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Utilization review programs are increasing in number and type, but their true contributions to payers' health care and cost management efforts vary tremendously, according to evaluations of over 100 private UR firms by National Medical Audit. Three senior executives of that firm discuss state-of-the-art criteria and methods for gauging the effectiveness of a UR program.
CONTEXT: Utilization review (UR) seeks to improve quality and cost-efficiency of health care. However, how well the process works in practice has not been assessed. OBJECTIVE: To describe the outcomes of a sample of physician reviews in terms of the explicit criteria that the UR was designed to implement. DESIGN: Retrospective analysis of transcripts of precertification reviews. PARTICIPANTS AND SETTING: California physicians employed by a UR firm conducted 96 interviews from April 1990 to July 1991 with attending physicians who had proposed to insert tympanostomy tubes on a patient younger than 16 years and whose proposals had been found to be inappropriate on an initial screen. MAIN OUTCOME MEASURES: The appropriateness rating assigned to each case by the physician-reviewer and by the investigators using explicit criteria. Logistic regression identified factors associated with the reviewers' recommendations to perform surgery and with recommendations at variance from the criteria. RESULTS: The reviewers recommended 78% of cases for surgery, of which only 29% were supported by the criteria or had extenuating circumstances. The criteria concurred with all 30 of the reviewers' recommendations against surgery. Two factors, female sex (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.2-53.8) and previous tympanostomy tube insertion (OR, 30.9; 95% CI, 2.4-394.8) were associated with reviewer recommendations in favor of surgery that were at variance from the criteria, despite the lack of evidence for either as a mitigating circumstance. CONCLUSION: Physician reviewers were more lenient than the explicit criteria that the reviews were designed to implement. In no cases did the reviewers depart from the criteria's recommendations in favor of surgery.
Drug utilization review screening criteria were applied to a sample of 30 000 prescriptions written by Iowa physicians. Characteristics of the physicians who had high percentages of prescriptions violating the explicit criteria were examined. It was found that the proportion of prescriptions failing the screening criteria did not differ significantly among physicians of differing board certification groups, medical school of graduation, year of graduation from medical school, age, or size of town where the physicians practiced. Regardless of the physicians' demographic characteristics, approximately 50 percent of their prescriptions violated the prescribing criteria. The three categories of screening criteria included irrational mixture, quantity prescribed, and daily dosage. An analysis of the relationship between physician ratings obtained for each of the categories revealed that no relationship existed between a physician's quantity prescribed rating and daily dosage rating, or between a physician's irrational mixture rating and daily dosage rating. A negative relationship was found between a physician's quantity prescribed rating and irrational mixture rating. This tends to indicate that the three categories measure different prescribing patterns and each warrants respective monitoring by pharmacists.
OBJECTIVE: To describe characteristics associated with inappropriate hospital use by patients in Manitoba in order to help target concurrent utilization review. Utilization review was developed to reduce inappropriate hospital use but can be a very resource-intensive process. DESIGN: Retrospective chart review of a sample of adult patients who received care for medical conditions in a sample of Manitoba hospitals during the fiscal year 1993-94; assessment of patients at admission and for each day of stay with the use of a standardized set of objective, nondiagnosis-based criteria (InterQual). PATIENTS: A total of 3904 patients receiving care at 26 hospitals. OUTCOME MEASURES: Acute (appropriate) and nonacute (inappropriate) admissions and days of stay for adult patients receiving care for medical conditions. RESULTS: After 1 week, 53.2% of patients assessed as needing acute care at admission no longer required acute care. Patients 75 years of age or older consumed more than 50% of the days of stay, and 74.8% of these days of stay were inappropriate. Four diagnostic categories accounted for almost 60% of admissions and days, and more than 50% of those days of stay were inappropriate. Patients admitted through the emergency department were more likely to require acute care (60.9%) than others (41.7%). Patients who were Treaty Indians had a higher proportion of days of stay requiring acute care than others (45.9% v. 32.8%). Patients' income and day of the week on admission (weekday v. weekend) were not predictive factors of inappropriate use. CONCLUSION: Rather than conducting a utilization review for every patient, hospitals might garner more information by targeting patients receiving care for medical conditions with stays longer than 1 week, patients with nervous system, circulatory, respiratory or digestive diagnoses, elderly patients and patients not admitted through the emergency department.
Utilization review has been regarded as one of the most promising approaches to the containment of health care costs. We analyzed insurance claims data on 222 groups of employees and dependents for 1984 and 1985 to evaluate the effects of utilization review programs instituted by a large private insurance carrier. The utilization review programs we studied were compulsory; patients who did not follow established utilization review procedures were subject to financial penalties. Controlling for employee characteristics, health care market area factors, and benefit-plan features, we found that utilization review reduced admissions by 12.3 percent, inpatient days by 8.0 percent, hospital expenditures by 11.9 percent, and total medical expenditures by 8.3 percent. When only groups that had relatively high admission rates before adopting utilization review were analyzed, it was found that they had a 34 percent reduction in patient days and a 30 percent reduction in hospital expenditures. The savings-to-cost ratio of utilization review for groups overall was highly favorable--approximately 8 to 1. Private utilization review programs of the type we studied appear to be effective in reducing hospital use and decreasing medical expenditures. This study did not address the possible effects of such programs on the health status of patients.
Utilization review of treatment for chemical dependence has become increasingly important as evidence accumulates that outpatient treatment can be effective in many cases. The authors discuss the basic questions that guide utilization review of treatment for chemical dependence, summarize research that has led to the increasing emphasis on outpatient and partial hospital treatment approaches, and review the American Psychiatric Association's guidelines for utilization review of chemical dependence treatment. Case examples illustrate issues in the treatment of adolescents, patients with dual diagnoses, and relapsing patients. The authors conclude that utilization review supports use of inpatient care only for patients who require intensive services, including those who are a danger to themselves or others, have serious physical or psychiatric disorders, or have not responded to an adequate trial of outpatient treatment.
A Student Model Utilization Review Committee Project is in progress at Jefferson Medical College. Students participate in the program for 90 minutes during the six weeks of their clerkship in family medicine at the university hospital. Information collected from participants and controls before and after the program indicates that the experimental group has greater knowledge and more positive attitudes about utilization review and cost control in the health care field than do the controls. Students express positive feelings about the program. More importantly, one year later, as seniors, those in the experimental group demonstrated clinical behavior which was more consistent with the objectives of the program than other students. These results have led the Department of Family Medicine to incorporate the utilization review program into its formal curriculum beginning in the 1979-1980 academic year.
OBJECTIVE: To develop and test a utilization review screening tool for use in European hospitals. SETTING: In 1993 a group of researchers financed by a European Union grant reviewed the use of utilization review in Europe. They quickly noticed a lack of specifically designed instruments able to take into account the health care and cultural differences across Europe, and available for use in different health care systems. Hence, they embarked upon the task of developing and testing a utilization review screening tool for use in European hospitals. RESULTS: The European Union-Appropriateness Evaluation Protocol's list of reasons was developed and assessed. This is a common taxonomy that classifies days identified as unnecessary and provides a list of levels of care to identify patients' needs. This new protocol not only substitutes for the multiple previous local versions of the Appropriateness Evaluation Protocol, but will also facilitate comparisons of the varying experiences in European countries. MAIN FINDINGS: Development of utilization review in Europe has been carried out mostly on a voluntary basis and the main objective was not control. The experience varies widely: from France, where utilization review is still developing and research has been implemented by local teams, to Portugal, where utilization review programmes have been initiated by government authorities. At this point different initiatives in quality improvement, and more specifically in utilization review, are being developed within the European context.
Drug utilization review programs have been recognized as an effective way to control health care spending while maintaining quality services. This article describes the structure, mandate and activities of Quebec's Drug Utilization Review Network. This 112-member network, which represents 45% of health care facilities in the province, was established to promote the optimal utilization of drugs through the provision of support to pharmacology committees, therapeutic committees and pharmacy departments. The network's main role is to coordinate multi-centre drug utilization studies. Future challenges include maintaining member interest and evaluating the clinical and economic impact of the network's efforts.
A set of computer programs collects, processes, and reports Professional Standards Review Organization (PSRO) and utilization data for all patients at the Miami Heart Institute. They help reduce the time spent by physicians in PSRO and utilization review activities and ease the clerical work load required to comply with rules and guidelines. Daily printed reports provide attending physicians with their patient census and inform them of the next scheduled PSRO review dates for each of their patients. Reports are produced also for the Utilization Review Committee and the Institute's PSRO office. This set of programs is part of a comprehensive automated hospital information system and has been designed to respond rapidly to the frequent changes in regulations and policies dictated by the administering agency. The PSRO subsystem had been in uninterrupted operation for over 6 years and has mitigated escalating clerical and, therefore, health care costs. Physicians' acceptance of this subsystem had been adequate; however, developmental and maintenance costs are high in comparison with other applications within the hospital information system. This article describes the methodology used in complying with PSRO requirements. It does not attempt to evaluate the impact of PSRO on quality of care or length of hospital stay.
The appropriate utilization and the quality of care in long-term care facilities should be documented and monitored. This is best accomplished at the local level by physicians and other professionals serving on Utilization Review Committees. Paper compliance to regulation of state or federal agencies is a poor substitute for active involvement of the professionals at the local level.
The impact of drug utilization review on quality control is outlined. Special attention is given to a drug utilization review at the individual patient level for which the methodology for implementation and maintenance are described, with special emphasis on the cyclic character of the process.
In this article, the author describes the potential liability of Health Maintenance Organizations for utilization review programs. Utilization review is used to determine whether certain medical treatment is necessary according to the standards of the HMO, and the HMO may decline to pay for treatments it deems unnecessary. If a doctor abstains from treatment because of this decision and the patient is harmed, the HMO may become the target of litigation. The author analyzes several recent cases and offers practical ideas for preventing and defending suits brought against HMO's for utilization review decisions.
The role of utilization review (UR) as a form of managed care is described. As technology has advanced, the use of diagnostic and therapeutic services has increased and care delivery has shifted to outpatient settings, but the increase in healthcare costs has not slowed. The shift to delivery of medical care outside the hospital setting has increased the need for effective UR in both inpatient and outpatient settings. UR is performed not only by private UR organizations and through external review programs of insurance carriers but also through care-providers' internal programs. UR has been driven by increased medical costs and by redesign of insurance benefit plans to include financial incentives and penalties and copayments. UR has attempted to control the use of hospital services through preadmission certification and concurrent review, requirements for second surgical opinions, and medical case management, which is the identification before or during hospitalization of patients who could safely receive treatment outside the hospital. In-patient mental health and substance-abuse programs have been the subject of intensive review because of high expenditures for such services. Practice indicators are being developed that will be used for prospective determination of treatment plans. As UR techniques improve, management of care in all organized health-care settings will intensify.
Utilization review (UR) has developed to the point where it soon will be, if it is not already, a separate profession. Yet it lacks practice guidelines and principles to guide practitioners. In the absence of such, practitioners may inappropriately use those of their original professions or other guidelines not in conformity with the objectives of UR. Practice guidelines for UR should arise out of professional consensus following extensive discussions. As a step in that direction, a number of proposed guidelines are presented.
A drug utilization review program of cefoxitin was conducted in a 714-bed teaching hospital. Health records of all 43 in-patients who received cefoxitin during the month of November 1987 were reviewed retrospectively. The use of cefoxitin (47 courses) was evaluated on the basis of "appropriate use" criteria developed from the literature and the physician's clinical experience. Of the 47 courses evaluated, cefoxitin was prescribed for prophylaxis in 47%, and its use was considered inappropriate in 86% of these. Overall, 66% of total cefoxitin usage was deemed inappropriate in this hospital. The cost associated with inappropriate use was estimated at $2672 for the period of the study. Corrective measures were then implemented to rectify the identified problems. A second study was conducted 2 years later to assess the impact of the corrective measures. This utilization review program of cefoxitin showed that optimal use of a drug requires not only close collaboration between pharmacists and physicians but a continuous and not a sporadic process of surveillance of the prescription for the drug being studied.
Family physicians are often in close contact with utilization review programs. Traditional hospital based review programs have included prehospital certification, outpatient and same-day surgery, second opinions, concurrent hospital review, and early discharge planning. The role of utilization review in ambulatory care is expected to increase in the future and will focus on the cost-effective allocation of resources. Family physicians need to be aware of several issues as they interact with utilization review programs, including the preservation of confidentiality, financial obligation in the face of negative review decisions, and the effect of utilization review on liability for adverse outcomes. Family medicine education should encourage familiarity with the structure and function of review programs and should enable practitioners to participate intelligently in such programs.
Utilization review practices, innovations and trends for the 21 states using diagnosis-related groups for Medicaid during 1992 are described. According to this descriptive survey, Medicaid inpatient utilization review programs vary widely in authority, approach and focus, reflecting state payment system incentives, health and hospital system characteristics, and provider practice norms. More than half of the states with Medicaid diagnosis-related group systems contract with a Medicare Peer Review Organization. State programs are developing complementary clinical and data analytic approaches, advised by multidisciplinary utilization review committees, and are moving from random review to strategies that focus on specific types of admissions/procedures, and shift as provider practices and utilization patterns change. Utilization review strategies also support payment incentives and system features, e.g., by targeting outliers, readmissions and transfers, and short stays. Overall, programs are becoming more flexible, targeted, and interactive. Trends and suggestions for refining utilization review programs for diagnosis-related group systems are presented.