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PubMed1988

Addressing concurrent review coding problems.

The coding policy/procedure manual, as one would expect, requires that constant attention be given to updating and clarification of coding practices and issues, but the rewards make the time spent well worth it. Coding consistency is achieved (although this is not an easy feat when dealing with a greater number of coders) and the coding supervisor is able to readily refer personnel to the coding policies/procedures and reduce communication time. The coders no longer waste time digging through stacks of journals, publications, and memos trying to find information pertaining to their present coding dilemma. The manual provides a mobile, organized filing device for staff members who spend the majority of their days on the nursing units performing concurrent coding. Last, but not least, the manual provides for a comprehensive, timely and historical coding resource base which works nicely for those times when an undesirable Professional Review Organization DRG modification needs to be appealed by the facility.

Abstracting and Indexing↗
PubMed1992

New methods for evaluating utilization management programs.

Blue Cross and Blue Shield of Massachusetts, Inc (BCBS), has developed two new methods for measuring the effect of utilization management (UM) in reducing unnecessary hospital use. The "program component" method measures the separate effect of preadmission review, concurrent review, and discharge planning. The "savable days" method produces a composite measure of the effectiveness of the program as a whole. The use of these two methods is illustrated with five years of utilization review data from the BCBS nongroup insurance product. The results can be used by operations managers and policymakers to measure the performance of individual UM components and the program as a whole, to establish goals and monitor program performance, to modify the program in response to changing utilization patterns, to assist in developing premiums, to establish risk-sharing agreements with employers or providers, and to demonstrate the effectiveness of the program for use in marketing.

Blue Cross Blue Shield Insurance Plans↗
PubMed1997

Impact of level III verification on trauma admissions and transfer: comparisons of two rural hospitals.

PURPOSE: To study the impact of Level III verification and other changes in rural hospitals on trauma delivery and to examine factors affecting transfer to a Level I trauma center. SETTING: Two rural Kentucky hospitals and a Level I trauma center. METHOD OF REVIEW: Concurrent review of all trauma patients in 1988 and re-review of the same parameters in 1995. FINDINGS: In 1988, both hospitals had similar management practices in trauma care. A significant number of patients were transferred for (a) patient choice, (b) serious and/or multiple trauma, (c) specialty care in non-life threatening situations, and (d) to exclude a potentially serious problem seen on radiologic evaluation (usually questionable cervical spine or widened mediastinum). Both hospitals had major changes in trauma delivery. One hospital received Level III verification, and the other had changes that lessened the general surgeon's involvement with initial evaluation and treatment. A re-review in 1995 disclosed major changes at both institutions. Transfers to exclude radiologic abnormalities had virtually disappeared. The Level III status had increased the surgical involvement in that hospital; there was actually an increase in patients transferred to the Level I hospital and an increase in patient acuity. More operations were performed locally, and the care was more efficiently delivered. The other hospital had a large increase in transfers and decreased admissions locally as general surgical involvement decreased. CONCLUSIONS: The factors related to patient transfer for trauma care are complex and require careful elucidation to improve care. The development of a Level III trauma service appeared to increase the number of seriously injured patients treated in the rural hospital and the efficiency of the care delivered.

Concurrent Review↗
PubMed1986

All-inclusive concurrent antibiotic usage review: a way to reduce misuse without formal controls.

During an 11-week period, all antibiotic usage on a 113-bed medical teaching service was reviewed concurrently in weekly sessions between house staff and a review team. Recommendations for change, based on accepted criteria, were communicated by the house officer to the attending physician. In one-half of the patients no change was suggested; in one-third, a recommended change was made; and in only one-sixth was a recommendation not followed. Cost savings were conservatively estimated to approach $10,000 in this pilot study; this extrapolates to almost $300,000 per year for the 714-bed medical center, or more than 18% of the antibiotic expenditures. This program achieves its objective in a nonthreatening, noncontrolling manner, provides continuing education, and contributes to improved patient care.

Anti-Bacterial Agents↗
PubMed1999

Concurrent strength and endurance training. A review.

Concurrent strength and endurance training appears to inhibit strength development when compared with strength training alone. Our understanding of the nature of this inhibition and the mechanisms responsible for it is limited at present. This is due to the difficulties associated with comparing results of studies which differ markedly in a number of design factors, including the mode, frequency, duration and intensity of training, training history of participants, scheduling of training sessions and dependent variable selection. Despite these difficulties, both chronic and acute hypotheses have been proposed to explain the phenomenon of strength inhibition during concurrent training. The chronic hypothesis contends that skeletal muscle cannot adapt metabolically or morphologically to both strength and endurance training simultaneously. This is because many adaptations at the muscle level observed in response to strength training are different from those observed after endurance training. The observation that changes in muscle fibre type and size after concurrent training are different from those observed after strength training provide some support for the chronic hypothesis. The acute hypothesis contends that residual fatigue from the endurance component of concurrent training compromises the ability to develop tension during the strength element of concurrent training. It is proposed that repeated acute reductions in the quality of strength training sessions then lead to a reduction in strength development over time. Peripheral fatigue factors such as muscle damage and glycogen depletion have been implicated as possible fatigue mechanisms associated with the acute hypothesis. Further systematic research is necessary to quantify the inhibitory effects of concurrent training on strength development and to identify different training approaches that may overcome any negative effects of concurrent training.

Adaptation, Physiological↗
PubMed1987

The psychiatric, alcohol, and drug algorithm: a decision model for the nurse reviewer.

Although preadmission review and concurrent review are useful tools for limiting unnecessary medical expenditures, psychiatric and chemical dependency cases are more difficult to assess than medical/surgical cases because they are described in relatively subjective terms and do not lend themselves to review by systems currently in use. The Psychiatric, Alcohol, and Drug Algorithm (PADA) is a straightforward utilization review system for these cases. PADA is organized in decision trees for each reason for admission and reason for continued stay; this system enables nurse reviewers to make recommendations on most cases without further review.

Algorithms↗
PubMed1985

Computer-assisted concurrent antibiotic review in a community hospital.

A computer-assisted program that monitors the appropriateness of antibiotic prescribing by matching microbiology reports and patient drug profiles is described. An antibiotic review committee in conjunction with the quality assurance department developed the computer-assisted antibiotic review program. An antibiotic order sheet was incorporated into the physicians' order form. Automatic stop dates were assigned according to the reason the antibiotic was ordered, e.g., surgical prophylaxis or documented infection. Numerous reports are generated from the data gathered from the physicians' order form. A drug/microbiology report is used to match patients' antibiotic drug profiles with their microbiology culture and sensitivity results. This report identifies all patients who have been receiving antibiotics for 72 hours or longer with sensitivities on file and mismatched sensitivity results. All mismatches that are considered important are investigated. Any actions taken are reported to the antibiotic review committee for peer review. The computer-assisted program has helped this hospital screen large populations of inpatients receiving antibiotics. The concurrent review of the drug/microbiology report has made it possible to detect within 24 hours, patients who are receiving antibiotics inappropriately. A computer can be used to perform daily concurrent antibiotic use review as a by-product of order entry by both the pharmacy and laboratory.

Anti-Bacterial Agents↗
PubMed2003

An exploratory cost analysis of performing hospital-based concurrent utilization review.

OBJECTIVE: To determine the costs associated with conducting concurrent utilization review, a utilization management strategy widely used by the managed care industry. STUDY DESIGN: A production process model focusing on resource utilization. SUBJECTS: The 29 clinical services of a 500-bed academic health center were aggregated into 9 clinical groups. A random sample of at least 15 reviews per group was studied. METHODS: Time sampling and cost analysis methods were used to determine the cost to the hospital of conducting utilization review. Component activities of the process were identified and analyzed to determine differences among clinical services and among the component tasks of the utilization review process. RESULTS: In 12 months, 13 126 reviews were completed in an average of 15 minutes 41 seconds. Across clinical groups, the average total time of each review ranged from 11 minutes 18 seconds (medical group) to 19 minutes 4 seconds (pediatrics group). Significant differences existed among clinical service groups for the activity of preparing for conducting the review, with the pediatrics group spending more time than the cardiology and oncology groups. The total cost of the process was nearly dollar 166 000 annually. The average cost per review was dollar 11, the average cost per patient-day denied was dollar 478, and the average cost per patient denial was dollar 1592. CONCLUSIONS: These figures are conservative in that they do not include the payer component of the costs, which could be as high as the hospital provider cost. Given a denial rate of < 2% and the high cost of the process, it may be beneficial to investigate alternative processes for conducting utilization review.

Academic Medical Centers↗
PubMed1988

Concurrent clinical review: using microcomputer-based DRG-software.

Since the introduction of the Prospective Payment System based on Diagnosis Related Groups (DRGs) in the U.S.A., important information technologies are arising. We discuss how Professional Review Organizations, (PROS) are forcing a better control of appropriateness and quality of medical care. Hospitals should have the internal capabilities to perform, at least, the same reviews as performed by the PROs. Concurrent Clinical Review Systems based on DRGs are a special type of information technology that take place during and even before patient hospitalization, therefore allowing an 'on line' monitoring information. Low-cost microcomputers are playing a major role in the popularization of this technology. 'Clinical Review System' is a microcomputer-based software that renders easy and feasible and otherwise complex task. An effort should be made in order to adapt the philosophy underlying this or other similar software to the European needs.

Computers↗
PubMedDate not supplied

Computerized decision support for concurrent utilization review using the HELP system.

OBJECTIVE: Development and evaluation of computerized concurrent utilization review (UR) support taking advantage of a clinically rich computerized patient database. DESIGN: The Automated Support System for Utilization Review (ASSURE) applies the Appropriateness Evaluation Protocol (AEP) Day of Care criteria to computerized patient data in the HELP hospital information system. This paper reports the development, verification, and validation of ASSURE. MEASUREMENTS: Implementation correctness was verified by measuring agreement with a nurse reviewer, using separate sample sets for all 20 criteria for a total of 560 current inpatients. Usefulness in detecting inappropriate days of care was validated by two nurse reviewers who were crossed with manual and computer-assisted review methods in a blocked design for 168 current inpatients. Agreement with reviewers, sensitivity, specificity, positive predictive value, and negative predictive value were measured. RESULTS: Agreement was very good for satisfaction of criteria, and good for appropriateness of day of care. A patient day identified by ASSURE as potentially inappropriate would be twice as likely to be judged inappropriate by a reviewer as a randomly selected patient day. Review of the 10% of patient days identified as potentially inappropriate by ASSURE would identify approximately 21% of the inappropriate days of care. CONCLUSION: ASSURE is a clinically useful tool for screening adult acute care patients for inappropriate days of care, and promises to make a major contribution to reducing health care costs. The prognosis for successful routine clinical use is good.

Artificial Intelligence↗
PubMed1996

Concurrent utilization review and inappropriate hospital stay: evaluation of a program.

Using a crossover design, we tested the hypothesis that concurrent utilization review by a utilization officer would reduce length of stay and inappropriate bed days in a tertiary care hospital. The intervention groups included 396 consecutive patients admitted to specified services during two 1-month study periods and followed for at least 1 month or until discharge. Controls were 410 patients admitted to the same services during a preceding or subsequent month, separated by a 1-month washout period. Intervention cases had daily review of their care plan and medical condition by the utilization officer to identify existing or likely inappropriate hospital stay. The officer used interdisciplinary and interdepartmental consultation in attempting to resolve identified problems. A separate research nurse identified the controls and gathered data on the medical condition and care plan for a random 50% sample of both intervention and control cases. These data were used by a multidisciplinary panel to count and classify the reasons for inappropriate hospital days. Overall, there were no significant differences between the corresponding intervention and control groups for length of stay or proportion of inappropriate days. There was evidence of a time-related reduction in both length of stay and inappropriate days only in the subgroup of patients with a length of stay of < 15 d. As further evidence of this period effect unrelated to the intervention, length of stay had been declining for 1 of the groups of services before this study began. We concluded that concurrent utilization review, as practiced in this study, was ineffective in the short term. However, utilization review and modification of hospital processes can reduce inefficiency, as evidenced by the time-related reduction in inefficiency illustrated in our study.

Admitting Department, Hospital↗
PubMed1999

Managed behavioral health care and supply-side economics. 1998 Carl Taube Lecture.

BACKGROUND: Within the past decade, the mental health care system in the United States has undergone a significant transformation in terms of delivery, financing and work force configuration. Contracting between managed care organizations (MCOs) and providers has become increasingly prevalent, paralleling the trend in health care in general. These managed care carve-outs in behavioral health depend on networks of providers who agree to capitated rates or discounted fees for service for those patients covered by the carve-out contracts. Moreover, the carve-outs use a broader array of mental health providers than is typically found in traditional indemnity plans, encourage time-limited versus long-term treatments and favor providers who are engaged in outpatient care. This phenomenal growth in managed behavioral health care over the past decade includes the rapid growth and quick consolidation of mental health MCOs. The period 1992-1998 shows steady and substantial annual increases in the number of enrollees in mental health MCOs, the figure more than doubling from 78.1 million people in 1992 to a projected 156.6 million in 1998, or 70% of insured lives. Moreover, these vast numbers of enrollees are becoming increasingly consolidated into a smaller number of firms. In 1997, 12 companies controlled nearly 85% of the managed behavioral health care market, with 60% of the market held by the three largest firms. STUDY AIMS: This article reviews empirical data and draws policy implications from the literature on managed behavioral health care in the United States. Starting with spending and spending trend estimates that show the average annual growth rate of mental health expenditures to be lower than that of health care expenditures in general over the past decade, the author examines utilization and price factors that may account for managed-care-induced cost reductions in behavioral health care, with special attention to hospital use patterns, fee discounting and the supply and earnings patterns of various types of mental health provider. In addition, data on staffing ratios and provider mixes of health maintenance organizations and mental health MCOs are reviewed as they reveal at least part of the dynamics of reconfiguration of the mental health work force in this era of managed care. CONCLUSIONS: As measured by changes in utilization and price, widespread application of "classic" managed care techniques such as preadmission review (gatekeeping), concurrent review, case management, standardized clinical guidelines and protocols, volume purchase of services and fee discounting appears to have led to significant cost reductions for providers of both impatient and outpatient mental health services. However, amidst a complex flux of market variables such as risk shifting, changing financial incentives and intensity of competition, not all of the reduction or slowdown in spending can be clearly and purely attributed to managed care. The data on the ongoing reconfiguration of the mental health work force are clearer in their implications: with an oversupply of all types of mental health providers, managed care has significant potential to increase the incidence of provider substitutions and spur the growth of integrated group practices. IMPLICATIONS FOR FURTHER RESEARCH: The current body of empirical and policy literature in mental health economics suggests several salient areas of follow-up. Is the proportionately greater impact of managed care on the annual growth rate of mental health care spending a temporary phenomenon or does it signal an enduring difference in the rates of increase between behavioral health care and health care in general? Beyond industry downsizing, what are the substitutions among mental health providers that are going on, and will go on, to produce cost-effective practices? What are the new financial or risk-sharing arrangements between providers and MCOs that will produce appropriate and high-quality mental health services?

Journal Article↗