective and concurrent utilization review programs were perceived most effective, important, and likely to receive support for implementation while cost sharing (using deductibles and coinsurance) and retrospective utilization review programs ranked low on all dimensions. Plan member-directed interventions perceived effective in encouraging utilization of preventive services included telephone and mail reminders while computer-generated reminders and medical record audits with feedback were perceived effective in encouraging providers to offer such services. Results identified preferred MCO strategies and interventions for ensuring appropriate utilization of preventive services. Further research is needed to develop methods to encourage people at high risk for chronic diseases not currently utilizing preventive services to receive such services.

Case Management↗
PubMed1983

Utilization review based on practitioner profiles.

Focused utilization review efforts to date have centered on patient categories, i.e., diagnosis, service, or classification. Since the patient's length of stay is mostly controlled by the attending practitioner, it seemed logical to use practitioner profiles to focus review. The profiles developed compare each practitioner's patients, case-mix-adjusted, using diagnosis-related groups, to statewide length-of-stay norms. Standards (range of acceptable variations from the norm) can be adjusted to increase or decrease the impact of the review. After experience, standards were set that resulted in a significant decrease in the average length of stay and a resultant significant drop in patient days.

Concurrent Review↗