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Today's environment offers a host of utilization management challenges for healthcare providers. If hospitals are to minimize denials and reduce costs amid these pressures, they will need to adopt several key strategies, including effectively employing use of a dedicated physician adviser.
Initiatives enable facility to gain high rankings in five clinical measures. Even though physicians know what they should do, reminders still are necessary. Physicians who are not compliant with new pathways are talked to by department chairs.
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In 1991 the third of a series of trials of concurrent case note screening was conducted over a 4 month period in one surgical and one medical unit of a busy metropolitan public teaching hospital in South Australia. The conclusion reached was that there is insufficient evidence of consistent improvement to justify the continuation of this expensive method of quality assurance. Traditional monitoring of performance by consultants, perhaps with the aid of computer-assisted management information, should achieve similar results.
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INTRODUCTION: The Appropriateness Evaluation Protocol (AEP) is an instrument to study the appropriate use of hospital beds based in objective criteria that classify a hospital admission as appropriate or inappropriate. OBJECT: Evaluate the appropriateness of hospital admissions and stays of the patients of our Internal Medicine Department using the concurrent version of AEP. METHOD: Transversal study where was evaluated the clinical record of the patients admitted to our Department of Internal Medicine on March 13th of 2003, excluding all these who were admitted the day of the study. We analyzed demographic and clinic parameters and the appropriateness of hospital admission and stay using the AEP. RESULTS: 22 patients fulfilled the inclusion criteria, 54.5% of male gender with a average age of 70.7 years. All the admissions were considered appropriate. The most common criteria was the need of intravenous therapy (100%), followed by the sudden lost of corporal mobility (12.3%). 27.3% of stays were considered inappropriate on the day of the study. The most common criteria of appropriateness was the need of intravenous therapy (93.7%). The most usual reason of inappropriate stay was the existence of planned discharge, but without the order written down in the clinical file (66.7%). CONCLUSIONS: The AEP allows an efficient evaluation of the appropriateness of the hospital admissions and stays in a Health Unit, being used for a better utilization of resources. In our department all admissions were justified and about a quarter of stays were considered inappropriate using the AEP.
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The implementation of practice parameters in laboratory medicine by changing physicians' behavior represents a major challenge. Education, restriction of tests, financial incentives, and concurrent chart reviews have not been effective in persuading physicians to improve their use of laboratory tests. The use of decision-oriented test request forms is suggested as an approach to this problem.
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A collaborative drug-use evaluation (DUE) of intraocular irrigating solutions (IOISs) at ophthalmic specialty hospitals nationwide is reported. Qualifying criteria for the use of an expensive fortified IOIS product were (1) the duration of surgery is more than 60 minutes, (2) the surgery is performed without a viscoelastic agent, (3) the patient's age is less than 50 years, (4) the patient has diabetes, and (5) the patient has evidence of compromised corneal endothelium. Surgical cases involving the use of IOISs were identified at each institution, and those cases involving fortified IOIS were reviewed for conformance with the criteria established. Of 23 institutions, 10 were able to perform the DUE. The review was concurrent at one institution and retrospective at the other nine. A case had to meet only one criterion to be considered in conformance. The cumulative mean rate of conformance with at least one criterion was 74%; the median conformance rate was 91%. The criteria that most frequently justified the use of fortified IOIS were surgical duration and nonuse of a viscoelastic material. Conformance with the DUE criteria varied with the institution, but valuable knowledge about the use of intraocular irrigating solutions was obtained by all.
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The degree of procedural compliance and the clinical outcome associated with a therapeutic interchange of extended-spectrum penicillins were assessed. Pharmacists conducted a concurrent chart review on all patients receiving mezlocillin as a therapeutic alternative for piperacillin or ticarcillin over a five-month period. The pharmacists assessed whether (1) the pharmacy appropriately dispensed mezlocillin when orders were written for piperacillin or ticarcillin, (2) physicians and nurses were properly notified of the therapeutic interchange, and (3) the bacterial isolates were susceptible to mezlocillin. Pharmacists and physicians evaluated clinical outcomes of all patients receiving mezlocillin through a retrospective chart review and classified the responses as "success," "failure," or "indeterminate." Fifty-one orders for piperacillin were written during the study period, and mezlocillin was selected as a therapeutic alternative in all cases. No orders for ticarcillin were written. Proper notification was made to nurses and physicians in 98% and 65% of cases, respectively. No mezlocillin-resistant gram-negative bacteria were found. Eighty-three courses of therapy were reviewed for clinical outcome; 68 were classified as successes, 0 were failures, and 15 were indeterminate. The cost savings after nine months of therapeutic interchange of mezlocillin for piperacillin was $6600. This study indicates that the pharmacy made a proper therapeutic interchange of mezlocillin for piperacillin and followed the correct procedure for notification of the nursing staff. However, more effort is needed to ensure communication with the prescribing physicians.
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