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PubMed1976

Professional review of health care services.

The question of professional accountability has frequently been raised with regard to the provision of health care services. Various systems, among them peer review, utilization review, and the PSRO, have accordingly been introduced to monitor the quality and the cost of health care. Social workers will have increased opportunities to participate in these review systems and, thus, to improve health care delivery.

Allied Health Personnel↗
PubMedDate not supplied

The need for ambulatory medical necessity review in multispecialty groups.

With the proliferation of HMOs, PPOs and other managed care payment methodologies which demand quality and efficiency, there is a shift from hospitals to clinics that creates the need for ambulatory care medical necessities review (utilization management). It is predicted that by the year 1995, 90 percent of all insured patients will be in a managed care system of some kind, thus the pressures to develop ambulatory care utilization review will likewise increase. Although there is some development in outcome measurement methodologies, currently there is an immediate need for UR techniques in the ambulatory care setting, techniques which are somewhat similar to traditional hospital methodologies. However, instead of the focus being case-by-case analyses, the large multispecialty group practice must rely on techniques which focus their review on large volumes of small services. Development of methodologies to influence and improve quality and efficiency is occurring in multiple areas. These methodologies are making inroads into the ambulatory setting and going far beyond traditional hospital UR. As Christian Ramsey Jr., M.D., notes, three methodologies are: 1. outcomes measurement; 2. data/information; and 3. continuous quality improvement (CQI) techniques. Indeed, the winds of demand for medical services are blowing in the direction of ambulatory care settings. Multispecialty group practices, like the sails of a ship, will catch this wind. To steer a course in the direction of improved quality and efficiency, the medical group practice must implement methodologies in ambulatory medical necessity review.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Care↗
PubMed1990

The infection control practitioner: an action plan for the 1990s.

Some articles have suggested that to survive in the 1990s an infection control practitioner (ICP) will have to be "smarter, brighter, or gone"--they assume that new initiatives for hospital peer review (utilization review, risk management, antibiotic use review, and quality assurance) soon will swallow up the ICP and the infection control program. This article questions that assumption. It reviews data supporting the continuing need for hospital infection control programs and presents information suggesting that the need for the ICP will increase rather than decline during the 1990s. Four essential characteristics for infection control programs are listed, and skills that make the ICP a valuable resource for other peer review programs are described. Several ways that the ICP can (and must) bring this information to the attention of other hospital personnel are suggested. Such actions help assure recognition of the continuing important role of the ICP and the hospital infection control program in each U.S. hospital and long-term care institution.

Communicable Disease Control↗
PubMed1983

Limited usefulness of the proportion of tests with normal results in review of diagnostic services utilization.

We tested the hypothesis that the proportion of normal results in tests ordered by a physician correlates directly with the proportion of tests that are disapproved by a utilization review audit for inappropriate test use. Auditors reviewed 3497 charts for 13 067 repeated determinations of 10 diagnostic tests ordered by 81 medical residents to determine if test use had been appropriate, according to explicit criteria. By the Pearson product-moment correlation coefficient, there was a significant (p less than 0.001) correlation between the proportion of normal results in tests ordered by residents and the residents' audit-disapproval rates, a previously undocumented relationship. Although statistically significant, the correlation coefficient of 0.25 means that the proportion of normal tests results predicted only 6% of the variance in the audit-disapproval rates. This relationship is not strong enough to use the proportion of normal results as a measure of a physician's inappropriate test use, except to select physicians for utilization review.

Chemistry, Clinical↗
PubMed1993

Utilization care plans and effective patient data management.

This article introduces the concept of a utilization care plan (UCP) for supporting the communication of data required for effective utilization review and utilization management. Utilization review is a process of measurement that compares the performance of a ward, department, or entire facility against accepted criteria to identify resource use shortfalls. Utilization management is the deliberate action by third party payers to ensure that shortfalls in resource utilization are minimized. Critical to the success of utilization management is effective data communication; utilization review data must be accurate, complete, accessible, timely, and coordinated. Computer-based UCP systems can remind caregivers when and what services should be provided to patients and also monitor the portion of those services that should be administered during each phase of a patient's therapy. Deviations from the UCP system template constitute variances that can be documented and highlighted in a friendly automated system that ensures highly accurate and extremely timely concurrent utilization information. Some implications of using UCP systems for future research and practice are also discussed.

British Columbia↗
PubMed1989

Peritoneal cytology in endometrial cancer: a review.

Utilization of literature review to evaluate peritoneal cytology as a test for the detection of malignant cells in the peritoneal cavity is limited by the size of the study populations, varied use of preoperative radiation, the lack of consistent methodology for specimen retrieval and processing, and the inherent subjectivity of cytologic interpretation. A standardized methodology for retrieval and processing of peritoneal cytologic specimens should be developed to allow meaningful comparisons of future studies. However, certain conclusions are permitted from published data: 1. The incidence of positive peritoneal cytology is 11.4 per cent among 3091 patients with FIGO stage I endometrial cancer. 2. The depth of the uterus does not influence the incidence of positive peritoneal cytology. 3. Positive peritoneal cytology is predictive of other known prognostic factors including advanced histologic grade, depth of myometrial invasion, and pelvic/periaortic lymph node metastases. 4. The presence of malignant cells in the peritoneal washings from some patients with no myometrial invasion and the high incidence of lymph node metastases in other patients with positive peritoneal cytology suggest that malignant cells gain access to the peritoneal cavity in a variety of ways. It is unclear whether each of these modes of access result in viable tumor cells with the potential for viable metastasis. The high incidence of lymph node metastasis in such patients suggests that lymphatic dissemination of malignant cells plays a significant role in the development of positive peritoneal cytology. In this setting positive peritoneal cytology clearly identifies that individual at high risk for recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma↗