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PubMed1980

Paranoia and progress notes: a guide to forensically informed psychiatric recordkeeping.

Trainees in the mental health professions, and their teachers, might well use paranoia as a motivating force to make psychiatric records effective for forensic purposes, utilization review, and sound treatment planning. The utilization reviewer maintains a highly quantitative view, as if all forms of treatment were like poultices of a predetermined size and predetermined rate of application. The utilization perspective is, If it isn't written, it didn't happen. It is also important not to confuse progress with process notes; process material and conscious and unconscious content belong in a private set of notes, while the public records contain the facts. The author outlines other considerations, such as what to do at the realization that a significant detail was omitted from an earlier note and how to document a situation in which a clinically based calculated risk was taken.

Commitment of Persons with Psychiatric Disorders↗
PubMed1995

Managed care liability and the capitated provider.

While there have been no reported cases as yet on the subject of ERISA preemption of claims arising from utilization review decisions by providers, it will unquestionably be a significant issue facing providers that participate in capitated arrangements. If preemption is determined not to be available, providers will be exposed to risks from which health plans are currently shielded. Providers conducting utilization review should be following this issue as it develops, but should also be obtaining insurance for this risk to the extent it is available (e.g., it will not be available for punitive damages). Providers should also consider negotiating provisions in their contracts with health plans to the effect that any utilization review conducted by the provider is on behalf of the health plan and that the provider's utilization review activities will be covered under the health plan's liability insurance.

Capitation Fee↗
PubMed1994

Relationship between practice characteristics of primary care internists and unnecessary hospital days.

BACKGROUND: Inpatient utilization review remains a useful approach for hospitals to achieve cost savings, however utilization review efforts need to become more focused and sophisticated. METHODS: In order to identify physicians with a higher percentage of unnecessary hospital days, and to analyze how their practice characteristics distinguished them from their colleagues, 364 consecutive admissions of 57 primary care internists were reviewed concurrently, on a daily basis. Days without acute hospital level of care that occurred while patients were awaiting placement in a rehabilitation or in a chronic care facility were adjusted out of the calculation. Analysis was undertaken to assess the impact of physician age, location of training, Board Certification, practice location, participation in medical training programs, years of experience, and participation in various types of managed-care programs on the level of unnecessary hospital days. Characteristics of the patients and their illnesses were included in the analysis. RESULTS: A large number of unnecessary hospital days occurred although there was no useful segregation of good from poor physician utilizers. Board certification and suburban practice location were associated with a significantly lower percentage of adjusted unnecessary days. Physician members of a closed-panel health maintenance organization had a lower percentage of adjusted unnecessary hospital days (14% vs. 41%, P < .001) when compared with the other primary care internists. Explanations for the difference are discussed. CONCLUSIONS: 1) The patients of primary care internists are still responsible for a large number of unnecessary hospital days; 2) Utilization review efforts need to become more sophisticated and focused; and 3) A change in physician incentives coupled with appropriate staff and systems possibly would be the simplest, large-scale remedy.

Health Services Misuse↗
PubMed1983

Use of anticholinergics in the nursing home: an empirical study and review.

The Medicare Utilization Review Committee conducted a survey to determine the use of drugs with anticholinergic effects in confused elderly nursing home patients. Twenty-nine patients (34.5 percent) were receiving anticholinergic drugs, predominantly from the antidepressant and antipsychotic class. Thioridazine (Mellaril) was the most frequently used antipsychotic. No patients received higher than the equivalent recommended daily dose of atropine when calculated in terms of relative anticholinergic potency. No statistically significant correlation could be found between the presence of confusion and the amount of anticholinergics administered. Confusion and cognitive deterioration frequently are encountered when caring for aged patients. Clinical experience and recent studies suggest that anticholinergics may increase the risk of or exacerbate existing confusion, and this possible effect of anticholinergic activity should be considered when prescribing for elderly patients.

Aged↗
PubMed1988

Managing the medical record on a concurrent basis: facts and possibilities.

In 1987, six Yale graduate students set out to study the concurrent review methods used in key hospitals across the US. They examined the advantages and disadvantages of concurrent review and the tie-in of medical record concurrent review coding with utilization review activities. The first part of their report is published this month, with the conclusion appearing next month.

Abstracting and Indexing↗
PubMed1988

Managing the medical record on a concurrent basis: facts and possibilities. Part 2.

In 1987, six Yale graduate students set out to study the concurrent review methods used in key hospitals across the US. They examined the advantages and disadvantages of concurrent review and the tie-in of medical record concurrent review coding with utilization review activities. The first part of their report appeared in the May issue of JAMRA. The second part appears below.

Abstracting and Indexing↗
PubMed1999

Effect of incentives on the use of indicated services in managed care.

In managed care, financial incentives and utilization review create conflicts of interest for physicians. We sought to determine whether these incentives would lead physicians to deny indicated services. We surveyed internists practicing in areas with at least 30% penetration of managed care. Our questionnaire included four scenarios in which a test or referral is indicated according to clearly established practice guidelines. We randomly assigned physicians to receive one of five versions of the questionnaire, which differed only in the type of reimbursement incentive and utilization review that applied to the scenarios. We received responses from 710 (70%) of 1,009 internists. Although physicians underutilized services regardless of incentives in all scenarios, physicians whose questionnaires depicted full capitation said that they would order fewer services than physicians whose questionnaires depicted fee-for-service. In the scenario in which an x-ray of the lumbosacral spine is indicated for a patient with low back pain, 86% of physicians randomized to the full capitation version said that they would order the test compared to 94% in the fee-for-service version. Similarly, physicians randomized to scenarios requiring utilization review said that they would order fewer services than those randomized to scenarios requiring completion of an insurance form. Scenarios depicting managed care incentives caused consistent, modest underutilization compared to fee-for-service scenarioes, although physicians underutilized services under all financial incentives and utilization review. In response, physicians must develop better methods for detecting underutilization and devise programs to increase the provision of indicated services.

Adult↗
PubMed1992

Advantages of the enlarged middle cranial fossa approach in acoustic neurinoma surgery. A review.

Utilizing an enlarged middle cranial fossa approach to the cerebello-pontine angle without destruction of the labyrinth or cochlea the authors have since 1981 operated on 263 unilateral acoustic neurinomas. Tumour sizes ranged between 3 mm intrameatal and 35 mm within the cerebello-pontine angle. Complete tumour removal was accomplished in 96%. There was one postoperative mortality, and only rarely neurological complications. Excellent function of the facial nerve was obtained in 78% (in small and medium sized neurinomas 90% House I and II) and severe paralysis persisted in only 6%. Preservation of hearing was possible in 70% of the small tumours, and in 50% of the total group. Against this background comparable data of the literature are reviewed, and the indications for the enlarged midfossa approach analyzed.

Adolescent↗
PubMed1997

Evaluating the effectiveness of child and adolescent group treatment: a meta-analytic review.

Utilizing 56 outcome studies published between 1974 and 1997, this meta-analysis specifically examines the effect of group treatment with children and adolescents (ages 4-18). Various types of group treatment were assessed, including preventative programs, psychotherapy, counseling, guidance, and training groups. Results indicate that group treatment was significantly more effective for children than wait-list and placebo control groups (effect size = .61). That is, the average child or adolescent treated by group treatment is better off than 73% of those in control groups. This meta-analysis strengthens and supports conclusions in the current literature and challenges others regarding the treatment of children and adolescents by group treatment. For instance, allegiance of the experimenter, setting of the therapy, socioeconomic status of the patient, and publication year of the study were variables that were significantly related to improvement, whereas diagnosis, content and source of the outcome measure were unrelated to improvement.

Adolescent↗
PubMed1996

Psychometric properties of a decision-support tool for the era of managed care.

This article reports psychometric properties of a decision-support scale designed to quantify the decision-making process for allocating psychiatric care. The authors developed a scale to evaluate the level of care needed for patients requiring psychiatric treatment in a health maintenance organization (HMO) setting. This study examines the reliability and validity of that scale by measuring interrater agreement among utilization reviewers from the HMO and between those reviewers and the clinicians who evaluated the patients directly. Agreement (kappa) among the five clinical raters acting in a utilization review capacity on dimensions of the scale ranged from .71 to .98. Kappas for agreement between the treatment intensity proposed by the reviewer/rater and used by the treating clinician were .41, .38, .40, .35, .36, and .39, respectively. The scale is reliable in the hands of trained personnel. Although there were important differences between clinicians' ratings and those of utilization review raters, these differences do not suggest that use of the scale would limit patient access to care.

Connecticut↗
PubMed1975

The PSRO hospital review system.

The 1972 Social Security amendments contained the landmark Professional Standards Review Organization (PSRO) provisions as well as several sections upgrading existing utilization review (UR) requirements under Medicare and Medicaid. With issuance of the PSRO Program Manual and the recent publication of the new UR regulations, HEW for the first time has brought Medicare and Medicaid hospital review requirements into conformity and made them compatible with and supportive of the PSRO program. This article defines the PSRO hospital review system, describes how the three major components-concurrent review, medical care evaluation studies, and profile analysis-interrelate and provides examples of each of these components. Under utilization review requirements or PSRO, hospitals will be required to implement an integrated system of review designed to assure appropriate utilization practices and improve the quality of care. These aims are to be accomplished through the application of concepts of peer review, the use of norms, criteria, and standards, the identification of deficiencies in the quality, administration, or appropriateness of health care services, and their correction through linkage with programs of continuing medical education. Although PSROs are initially responsible for review in hospitals, they will likely provide the locus for a community-wide system of peer review for all services provided under National Health Insurance.

Evaluation Studies as Topic↗
PubMed2001

Defining the parameters of case management in a managed care setting.

The authors explore how case management evolved from utilization review in order to address the lack of flexibility of basic utilization review. They examine case management's widely diverse state regulatory oversight as well as its lack of a clear definition. The authors then suggest three mechanisms that might be used to devise a universal definition of case management. For the purposes of this article, the authors use the term case management in connection with health benefits plans.

Accreditation↗
PubMed1986

Antimicrobial surveillance in a VAMC teaching hospital--resulting cost avoidance.

The economic impact of an antimicrobial surveillance service is presented. The antimicrobial surveillance service operates as a component of antimicrobial utilization review and serves as a means of identifying and reporting patterns of antimicrobial usage for the hospital. A record of all antimicrobial agent orders is maintained by the pharmacy service. Concurrent antimicrobial utilization review is conducted on specific agents using previously approved criteria. All cases of antimicrobial use failing to meet established criteria receive immediate intervention. From September, 1983 to June, 1985, a total of 229 cases of antimicrobial use received clinical pharmacy intervention. The cost avoidance appreciated from the selection of a more cost-effective regimen was $65,381.60. Additionally, extensive educational efforts directed to cefazolin q8h vs. cefazolin q6h administration resulted in a substantial reduction in cefazolin expenditures. Indiscriminate/inappropriate use of antimicrobial agents delivers a tremendous economic burden to the health care system. Utilizing antimicrobial surveillance as a component of antimicrobial utilization review serves as a means for identifying and reporting patterns of antimicrobial usage for the medical center and has a positive economic impact as illustrated.

Anti-Bacterial Agents↗
PubMed2006

Application of regression-discontinuity analysis in pharmaceutical health services research.

OBJECTIVE: To demonstrate how a relatively underused design, regression-discontinuity (RD), can provide robust estimates of intervention effects when stronger designs are impossible to implement. DATA SOURCES/STUDY SETTING: Administrative claims from a Mid-Atlantic state Medicaid program were used to evaluate the effectiveness of an educational drug utilization review intervention. STUDY DESIGN: Quasi-experimental design. DATA COLLECTION/EXTRACTION METHODS: A drug utilization review study was conducted to evaluate a letter intervention to physicians treating Medicaid children with potentially excessive use of short-acting beta(2)-agonist inhalers (SAB). The outcome measure is change in seasonally-adjusted SAB use 5 months pre- and postintervention. To determine if the intervention reduced monthly SAB utilization, results from an RD analysis are compared to findings from a pretest-posttest design using repeated-measure ANOVA. PRINCIPAL FINDINGS: Both analyses indicated that the intervention significantly reduced SAB use among the high users. Average monthly SAB use declined by 0.9 canisters per month (p<.001) according to the repeated-measure ANOVA and by 0.2 canisters per month (p<.001) from RD analysis. CONCLUSIONS: Regression-discontinuity design is a useful quasi-experimental methodology that has significant advantages in internal validity compared to other pre-post designs when assessing interventions in which subjects' assignment is based on cutoff scores for a critical variable.

Bronchodilator Agents↗
PubMed1987

Communicating P & T guidelines: how one committee meets the challenge.

The P & T Committee's role in advocating rational therapeutics is addressed in this exclusive Hospital Formulary interview with Richard Dreyfus, MD, and Fredrick Bender, PharmD, P & T Committee chairman and secretary at Saint Vincent Health Center in Erie, PA. This Committee has evolved beyond providing strictly formulary review and regulation and is now involved in utilization review of certain drugs in an effort to maximize their therapeutic potential. They stress the importance of communicating and educating the medical staff with regard to formulary issues and discuss the methods they find to be most effective. Methods for maintaining altered prescribing patterns, drug utilization review, adverse drug reaction reporting, and formulary review are highlighted.

Communication↗