A systematic review of utility measurements in the surgical literature.
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Cost-Benefit Analysis↗
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Identifying and managing inappropriate hospital utilization: a policy synthesis.
Utilization review, the assessment of the appropriateness and efficiency of hospital care through review of the medical record, and utilization management, deliberate action by payers or hospital administrators to influence providers of hospital services to increase the efficiency and effectiveness with which services are provided, are valuable but relatively unfamiliar strategies for containing hospital costs. The purpose of this synthesis is to increase awareness of the scope of and potential for these approaches among health services managers and administrators, third-party payers, policy analysts, and health services researchers. The synthesis will assist the reader to trace the conceptual context and the historical development of utilization review from unstructured methods using individual physicians' professional judgment to structured methods using explicit criteria; to establish the context of utilization review and clarify its uses; to understand the concepts and tools used in assessing the efficiency of hospital use; and to select, design, and evaluate utilization review and utilization management programs. The extent of inappropriate (medical unnecessary) hospital utilization and the factors associated with it are described. Implications for managers, providers, and third-party payers in targeting utilization review and in designing and evaluating utilization management programs are discussed.
Diagnosis-Related Groups↗
Characteristics of private-sector managed care for mental health and substance abuse treatment.
OBJECTIVE: This study examined diversity during the late 1980s in managed care programs for mental health, alcohol abuse, and drug abuse to identify ways in which research can generate more meaningful data on the effectiveness of utilization review programs. METHODS: Telephone interviews were conducted with representatives of utilization review programs for employee health insurance plans in 31 firms that employed 2.1 million people in 1990. Questions addressed qualifications of personnel, clinical criteria to authorize care, integration with employee assistance plans, penalties for not complying with utilization review procedures, outpatient review, and carve out of mental health and substance abuse review. RESULTS: Large variations in utilization review programs were found. Programs employed a range of review personnel and used a variety of clinical criteria to authorize care. More than two-thirds did not carve out mental health and substance abuse review from medical-surgical review. Some firms' employee assistance plans were integrated with utilization review programs, while others remained unintegrated. Penalties for not following program procedures varied widely, as did review of outpatient services. CONCLUSIONS: Because of trends toward even more diversity in utilization review programs in the 1990s, research that identifies the specific features of managed care programs that hold most promise for controlling costs while maintaining quality of care will increasingly be needed.
Alcoholism↗
Computer assisted prospective review of blood product utilization: a large hospital experience.
In an effort to assess need to administer blood products, we developed a computer-assisted prospective blood utilization review system. Prior to transfusion, clinical information (from the blood requisition form) and pertinent laboratory data (from the laboratory information system) are checked against approved hospital transfusion guidelines (HTG). If request-review is outside HTG, the blood bank physician is called to review and consult with ordering physician. Of 27,840 requests received in a year period (1995-1996), 1.2% (327) were outside HTG and were physician reviewed. The great majority, 120/160 (88%) of requests for red blood cells (RBC) or whole blood were approved; about 65% of these were approved in patients with cardiorespiratory dysfunction and hemoglobin (Hb) > or = 90 g/L. Slightly more than two-thirds, 84/119 (71%) of platelet concentrate requests reviewed were approved; about 69% of them were approved in patients who were either bleeding or were undergoing an invasive procedure and had platelets > or = 20 x 9/L. Almost four-fifths, 38/48 (79%) of fresh frozen plasma or cryoprecipitate requests reviewed were approved; all in bleeding patients with sepsis and/or disseminated intravascular coagulation. Based on the frequent request for RBC transfusions in patients with cardiorespiratory dysfunction and Hb > or = 90 g/L, we have obtained approval to increase the Hb threshold to < 130 g/L as a means of facilitating measures to increase oxygen delivery.
Blood Banks↗
Development and application of a population-oriented measure of ambulatory care case-mix.
This article describes a new case-mix methodology applicable primarily to the ambulatory care sector. The Ambulatory Care Group (ACG) system provides a conceptually simple, statistically valid, and clinically relevant measure useful in predicting the utilization of ambulatory health services within a particular population group. ACGs are based on a person's demographic characteristics and their pattern of disease over an extended period of time, such as a year. Specifically, the ACG system is driven by a person's age, sex, and ICD-9-CM diagnoses assigned during patient-provider encounters; it does not require any special data beyond those collected routinely by insurance claims systems or encounter forms. The categorization scheme does not depend on the presence of specific diagnoses that may change over time; rather it is based on broad clusters of diagnoses and conditions. The presence or absence of each disease cluster, along with age and sex, are used to classify a person into one of 51 ACG categories. The ACG system has been developed and tested using computerized encounter and claims data from more than 160,000 continuous enrollees at four large HMOs and a state's Medicaid program. The ACG system can explain more than 50% of the variance in ambulatory resource use if used retrospectively and more than 20% if applied prospectively. This compares with 6% when age and sex alone are used. In addition to describing ACG development and validation, this article also explores some potential applications of the system for provider payment, quality assurance, utilization review, and health services research, particularly as it relates to capitated settings.
Adolescent↗
Optimal investigation policies under selected PSRO procedures.
This article presents a methodology for utilization review which aids the local Professional Standards Review Organization (PSRO) in selecting optimal timing of Concurrent Stay certification by diagnosis. This procedure is accomplished by modeling patients' admissions, inpatients stays and discharges for each diagnosis as a stochastic process which is audited under the PSRO by three utilization review techniques: preadmission, concurrent and retrospective review. The timing of concurrent stay certification is determined so that the maximum benefits are derived for the utilization review cost expanded. The methodology presented here is a tool to aid local PSRO management in determining the most cost-beneficial utilization review process to utilized in their jurisdiction. It is not an attempt to demonstrate the effectiveness of our utilization review policy over another in general. On the contrary, while the model is generalizable to every PSRO, the utilization review policies resulting from any application are situation-specific. The major contributions of this article are new insight into modeling the utilization review process and the provision of a methodology for which computer programs exist and are readily available to any PSRO that should desire to determine its utilization review procedure in this cost-benefit framework. In order to apply the model it is necessary that certain parameters specific to the application site be estimated or assumed. Exact procedures to aid the PSRO in parameter estimation is the subject of current investigation.
Concurrent Review↗
Providers and reviewers teach informed managed care.
Two utilization review case studies are summarized, with discussion of both the provider's and the reviewer's perspective. This interface between managed care organizations and behavioral health care professionals offers some instructive guidelines on how to best approach the utilization review process.
Adult↗
Integrated concurrent utilization quality review, Part one.
This article is the first of a two-part series which argues for the concurrent management of the appropriateness, necessity, and quality of patient care. Intensifying scrutiny by the credentialing groups, the PROs and all third-party payors underscores the vital need to implement cost-effective information systems which integrate the departmentalized functions of patient-physician profiling, DRG case-mix analyses, length of stay monitoring, pre-admission/admission and continued stay review, discharge planning, risk management, incident reporting and quality review. In the domain of physician performance regarding admitting and practice patterns, the ability to exercise concurrent utilization-quality review means early detection and prevention of events which would otherwise result in denials of payment and/or compromised patient care. Concurrent utilization-quality review must, by definition, be managerially invasive and focused; hence, it is integral to maintaining the integrity of the services and product lines offered by the provider. In fact, if PPO status is a marketing agenda, then the institutional objectives of cost-effectiveness, productivity, value, and competitiveness can only be achieved through concurrent utilization-quality review.
Concurrent Review↗
Conceptual framework for drug usage review, medical audit and other patient care review procedures.
The following concepts are discussed: (1) quality assurance programs, (2) drug usage review, (3) utilization review, (4) peer review, (5) medical audit, (6) patient care audit and (7) medical care evaluation studies. A framework within which all types of hospital quality assurance mechanisms can be constructed is proposed and their interrelationships are described. The pharmacist's particpiation in the hospital's overall quality assurance program is stressed in two main areas-drug usage review, performed jointly with the medical staff, and quality assurance of pharmaceutical services, a peer review function of the pharmacy profession. These services are primarily drug distribution and control, drug information, clinical pharmacy, continuing education, and other pharmacy and pharmacist functions. Both functions may be viewed as parts of the pharmacy audit, one of several patient care audits within the facility. Pharmacists in skilled nursing facilities have quality assurance responsibilities similar to those of hospital-based pharmacists.
Drug Utilization↗
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↗
Evaluating drugs and determining the drug needs of developed and developing countries.
The practice of reviewing drug utilization provides a surveillance system for monitoring the efficiency of drug distribution and drug consumption; it also provides a data base for the interpretation of the frequency of adverse drug reactions and helps to identify gaps in the delivery of a crucial aspect of health services: the provision of safe and efficacious medicines. Malconsumption (either over- or under-utilization or needless prescribing) can be identified and economies might be achieved, once these problems are corrected. Linking drug utilization with standard health indices, such as morbidity and mortality rates, can help assess the effects of widely used drugs, both adverse and beneficial. Drug utilization review should be considered an essential activity of a well-organized health delivery system; it has great potential for both health planning and evaluation. These positions are discussed as they relate to developed and developing countries.
Developing Countries↗
Abstract scoring for the annual SMR program: significance of reviewer score normalization.
Presently, the scores of three to four reviewers of each abstract are averaged and form a major component of the input for decisions made in choosing papers for oral and poster presentations, and in rejecting others. No normalization is made for differences in either mean or standard deviation between the reviewers of the same abstracts. In this paper, several techniques for normalizing the scores of reviewers are examined, and the consequences of applying such normalizations to several categories of the 1994 abstract submissions are examined. It was found that some alterations in the acceptance and assignments of papers as oral and posters resulted for one of the categories, and the normalized scores were used during the program assembly. It is recommended that future review procedures utilize reviewer normalization.
Abstracting and Indexing↗
Single-subject evaluation: a tool for quality assurance.
The use of single-subject designs in peer review, in utilization review, and in other quality-assurance audits is encouraged. In this article, the authors present an overview of the methodologies of single-subject designs and quality assurance, and they provide examples of cases in which single-subject techniques furnished relevant quality-assurance documentation. Readers are referred to the literature for further study of the two frameworks under discussion.
Evaluation Studies as Topic↗
The economic benefits of acetylcholinesterase inhibitors for patients with Alzheimer disease and associated dementias.
Most cost-effectiveness studies using simulation modeling have demonstrated that donepezil, rivastigmine, and galantamine are cost effective for the treatment of mild-to-moderate Alzheimer disease (AD). These conclusions are in large part based on the assumption that improvement in cognitive status, or prevention of cognitive and functional decline, reduces the amount of time patients spend institutionalized or receiving other full-time care. However, as discussed in this article, outcomes besides delay to institutionalization affect the costs of AD. In reviews of utilization data from Medicare and managed care organizations, it was noted that hospitalization and post acute care in skilled nursing facilities accounted for the largest amount of excess direct costs, even among patients with mild or moderate AD. These utilization reviews also suggest that many patients with AD and related dementias require inpatient care because they are not able to self-manage comorbid conditions. The improvements in cognitive status and daily functioning associated with acetylcholinesterase inhibitor (AChEI) therapy are expected to translate into improved management of comorbidities and reduced caregiver burden, thus reducing the total cost of care. To confirm these and other economic benefits of AChEIs, pharmacoeconomic outcomes should be evaluated routinely as part of randomized, controlled trials and through well-controlled observational studies of AD patients in community and institutional settings.
Aged↗
The outcomes of back conservation education: occupational therapy study results in increased referrals and demonstrates program's benefits.
As part of a larger multidisciplinary study conducted at an acute care hospital, a three-phase study focused on an occupational therapy back conservation education program. A problem in care--limited patient education about back conservation--was identified. Because dissemination of information about underutilization of the program improved referrals only slightly, the basic procedure for referral was changed; this resulted in significant improvement. Flexibility and innovation in assessment approach were demonstrated by a post-discharge patient questionnaire and literature review utilized in the final phase of the study.
District of Columbia↗
Implementation of an interdisciplinary psychotropic drug review process for community-based facilities.
A continuing psychotropic drug review process developed and implemented in 1986 by a community-based agency serving individuals with mental retardation was described. This process has proven to be a feasible and effective system that has taken into account the practical realities of integration into the community and the use of community-based resources. The goals of establishing data-based interdisciplinary team review, utilizing concurrent alternative treatments, and prescribing psychotropic medication at the lowest effective dosage only to those individuals for whom it proves to make a positive difference have been met. For the residents of the agency's facilities, this process has led to a low psychotropic utilization rate of 17%. Dosage levels have been reduced for 75% of the individuals who have been prescribed psychotropic medication.
Drug Prescriptions↗
The effect of concurrent feedback in reducing inappropriate hospital utilization.
This study conducted in four general hospitals, evaluates the effectiveness of feedback from utilization review coordinators in reducing the number of inappropriate hospital days. Experimental control was exerted over the type of feedback provided in the utilization review process to produce four treatment groups (including a control group) that vary according to 1) the channel used to inform an attending physician of a probable inappropriately located patient and 2) the amount of discretion permitted the nurse coordinator in deciding whether, when and to whom this information is provided. The results of the study indicate that physician and hospital performance in utilization review, measured both by inappropriate patient days and length of stay, are affected by the feedback strategy employed. For patients inappropriately located for a portion of their hospital stay, provision of concurrent feedback resulted in reduction of approximately two thirds of an inappropriate day and two and one half total days, compared with patients for whom no feedback was provided or for whom physician advisor involvement was required. In addition, the effect of reasons causing patients to be inappropriately located (barriers) was assessed. Barriers outside the realm of influence of the hospital or the physician were found to impede the effectiveness of the utilization review systems.
California↗
Delegates approve protocol for third-party telephone review.
The Texas Medical Association Physician-Patient Advocacy Committee has conducted an extensive study of the telephone utilization review activities of private third-party payers and self-insured arrangements. Many of these organizations contract with private firms to conduct pre-certification and concurrent review of hospital admissions. These reviews often are accomplished by telephoning the attending physician's office. The procedures and criteria used by these firms and the qualifications of their review staff vary greatly. Physicians and their office staff are spending an increasing amount of time dealing with telephone utilization review. These review firms are not regulated or controlled by any agency. In response to the concerns expressed by physicians in dealing with telephone utilization review, Texas Medical Association's House of Delegates has approved the "Texas Medical Association Recommended Protocol for Physicians Responding to Private Third Party Telephone Review." The guidelines address concerns about confidentiality, physician documentation, patient advocacy, appeals, and cost and billing.
Confidentiality↗